Overcoming Resistant Personality Disorders: A Personalized Psychotherapy Approach

March 1, 2008
F. Theodore Reid, Jr, MD
Volume 25, Issue 3

Overcoming Resistant Personality Disorders is a provocative and well-reasoned, yet frustrating volume. In it, the authors challenge various authorities on the subject; for example, they criticize the DSM for its failure to "officially endorse an underlying set of principles that would interrelate and differentiate the categories in terms of their deeper principles" and for its current Axis II categories.

Theodore Millon and Seth Grossman;
New York: John Wiley & Sons, 2007
344 pages • $49.95 (softcover)

Overcoming Resistant Personality Disorders is a provocative and well-reasoned, yet frustrating volume. In it, the authors challenge various authorities on the subject; for example, they criticize the DSM for its failure to "officially endorse an underlying set of principles that would interrelate and differentiate the categories in terms of their deeper principles" and for its current Axis II categories.

To address their dissatisfaction, the authors choose to use their own classification system. In an era that focuses on empirically supported and psychopharmacological therapies, the authors also challenge the notion that any single approach, or even an eclectic one, can be effective as treatment for personality disorders. Instead they advocate an integrated psychotherapeutic approach that views the patient as the focus of the integration.

However, the authors do not simply criticize current diagnostic and treatment approaches. Millon is a leading figure in the study of personality and personality disorders, and Grossman has been his collaborator for many years. The first chapter recapitulates, for those to whom it is unfamiliar, their theory of personality and personality disorders, which postulates there are 15 personality prototypes and 7 personality disorders. The book includes associated measurement instruments so that even neophytes can use their approach. The authors remind us that despite systems of classification, each patient is unique and must be approached accordingly.

What, then, is my source of frustration? For a book subtitled A Personalized Psychotherapeutic Approach, it is annoyingly sketchy about psychotherapy. This is foreshadowed in the opening chapter when, after 46 pages of exposition of the theory of personality disorders and their classification and measurement, the authors spend 2 paragraphs on therapy. They express their "belief that the majority of therapists have the ability to break out of their single-minded or loosely eclectic frameworks, to overcome their prior limitations, and to acquire a solid working knowledge of diverse treatment modalities." The reader learns that these modalities include behavioral, interpersonal, cognitive, self-image, motivational interviewing, intrapsychic, and psychopharmacological techniques that may be delivered in dyadic, couple, family, or group settings. One wonders how the "majority of therapists" will acquire a "solid working knowledge" of these theories and modalities and how long that might take.

There is an imbalance between the theoretical description of the personality disorders with their variants and their treatments. Chapters run between 35 and 40 pages; however, the description of the treatment for any particular personality disorder variant is rarely more than a page (and even those are presented with a paucity of detail). As a reader, I want to know more about the rationale for a particular sequence of approaches, their timing, how the therapist transitions from one modality or theory to another and whether that ever confuses the patient, and whether the shifts create countertransference problems. Instead, the reader is ultimately left with the authors'-at times verbose and convoluted-reasoned, articulated theory and description of personality disorders. However, this reader, despite interest in integrative therapy, is left wanting to know much more about their unique approach to the treatment of this difficult group of disorders.