8c
Michael J. Roche and Emily B. Ansell
First, we wish to thank Drs. Durbin and Hopwood for their insightful remarks on our chapter. We will begin by addressing the questions posed by Dr. Durbin, primarily the concern around using specific interpersonal styles to inform treatment approaches. Specifically, she notes that it is important to consider the role of relationship context, and challenged us to be more specific around the goal of therapy informed by interpersonal styles.
Although we do feel interpersonal styles can inform treatment targets (as described in our chapter), we agree that it should not be the only consideration. Another limitation she noted was the diagnostic overlap of PDs, making it difficult to advance an approach where PD and interpersonal style link to specific interventions. Although we agree this is a concern, both could be merged to enhance treatment. For example, the interpersonal theme (e.g., vindictiveness) could guide the initial treatment target (e.g., to decrease vindictive intensity and create flexibility so that other interpersonal styles are possible), whereas the personality disorder(s) may further inform the motivations underlying that behavior (e.g., paranoid defensiveness, narcissistic entitlement).
Depending on the case conceptualization, the treatment targets could be pursued in myriad ways, drawing from cognitive-behavioral (e.g., psychoeducation about interpersonal rigidity, addressing hostile attribution biases, behavioral rehearsal and exposure to social interactions) or psychodynamic (exploring the function of vindictiveness in past and current relationships, identifying the style as a defense against a more vulnerable interpersonal style toward others, etc.) approaches. Hopwood (2018) recently published a paper linking pathological personality traits from the DSM-5 alternative model for personality disorders to associated treatment techniques. As such, interpersonal traits like antagonism (dominance and unfriendliness) and detachment (submissiveness and unfriendliness) were explicitly linked to possible interventions.
Dr. Durbin also aptly noted that patients with personality disorders are often distressed about specific relationships in their lives. This fits with the fifth assumption’s premise that context-driven demands for specific relationships may drive normative or non-normative patterns. For some patients we’ve seen, the theme is strikingly similar across all relationships (e.g., the individual with narcissistic personality pathology who treats coworkers, family, and friends as an opportunity to communicate superiority); in those cases, the interpersonal style of dominance is clear and informs a specific treatment target (e.g., decrease intensity of dominance, increase flexibility toward interpersonal behaviors other than dominance). Other, less severe cases will present as a more nuanced picture where only certain relationship contexts are relevant for the personality dysfunction. We noted this specifically in our chapter with a person-specific application that described a patient who had a specific relational difficulty with his wife (but not others). Here, we can see the utility of considering unique relationships as both we and Dr. Durbin are advocating for.
Dr. Hopwood correctly noted that our chapter defined personality disorder as a static construct. Our approach is consistent with the DSM-5 definition, which assumes personality dysfunction is relatively stable over time and circumstances. We recognize and agree with Dr. Hopwood that the field is in flux regarding this definition, and that evidence is already accumulating that dynamic processes underlie personality pathology. Our view is that a personality disorder is best characterized through both between-person (static) distinctions (e.g., who has a higher level of personality dysfunction) and within-person (temporally dynamic) contrasts (e.g., when does that individual evince greater difficulty). As we noted earlier, the interpersonal model can identify the “who” through static self-report measures that capture profile elevation and style, which sometimes can be used to formulate treatment goals (around intensity and flexibility). The interpersonal model increasingly also recognizes methods to identify “when” and “in what context,” which we would describe as additionally informative.
Dr. Hopwood also suggested further refinement for the fifth assumption, noting that elements of this assumption could be captured in previous assumptions. For instance, he suggested that our addition of “context” could be folded into assumption 2, noting that agency and communion may vary in relation to additional important constructs (e.g., emotions, motives, perceptions of contexts) needed to comprehensively describe the interpersonal situation. Those additional constructs can be a part of the real or imagined exchange (assumption 3), and can be described in normative patterns (assumption 4). As both we and Hopwood have noted, context is nothing new to interpersonal theory, but the theory and research around the interpersonal constructs of agency and communion are better articulated than those related to these other components. For instance, the term complementarity governs how exchanges of agency should unfold, but what about interpersonal exchanges of emotions (e.g., to match the valence and arousal of one’s interaction partner) or the link between acting dominant and one’s own emotions? Our efforts were aimed at updating these assumptions to be in line with recent research that often includes more context-related nuance than was specifically articulated in those assumptions. By adding a fifth assumption, we hope that clinicians and researchers alike will take particular notice of the importance of context and dynamic processes throughout their work.
In summary, both Drs. Durbin and Hopwood provided important insights into how our description of interpersonal theory can be better articulated. We look forward to further refinement of this model so that conceptualization and treatment of personality disorders can be enhanced.
References
Hopwood, C. J. (2018). A framework for treating DSM‐5 alternative model for personality disorder features. Personality and Mental Health, 12(2), 107–125.