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2 - The treatment of choice: what method fits whom?

Published online by Cambridge University Press:  14 August 2009

John F. Clarkin
Affiliation:
Clinical Professor of Clinical Psychology in Psychiatry Co-Director, Personality Disorders Institute, Weill Medical College of Cornell University, New York, NY USA
Bert van Luyn
Affiliation:
Symfora Group, The Netherlands
Salman Akhtar
Affiliation:
Thomas Jefferson University, Philadelphia
W. John Livesley
Affiliation:
University of British Columbia, Vancouver
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Summary

Two dominant methods can be utilized today for matching the individual patient with the most optimal treatment. The method receiving extensive attention at this time is the empirically supported treatment movement (Chambless and Hollon, 1998). In this methodology, the patient who presents with a particular DSM disorder is matched with a therapist who is armed with a specific treatment, usually cognitive-behavioral, that will focus on and alleviate the symptom in a brief period of time. The suggestion that it is unethical to do otherwise implies that our training programs for clinicians should be focused on this match of patient symptoms with cognitive-behavioral technology.

However, a number of issues make one pause and resist joining the band-wagon of the empirically supported psychotherapy movement:

  • Most patients present with more than one, clearly defined, DSM disorder. This is especially true of those individuals with severe personality disorders.

  • Focused cognitive-behavioral treatments are limited in their effectiveness in the short-run, and often seem inadequate in the long-run. At termination from short-term treatment, a majority but not all patients has been helped with his/her symptoms. Upon follow-up, a much smaller group of patients has maintained their gains (Westen and Morrison, 2001).

  • The emphasis on therapy as a set of technical interventions tends to ignore the attributes of the therapist beyond just his/her skill in delivering specific techniques. This metaphor of a therapist as a dispenser of techniques leads logically to a computer providing programmed direction.

  • If a treatment fails and the patient drops out prematurely, it is often assumed that the patient's characteristics are the major contributor to the disruption. We have examined data describing such patients, including but not limited to diagnosis (Clarkin and Levy, 2004). The therapist's contribution to the failure has been less frequently examined.

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Publisher: Cambridge University Press
Print publication year: 2007

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References

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