Etiology and treatment of Cluster C personality disorders.

Of challenge to mental health counselor's (MHCs) is the management and treatment of personality disorders. This article will elaborate on the etiological development of Cluster C personality disorders (avoidant, dependant, and obsessive-compulsive), review the self-maintenance functions they provide, and review the cognitive-behavioral, group, and psychodynamic treatments for each of the three Cluster C personality disorders. The central aim of this manuscript is to assist MHCs in better understanding biological and environmental antecedents, treatment interventions, and to ensure that personality dynamics are not overlooked in the treatment process.

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Historically, Axis II Personality Disorders have been recognized as being unresponsive and untreatable (Eskedal, 1998). This category of disorders has been viewed as long-standing and is distinguished by deeply ingrained maladaptive attitudes and behaviors that are ego syntonic, or one with the personality disordered client. These maladaptive beliefs and behaviors are recognized by Seligman (1998) as showing up in at least two of the following areas: perceptions and understandings of oneself and one's environment; expression, nature, range, and appropriateness of emotions; interpersonal skills and relationships; and impulse control. The attitudes, beliefs, and behaviors of the personality disordered individual are usually rigid and inflexible, causing significant impairment in the life of the affected individual.

Traditionally, the treatment of the personality disorders was relegated to the psychodynamic approaches and long-term psychotherapy was considered the treatment of choice (Kernberg, 1996; 2001). Generally, the goal was to change the character structure or life style; however, the outcomes were mixed even among those highly motivated for change (Eskedal, 1998). Treatment methods today differ in that the approach is more focused and structured, with the therapist taking a more active role in the therapy process (Millon, 1996; Pretzer & Beck, 1996).

As recognized by Millon (1996), personality disorders lend themselves to a three-category classification with regard to treatability, analogous to the DSM-IV-TR (APA, 2000) diagnostic categories: Cluster A (paranoid, schizoid and schizotypal), viewed as the treatment resistant category, is believed not likely to benefit or accept change; Cluster B (antisocial, borderline, histrionic, and narcissistic), viewed as the treatment with mixed results group, is often viewed as possessing both treatable and untreatable qualities depending upon the individual; and Cluster C (avoidant, dependant, and obsessive-compulsive), viewed as the treatment responsive category, is believed to have a high amenability.

This paper focuses on Cluster C, which represents behaviors manifested in anxious or fearful patterns and includes: avoidant personality disorder (AvPD), dependent personality disorder (DPD), and obsessive-compulsive personality disorder (OCPD). In the past, personality disorders were explained almost exclusively from a psychodynamic perspective. Most language used to conceptualize personality disorders is in terms of "character language," such as anal character. Despite biological tendencies in the field that emphasized temperament, the psychological tradition that emphasized character was utilized for most of the 20th century (Sperry, 1995). Currently, a paradigm shift has altered the field's perspective on personality disorders, which are now viewed as resulting from a combination of biological, psychological, and social factors (Sperry, 1995). It is recognized that personality disorders represent an enduring pattern of thinking, feeling, and behaving that is relatively stable over the life cycle, beginning in adolescence or early adulthood and continuing on throughout the life cycle. Over time, this maladaptive life-style places the individual at odds with his or her social and cultural environment, leading to distress and/or impairment (Eskedal, 1998).

According to Seligman (1998), Cluster C personality disorders involve the least dysfunction, deeming them more treatable than other personality disorders. Additionally, individuals with Cluster C personality disorders are usually aware of their psychopathology, desire change, and are willing to undergo treatment. Individuals diagnosed with Cluster C personality disorders also have the best outcome with every type of short-term psychotherapy (Magnavita, 1997). Thus, in an era where the number of sessions and amount of time MHCs have to dedicate to their clients is limited, short-term techniques may often surface as the treatment of choice. Despite the fact that these personality disorders have been recognized as being the most responsive to psychological treatment, a dearth of literature exists. This paper elaborates on the etiological development and maintenance of the Cluster C personality disorders, in addition to providing an overview of cognitive-behavioral, group, and psychodynamic treatments for each of the three categories.

AVOIDANT PERSONALITY DISORDER (AVPD)

Etiology

Biological predisposition.

It is commonly believed that biological factors set the foundation for personality while environmental factors shape the form of their expression along a reaction range. In the case of AvPD, the evidence of major biogenic influences in its etiology and development is speculative (Millon & Davis, 2000). However, there is some evidence that a timid infantile temperament may predispose an individual to avoidant patterns of behavior. Kantor (2003) believed that this inherited tendency to be shy is the result of overstimulation or an excess of incoming information, thus, socially timid children display heightened sympathetic reactivity to various environmental changes. Furthermore, this pattern of sympathetic sensitivity has been observed in socially timid children as young as 2 years of age and has been found to be stable throughout childhood (Bartholomew, Kwong, & Hart, 2001). Timid individuals cannot handle an excess of incoming information; therefore, they withdraw from the situation as a self-protective measure.

Biological substrates exist within AvPD as a foundation for the emergence of the disorder itself and full development of AvPD is likely due to significant environmental influences (Millon & Davis, 2000). Biological predisposition alone is insufficient to account for the emergence of this condition suggesting that environmental factors may transform the predisposition into the longstanding behavioral pattern (Benjamin, 2003).

Environmental influences.

Developmentally, individuals diagnosed with AvPD began with adequate nurturance and social bonding, laying the foundation for a continued desire for social contact and encouragement. Despite an adequately nurturing environment, individuals diagnosed with AvPD were often subject to relentless parental control with regard to creating an impressive social image (Benjamin, 2003). Thus, they experienced demands to be admirable in the eyes of their parents, and if they did fail, they were subject to degrading mockery for their imperfections and shortcomings. As a result, they became socialized to perform adequately and manage an appropriate impression while avoiding occasions for embarrassment or humiliation (Sperry, 1995).

Psychodynamic theorists see AvPD behavior as being driven by the shame of not measuring up to their ego ideal. These self-effacing attitudes that develop out of a fear of parental and peer rejection give rise to the following self-perpetuating, avoidant tendencies: (1) hypersensitivity to rejection and a tendency to misread a neutral or even positive reaction as negative, (2) restriction of social experiences so as to avoid situations where they may be prone to failure and inevitably, rejection, and (3) avoidant behaviors through operant conditioning.

Treatment

Cognitive-behavioral therapy.

Cognitive-behavioral techniques are designed to help individuals with AvPD overcome their social fears and gain a better sense of self-worth. Beck, Freeman, and Davis (2003) found that the focus of treatment is on pattern analysis, pattern change, and pattern maintenance, but before counselors can begin to identify these patterns, the establishment of trust must occur. Since avoidant individuals enter into therapy hypersensitive to rejection and criticism, it is expected that they will be observing and testing the MHC for any indication of acceptance or rejection. Maintaining accurate empathy and unconditional acceptance throughout this time will most likely allow the client to become increasingly trusting and able to open-up and address more detrimental issues.

Sperry (1999) identifies "triggers" or "triggering" situations as well as underlying maladaptive schemas as working together to produce self-perpetuation of avoidant thoughts, beliefs, and behaviors, or patterns. The main "triggering" situations for avoidants are stressors related to close relationships and public appearance (Cottraux & Blackburn, 2001). Triggers result in characteristic symptomatic emotions, behaviors, and cognitions that are indicative of, and contributing to the individual's rise in anxiety. Identification of the clients' triggers allows them to prepare for these anxiety producing situations and recognize them before they even occur, increasing their capacity to tolerate such circumstances.

From a cognitive perspective, schematic change results from the counselor and client working collaboratively to understand the developmental roots of the maladaptive schemas. In addition to uncovering the roots, clients are encouraged to remember counter-schema data about themselves and their social experiences. Behaviorally, Millon and Davis (2000) identify systematic desensitization as a helpful technique to be used for specific situations a client may be having difficulty with, so as to increase his or her tolerance to the condition.

Research on cognitive-behavioral treatment strategies for interpersonal problems has generally looked at systematic desensitization and skill training strategies. Young, Klosko, and Weishaar (2003) concluded that social skills training were superior for those clients deemed "unskilled" but that the two strategies were comparable for socially phobic clients. It was found that a combination of skill training and gradual exposure was more effective than either procedure in isolation.

Group therapy.

AvPD clients need to avoid relationships to protect themselves from the painful rejection that they believe some relationships can bring (Kantor, 2003). The avoidant tendency has been supported by Barber, Morse, Krakauer, Chittams, and Critis-Christoph (1997) who concluded that AvPD clients tend to avoid therapy and researchers, as well as other people in their lives. This underlying concern lays the foundation for understanding why group therapy can be beneficial to individuals with this personality disorder. Group therapy offers avoidant individuals a sense of belonging, a feeling of being wanted, and a boost to their ego resources, overall, an experience that goes against previously held beliefs.

The initial interaction between the group leader and the avoidant individual takes place during the pre-screening. Pre-screening becomes the first of many essential steps that help build a structure conducive to both individual and group success. The primary problem at this stage is one of early identification and screening out of AvPD individuals who may be overwhelmed in the group (Yalom, 1995). Research has indicated that those who profit most from the group are those who highly value and desire personal change. Contributions to the development of this high motivation can range from viewing the self as deficient both in understanding one's own feelings and in one's sensitivity to the feelings of others, to having high expectations set for the group (Corey & Corey, 2002; Seligman, 1998).

Once the pre-screening process has passed and individuals have been selected for involvement, the initial phase of group begins. At this phase, members take active steps to create a trusting environment. If this fails to occur, members may keep their feelings of distrust or fear pertaining to the group to themselves: thus entrenching themselves in the role of the deviant. Yalom (1995) recommended that leaders encourage other members to reflect on their perceptions of the avoidant individual's emotional experience and have the AvPD member comment on or validate these perceptions.

Cognitive-behavioral theorists have concluded that behavioral group treatment as well as social skills training in group settings provides a context of acceptance and support. Results from a study conducted by Wilberg, Karterud, Umes, Pederson, Friis (1999) indicated a significant improvement in clients with personality disorders (AvPD being most heavily represented) who participated in cognitive-behavioral therapy groups as compared to clients who did not take part in the groups. A recent study by Harper (2004) found that AvPD individuals who completed a 10-week behavioral group treatment program displayed significantly greater improvement on a variety of dimensions than did the untreated control participants. According to the researchers, although treatment was beneficial, these avoidant individuals did not achieve normative levels of functioning, indicating that a more integrative approach might be beneficial.

Psychodynamic psychotherapy.

Psychodynamic psychotherapy is the most commonly used individual therapy with AvPD clients. It is similar to psychoanalytic therapy, which focuses on past events and long-repressed feelings, but the psychodynamic mode integrates the past with the client's current life. Psychodynamic psychotherapy requires that thoughts and emotions are discussed openly; unfortunately, this is exactly what AvPD individuals fear, making open and honest communication difficult. Since they are reluctant to share themselves openly due to painful experiences in the past, reassurance, pacing, and supportive aspects of psychotherapy are essential. This treatment approach must first be directed at solidifying an alliance between the MHC and client to prevent early termination.

The expressive aspect of psychodynamic psychotherapy focuses on exploring the underlying causes of shame as related to past developmental experiences. To the extent that the clients are motivated to change and willing to confront feared circumstances, the expressive aspect is greatly enhanced (Sperry, 1995). Millon and Davis (2000) suggest a general poor prognosis for AvPD individuals because the characteristics of the disorder run counter to the basic requirements of successful psychotherapy. Despite the validity of Millon and Davis' conclusion, an avoidant individual may be quite able to explore expressive aspects of psychotherapy if a strong, trusting therapeutic alliance can be established (Barber et al., 1997).

DEPENDENT PERSONALITY DISORDER (DPD)

Etiology

Biological predisposition.

Millon and Davis (2000) suggest that those individuals who develop DPD exhibit fearful, withdrawing, or sad temperaments as infants, thereby eliciting overly protective reactions from caretakers. Millon and Davis (2000) also recognize that prolonged health issues in childhood may also force a parent to become over-concerned and overprotective of his or her child, beyond what is medically necessary. In addition, endomorphic and ectomorphic body types, which are common among dependant individuals, contribute to low energy thresholds and a lack of vigor, eliciting heightened concern and care from caretakers. All of these conditions may elicit overprotection from parents and unindustriousness from the child, but it is the environmental factors interacting with these biological predispositions that contribute to the development of DPD (Sperry, 1995).

Environmental influences.

Developmentally, DPD individuals experience adequate nurturance much like those with AvPD but were never detached from their nurturing environments. Parental overprotection, over-concern, over-nurturance, and discouragement of autonomy may contribute to the development of an underlying belief that one is helpless and needs to be taken care of. In support of this perspective, several studies have found significant correlations between parental overprotectiveness and increased dependency in children across ages (Parker & Lipscombe, 1980; Gorden & Tegtemeyer, 1983; Ojha & Singh, 1988). Additionally, consistent results in this area have been obtained in independent samples of Indian (Ojha & Singh, 1988) and British subjects (Parker & Lipscombe, 1980). Suggesting that DPD may be a cross-cultural phenomen.

As toddlers, when most children begin to express curiosity about the world around them, the DPD individual's parents, rather than letting curiosity unfold naturally, intervene and cater to their child's habits and needs. As a result, competency and industriousness fail to develop and in some cases, the child never outgrows the parental overprotection, living his or her life dependant on powerful figures. Certain dependency-fostering practices are particularly likely to be exhibited by parents who are themselves dependent (Kochanska, Friesenberg, Lange, & Martel, 2004). The perpetuation of DPD involves a combination of self-doubt, avoidance of social/competitive activity, and the availability of an individual willing to take care of the dependant person (Loranger, 1996).

It is important to note that limited gender research has been conducted regarding DPD. The vast majority of studies addressing this topic have indicated that when self-report measures of dependency are used, gender differences in adult dependency have found higher levels of dependency in women than in men (Ojha & Singh, 1985; Singh & Ojha, 1987). Furthermore, comparable gender differences were found with self-report dependency measures in British (Birtchnell & Kennard, 1983) and Indian subjects (Singh & Ojha, 1987). Conversely, when projective measures of dependency were used, researchers tended to find that men and women had similar levels of dependency (Bomstein, 1992; Bornstein, Leone, & Galley, 1988; Greenberg & Bornstein, 1989).

Treatment

Cognitive-behavioral therapy.

According to Beck et al. (2003), cognitive-behavioral therapy provides the necessary focus on pattern analysis, pattern change, and pattern maintenance that is needed for the dependant individual's development of a healthy self-concept. Much of the ease with which rapport is established stems from the dependant individual's need to please and be agreeable so as to ensure acceptance from the counselor. Sperry (1999) noted that DPD is considered one of the easiest personality disorders to engage in the therapeutic process. Despite the comfortable process of establishing the alliance, however the MHC must still exercise a degree of caution due to the dependant individual's intense need to please.

Once past the initial phase of building trust and establishing the client-counselor alliance, pattern analysis and evaluation of the client's styles, schemas and triggering stressors commence. The primary style specified for DPD individuals is that the client needs others to assume responsibility for change (Allnutt & Links, 1996; Wessler, Hankin, & Stem, 2001).

Sperry (1999) suggests that the "triggers" for DPD clients are stressors related to "self-reliance and being alone." Therefore, whenever the dependant individual is faced with situations related to being alone and independent, his or her maladaptive pattern is triggered, causing anxiety. By learning to identify these "triggers," the client is then able to prepare for and deal with situations in a more adaptive manner. Critical to the dependant individual's world-view is the assumption that others will protect and care for him or her (Sperry & Mosak, 1996). Once the maladaptive patterns are recognized, the focus of therapy can shift from pattern analysis to pattern change.

Since the majority of schematic distortions stem from core beliefs caregivers presented early on in life, the MHC and client must work collaboratively to determine the roots, or developmental origins of the maladaptive schemas. Counter-schema data are also helpful to the process of establishing a more adaptive level of functioning. The use of desensitization techniques may also assist clients with co-occurring symptoms of avoidant personality or social phobia (Alden, Laposa, Taylor, & Ryder, 2002).

Group therapy.

Group treatment has been shown to be successful with DPD and is indicated because it affords clients the opportunity to experiment with new ways of self-expression and relating while receiving support and encouragement (Seligman, 1998). A noteworthy factor contributing to the success of group therapy with DPD clients is their desire to obtain nurturant support. According to a study conducted by Bomstein (1992) the fundamental motivation of the DPD client is a strong desire to obtain and maintain nurturant, supportive relationships.

Interactional groups provide a milieu for experiencing the inappropriateness of passive dependent behaviors as well as for experimenting with greater assertiveness (Yalom, 1995). The group setting helps expand the dependant individual's view of the interpersonal world from the idea that a person is either in control or submits to others, to a broader array of interpersonal interactions (Benjamin, 2003). The interactional group also allows the DPD client to test more adaptive behaviors in a supportive setting, enabling him or her to generalize and make use of adaptive interactive skills outside of the group setting.

Homogeneous group settings, in which all members are diagnosed with DPD but are at various stages of recovery with clearly defined goals, tend to prevent the dependent client from getting "lost" in the group (Rutan & Stone, 2000). Although homogeneous groups are viewed by many counselors as remaining at superficial levels and never altering the core character structure, Yalom (1995) suggests that they do establish cohesion more quickly, provide for immediate support, have less conflict, and can provide more rapid relief of symptoms.

The dependent client's need for an authority figure is always at risk of being projected onto the MHC. In a group setting, this type of projection is greatly reduced. The group essentially refuses to reinforce the dependent client's helpless position by not filling the dependency needs since transferences are multiple (Carroll, Bates, & Johnson, 1997; Corey & Corey, 2002). Thus, the DPD client's need to be dependent upon an authority figure is diluted in the group setting since there are multiple individuals for the DPD individual to work with, none of which are a set authority figure.

Psychodynamic psychotherapy.

A central purpose of psychodynamic psychotherapy is to help clients cope better with previous separations and object losses: revisiting and properly resolving relationships in the past. The identification of transference is recognized as providing insight and plays a major role in revisiting and resolving the DPD client's therapeutic issues.

Perry's (1995) theoretical work recognized both long-term and short-term psychodynamic approaches may be effective in treating DPD. Long-term therapy promotes a greater dependent transference which can be dealt with in a way to promote emotional growth. On the other hand, short-term or time-limited dynamic psychotherapy has also been advocated as the treatment of choice for dependent clients. Sperry (1995) points to three conditions necessary for the success of this method: a circumscribed, dynamic conflict or focus must be present; the client must be able to quickly form a therapeutic alliance; and there must be little or no tendency to act out or regress to extreme dependency. Therefore, individuals with limited ego strength or greater degree of separation anxiety may benefit from an alternative method, such as a supportive treatment approach (Harper, 2004). Counselors should also prepare for countertransference contempt or disdain toward these clients, which often develop as a result of the client's dependency that develops upon the counselor (Benjamin, 2003; Magnavita, 1997).

Although there have been numerous studies on the efficacy of psychotropic medication in the treatment of DPD, clear support has not been established (Moore & Blackburn, 1996; Rector, Bagby, Segal, Joffee, & Levitt, 2000). Despite such findings, dependent clients' generalized help-seeking behaviors have resulted in physicians frequently prescribing medications in response to the client's persistent complaints (Tryer, Mitchard, Methuen, & Ranger, 2003). For example, in hospital settings, O'Neill and Bornstein (2001) found that dependent psychiatric patients received nearly 50% more medications than did nondependent patients with similar Axis I diagnoses. In general, time-limited approaches are seen as a starting point with dependent individuals but if the client has multifocal conflicts or fails to improve, either a long-term dynamic, supportive, or psychoanalytic approach may be more beneficial.

OBSESSIVE-COMPULSIVE PERSONALITY DISORDER (OCPD)

Etiology

Biological predisposition.

According to Millon and Davis (2000), no research evidence exists to support a contention that biological predisposing factors underlie OCPD. Although biological predispositions are not seen as a point of origin when searching for the roots of this personality disorder, environmental factors are suggested to play a major role. Based on his experience with these clients, Sperry (1995), for example, suggested the following as the primary etiological factors of OCPD: parental over-control, learned compulsive behavior, and a focus on perfectionism.

Environmental influences.

As children, individuals with OCPD experienced consistent parental over-control as well as strict disciplinary reactions for misbehavior or failure to meet expectations. According to Anderluh, Tchanturia, Rabe-Hesketh, and Treasure (2003), subjects who reported perfectionism and rigidity in childhood had significantly higher rates of OCPD and obsessive-compulsive disorder (OCD) later in life compared with subjects who did not report those traits. In addition, nurturance and emotional attention was minimal and did not often convey "soft" emotions, such as nurturing, loving, and supportive sentiments. Instead, the parent-child relationship was marked by deference for superiors. As a result, these individuals learned to avoid punishment by accepting and meeting the demands of perfectionist and punitive caregivers, with little emotional attachment to them (Sperry, 1995). Individuals who develop OCPD were never well bonded and failed to develop emotionally and empathically. In addition to an obsession with control and perfectionism, OCPD individuals would imitate behaviors modeled by caregivers, so as to try and ensure flawlessness, thus further ingraining their compulsivity.

Thus, the OCPD individual is taught to feel guilty if she or he falls short of perfection, and experience shame for exploring other options and alternatives beyond the expectations of caregivers. Individuals with OCPD find their source of stress and anxiety to reside in their need to present an ideal self to the world as contrasted with their actual self (Gibbs & Oltmanns, 1995). In order to avoid the fear of shame and guilt that is associated with falling short of perfect, OCPD individuals must foresee all dangers and possible slip-ups, forcing them to live in the future and focus on minute details. It is this preoccupation with the minutia that often results in the OCPD client's entrance into therapy. For example, in the workplace the OCPD individual is often diligent and hardworking, sometimes considered a workaholic, but can, and usually does, become over-involved in small details. This causes him or her to fall behind in work and lose sight of the overall purpose of the job. Chessick (2001) found that OCPD clients often seek treatment on their own because they are aware of their suffering.

Treatment

Cognitive-behavioral therapy.

Cognitive-behavioral therapy is well suited for OCPD clients and has been suggested, by several authors, as being accepted by them because it is structured, problem-centered, present-oriented, and usually requires limited emotional expression (Seligman, 1998; Beck et al., 2003). Since OCPD individuals may prefer a therapeutic plan that can be explained to them in a point-by-point, logical manner, cognitive-behavioral therapy materializes as a perfect match.

Circumstantiality, perfectionism, and ambivalence, prominent characteristics of OCPD, make the initial stages of therapy difficult and challenging. Open-ended questions, which are usually preferable in therapy, are not so productive with OCPD clients. Millon and Davis (2000) report, that emotions, for OCPD clients, are equated with being out of control and threatening, thus, reinforcing the desire for structure and boundaries. Sperry (1999) suggests the use of a "collaborative contract" to help raise the client's level of comfort with therapy. This contract establishes the goal, a method for achieving the goal, and role expectations of both the MHC and the client. A mutually agreed upon list of prioritized goals can keep OCPD clients working productively and minimize the chances of oppositional behavior. Tallis, Rosen, and Shafran (1996) recognized that general "triggering" situations for OCPD clients are related to authority, unstructured situations, and/or involvement in close relationships.

The OCPD client's maladaptive schematic beliefs may support the notions that they are never good enough and must always perform better, they must always be in control of situations and their emotions, and the dichotomous beliefs that if their performance falls short of perfect it is a failure (Benjamin, 2003). The process of changing these maladaptive schemas begins with collaborative exploration of the developmental roots of these schemas. The maladaptive schemas are then tested through predictive experiments, guided observation, and re-enactment of early schema-related incidents (Sperry, 1999).

In addition to affective self-awareness, OCPD clients have empathic deficits, or difficulty recognizing the feelings of others, thus, empathy training as well as interpersonal skills training may be helpful. Thought stopping (extinction) training is recommended by Sperry (1999) for the reduction of ruminative thinking.

Group therapy.

Benjamin (2003) highlighted the OCPD client's tendency to try to maintain complete control of every situation. Further complicating the situation is the OCPD client's tendency to avoid emotions; since the intensity of feeling cannot always be controlled. The OCPD individual may choose to talk about issues in group that do not reflect deep, personal concerns while dominating discussions in an effort to maintain control of the situation. The level of control an OCPD client displays, as well as his or her capacity to be empathic, seems to be the two main indicators of preparedness for group therapy (Yalom, 1995). If the OCPD client displays a high need for control and low levels of empathic behavior, therapy should be restricted to an individual approach until she or he is more prepared for an interactive environment where both the OCPD client and the group may benefit.

Combined with this need for controlling, or as Yalom (1995) calls it, "monopolizing" the group session, is the fact that the OCPD client is seemingly unaware of his or her interpersonal impact or of the responses of others. Other group members recognize this deviant position and they too are unable to develop empathy towards others. Eventually, the group may confront the individual on its own, leading to silencing the client or worse, resulting in early termination (Yalom, 1995).

Sperry (1995) pointed to heterogeneous group formats as a way of diffusing the intensity of the OCPD client's impact. The variety of personalities in a group create an atmosphere where multiple transferences may occur, increasing the likelihood of having a corrective family experience as well as engaging in reality testing.

Psychodynamic psychotherapy.

In the psychoanalytic literature, obsessional behavior is described as a fixation at the anal stage of psychosexual development; as a result, these client's are characterized as being anal-retentive (Chessick, 2001). This fixation is believed to have been caused by a rigid, impatient or demeaning attitude taken by parents regarding toilet training. Subsequently, the child may develop a harsh superego, ready to condemn him or herself for failures of all types (Benjamin, 2003; Gabbard, 2001; Kemberg, 1996). The uncertainty and insecurity that underlies OCPD clients have them seeking structure for situations without clear directives. Structure provides security because it allows clients to be planful, thus avoiding opportunities for failure. These individuals are also emotionally restricted because they equate the expression of emotion as being out of control, thus threatening (Seligman, 1998).

Traditional psychodynamic psychotherapy must undergo some modifications when dealing with OCPD. First, the MHC must take on a more active role so as to avoid an atmosphere of confusion and rumination. Sperry's (1995) experiences working with OCPD clients indicates that since free association tends to break down into discussion of insignificant, minute details, such an unstructured technique is not recommended. Instead of eliminating such a beneficial technique altogether, Sperry (1995) recommends that the counselor make periodic interruptions when associations become bogged-down in irrelevancies and avoidances as a way of breaking the cognitive focus on insignificant details. Second, a shift in therapeutic focus from the past to a more present-oriented method may allow the client to focus on experiences in the here-and-now, something that is often cut-off from his or her awareness. In so doing, the client may be able to challenge irrational fears of emotional expression and identify with the current experience.

There has been little empirical research concerning the treatment of OCPD, thus, most data is derived from generalized clinical experience (Barber et al., 1997). Barber et al. (1997) found significant decreases in OCPD symptoms when a longer term, supportive-expressive psychodynamic psychotherapy was used. Benjamin (2003) has suggested that brief interventions may be insufficient with these clients because personality reconstruction is viewed as the goal of treatment. Since it is difficult to involve OCPD clients in an unstructured, introspective therapy such as long-term psychodynamic therapy, a present and action-oriented approach may provide a more realistic format (Sperry, 1995). For this reason, short-term psychodynamic therapy that deals with particular issues and goals may be more suited for the OCPD.

In most cases, there are two main goals to focus on with this population. The first is to switch the client's impossible expectations for him or herself and others to be more realistic and, second, to realize that by relinquishing rigid, inflexible patterns of control they may actually feel more productive (Sperry, 1995). The second goal focuses on superego modification and may require a more long-term technique due to the change in character structure necessary to reach such a goal.

DISCUSSION

Conclusions

Cluster C personality disorders characterize three personality disorders that may be responsive to a variety of treatment techniques. Based on our review, we have seen how traditional and modified versions of cognitive-behavioral therapy, group therapy, and psychodynamic psychotherapy may be beneficial for the development of a more adaptive lifestyle for individuals diagnosed with AvPD, DPD, and OCPD. The anxious and fearful patterns that individuals with these personality disorders exhibit make interpersonal and independent living a daily challenge fraught with depression, angst, and panic. Therefore, it is of little surprise that their willingness and determination to change is high, making therapy a worthy option. Additionally, if the MHC is equipped with the skills to treat such clients with short-term techniques, the opportunity to make use of a time-limited intervention can be embraced. Messer (1992) introduced the concept of assimilative integration as a method for combining treatment approaches to maximize treatment outcome. This model builds flexibility into the treatment relationship, allowing the MHC to use whatever modality best suits the client's presenting problem and then introducing additional interventions in response to new evolving insights.

When many Cluster C clients do seek treatment, their underlying personality disorder is often undiagnosed (Sperry, 1995). It is common in the field to treat the more florid Axis I disorders especially when MHCs and their clients are faced with a limited number of therapy sessions (Eskedal, 1998). Unfortunately, the underlying maladaptive character structure that embodies the personality disorder may go untouched and untreated, inevitably leading to the re-emergence of another Axis I condition. Treatment of the underlying psychopathology is the necessary step toward achieving long-term personality change and positive social development. Consistent findings across many studies support a clear recommendation; standard brief treatments for Axis I disorders often fail when Axis II pathology is also present (e.g., Barber & Muenz, 1996; Markovitz, 2001). Therefore, the MHC may need to reevaluate the selection of treatment if there is limited progress within a period of brief therapy. A growing number of clinicians have embraced the idea that anxiety management medication should be considered in the treatment of Cluster C disorders of personality (Silk, 1996). The short-term treatment of Cluster C personality disorders is not only appropriate, but it is flexible enough to accommodate the regulations imposed upon treatment by outside forces such as health maintenance organizations that are concerned with time-limited remediation (Eskedal, 1998).

Cluster C personality disorders are treatable and those individuals who have them often present for help. Typically, defects in self-maintenance are reflected in the inability to self-soothe, experience self as real, develop self-esteem, and experience a sense of personal identity.

IMPLICATIONS FOR FURTHER RESEARCH

Despite the responsiveness to treatment and motivation to change that is common among individuals with a Cluster C disorder, empirical research on effective treatment methods for AvPD, DPD, and OCPD is limited. The implication this dilemma has for MHCs is that a population of individuals seeking help for symptoms related to personality disorders is often overlooked, ignored by researchers and eventually counselors. Empirical research on treatment of Cluster C personality disorders is limited and cross-cultural, as well as gender-related research on this subject is even more restricted; resulting in an inability to generalize conclusions drawn from the available literature.

It is imperative that more research be conducted on the effectiveness of short-term and long-term treatment methods for Cluster C personality disorders with attention paid to gender and diversity issues. With a better understanding of the responsiveness of individuals with Cluster C personality disorders, MHCs may better tailor treatment to the client's individual needs.

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Glen A. Eskedal is the chair and professor of Education and Human Services at Suffolk University. Jamie M. Demetri is a milieu therapist at Bournewood Hospital Correspondence concerning this article should be addressed to Glen A. Eskedal, Education and Human Services Department, Suffolk University, Beacon Hill, Boston, MA 02114. E-mail: [e-mail].