Treating Personality Disorders in Children and Adolescents: A Relational Approach, Efrain Bleiberg
Pearson, Lisa, Journal of Professional Counseling, Practice, Theory, & Research
Treating Personality Disorders in Children and Adolescents: A Relational Approach, Efrain Bleiberg. New York: Guilford Press. 2004 (paperback edition). 348 pp. ISBN 1-59385-018-2 $25.00.
Like most people in the helping professions, I encounter people with personality disorders on a regular basis. After more than twenty years of working in secondary public schools, the last eight as a high school counselor, I find that (involuntarily) frequent practice has made me fairly effective in the two tasks one must accomplish to interact effectively with borderline or narcissistic students and parents: defusing their extremes of emotional reactivity, and setting/keeping appropriate boundaries with them. However, now that I have also begun working in private practice, I find that I need some additional skills to accomplish the somewhat different goals of psychosocial treatment. With that in mind, this summer I began to read as much as possible on the subject of personality disorders and their management and treatment.
A psychiatrist had recommended Bleiberg's book to me in the course of a consultation about a mutual client, so I started with it. Dr. Bleiberg, a psychiatrist and neo-Freudian psychoanalyst, writes elegantly and fluently, drawing on a vast number of sources as well as his own considerable clinical experience with this population. So well written is the book, indeed, that even the chapter on pharmacotherapy is quite readable!
Bleiberg's premise is that the central feature of a severe personality disorder of the dramatic cluster (antisocial, narcissistic, borderline) is the underdevelopment of what he calls reflective function. Reflective function, a term coined by Fonagy, is "the developmental acquisition that permits people to respond not only to other people's overt behavior but also to their conception of [others'] beliefs, intentions, feelings, and the like." (36) Dr. Bleiberg notes that it is through "attributing mental states and intentions to themselves and others [that] human beings make people meaningful and predictable." (36)
Drawing on the work of attachment researchers like Bowlby, Fonagy, Gergely, Watson, and others, Bleiberg argues that when the normal attachment process, mediated by attunement and the reflective responses of caregivers, fails, dysfunctional schemas arise in which the caregiver dispenses with reflective function and responds instead in the form of what Bleiberg calls "procedural," or mechanistic, scripts. A child whose caregiver fails to "teach" reflective function, through understanding and reflecting the infant's affective states, will in later life himself be prompted by certain stressors to lapse into nonreflective, "procedural" schemas. (36-42) These schemas, probably in combination with certain physiological/genetic vulnerabilities to arousal, as well as early trauma, can lead to patterns of response typical of the dramatic personality disorders most often first identified in adolescence or early adulthood.
Furthermore, Bleiberg sees the optimum treatment of these patients as "centered on a systematic effort to help patients/clients regain reflective function in the face of internal and/or external cues that trigger its inhibition. …