Last week we presented the second part of my interview with Rachel McMurray, MA, LMFT, who specializes in working with cluster B personality disorders. The following is the remaining portion of my interview with Rachel. I hope you continue to find the information educational and valuable!
Ashleigh: What tips would you give someone with a personality disorder who is seeking treatment?
Rachel: I want them to know two things: They’re not bad people and their condition it is treatable. It’s the brain, wiring, and not about morals and/or personal ethics. It’s really important that they seek out a therapist who specifically specializes in treating personality disorders. That doesn’t mean those therapists will approach it the way I do, but it is important that the therapists are able to conduct an effective assessment process and separate out differential diagnoses. They should also be familiar with DBT, psychodynamic work (specifically savvy working with transference/countertransference) and other established effective approaches for personality disorder treatment.
Medication is rarely effective because we are not talking about a chemical imbalance here. It can be helpful for comorbid issues, like depression or anxiety, or symptoms of the disorder itself, like obsessive thinking, but it won’t help or cure the personality disorder itself. Most psychiatrists do not seem to know that medications are not highly effective in treating personality disorders and are often unaware or misinformed about personality disorders overall. It’s important to help inform clients about what to expect from their meetings with their medication providers and to educate them about important aspects of their medications, like compliance and risk factors (clients tend to engage in dangerous behaviors such as going off meds “cold turkey” and not communicating openly with their physicians). Coordinating care with psychiatrists is quite important as well.
Early intervention is essential. Thus, it is incumbent upon the support system to be aware of presentation and work with the provider(s) to create a strong container and non-judgmental stance, to seek out education vs. engage in blaming and cut-off. There is not a “too early.” These disorders are pervasive and enduring, like having normative personality traits on steroids, so it’s helpful to identify this difference to detect identification. Support people will ideally get them in for treatment as soon as possible.
Dr. Lester offers a good metaphor to explain how treating personality disorders is qualitatively different than treating those with other diagnoses. Metaphor: If you see a car and the car is smoking, it demonstrates that something is wrong. You pull up the hood and the engine is on fire so you need to get it fixed. Someone with a personality disorder will have a similar presentation with the car smoking under the hood, but this time you pull up the hood and there is no engine. The engine is the observing ego, something most well-adjusted people possess or are able to access with the aid of traditional therapy. In this case, you are creating the “engine”, installing it, and teaching them how to maintain engine/car functions for the long run. He goes on to clarify that when the clinician hears their words coming from the client spontaneously (with or without recognition that it came from therapy), one knows the engine is securely in the car and the client is working to maintain it. Sometimes you see regression as a result of stressful life events because the personality disorder is always there to some degree and thus clients are influenced to a higher degree by environment than an average person (aka diminished ego strength). This explains in more clarity why medication doesn’t work; the neuronal pathways are missing (the engine, so to speak), so we have to create a new neuronal structure vs. adjusting what is there.
Ashleigh: What do you think is the biggest mistake therapists make when working with people with personality disorders?
Rachel: Therapy with individuals who have personality disorders should not be collaborative. Again, the therapist must respectfully and consistently show that they are the bigger dog in the room, showing the client they can lead and that the client’s attempts to self-lead are not working (redirecting the grandiosity that is often apparent and destructive). The client with a personality disorder does not possess inner wisdom/insight about themselves. Again, they do not have an observing ego, and in addition, they do not have many adaptive traits or a variety of traits altogether. Each type of personality disorder centers around one dominant trait used for problem-solving, engaging, and this limits their ability to move through life smoothly. Hence, therapy is not a shared journey. The therapist is more like a surgeon and the client is the surgical patient until the latter phase of end of treatment. This phase is indicated when the individual has learned how to take care of themselves and prevent further self-destructive and interpersonally destructive behaviors.
I see the majority of my clients once a week because I do not want them to develop a dependence on me as their therapist and I don’t want them to feel too comfortable. Again, we are not friends; boundaries are essential for positive results/therapeutic retention. More frequent interaction makes it harder to maintain boundaries as you develop more familiarity. They need time outside of session to do the work and practice skills. However, if the presentation is severe (especially in matters of safety), the client has been struggling for years, and/or they strongly endorse needing more than one session per week, I’m likely to offer it if I agree that it’s in their best interest.
Last, therapists need to know that teaching DBT (dialectical behavior therapy) skills is not enough. I don’t personally find workbooks/classes alone to be sufficient for lasting change. I prefer the process work blended with the DBT tenets of pointing out dialectics, teaching/practicing mindfulness, distress tolerance skills, and engaging in role-play to increase interpersonal effectiveness. I do not communicate with clients outside of session unless it’s an actual emergency. If they abuse that privilege, we talk about it, and they eventually might be released from treatment if they can’t stay within the guidelines. I find it enables them and encourages their “victim” narrative, encouraging a continued lack of accountability to themselves and others. Excessive communication/rescuing makes these clients sicker, so to speak, and more dependent on treatment vs. themselves and outside support. I’m not doing my clients any favors by colluding with their idea that their problems are due to the world and not a result of their own behaviors. Additionally, a lack of boundaries tends to cause therapist “burn out” and thus causes problems in client care.
Ashleigh: In what ways do family, friends, and work-related factors negatively impact people with personality disorders?
Rachel: Anytime psychosocial stressors go up, functioning goes down. It’s hard for them to remember how to properly maintenance their engine and this kicks off episodes of regression, or flares as I like to call them. Again, structure is hugely important; i.e., showing warmth, support, and boundaries. They have difficulty recognizing their limits and engaging in appropriate self-care. In many cases, they’re lacking social support and effective problem-solving and self-care strategies. These are things support people can teach and model.
In terms of employment stressors/influence, there are definitely fields that are generally not stabilizing for those with cluster B disorders. These include the entertainment industry, mental health work, law, the medical field, and politics. These fields are unfortunately inundated with sufferers of cluster B personality disorders which is extremely problematic because it enables their narrative of being the exception to the rule, having absolute power, and having to use the extreme emotionality that comes naturally. They do not necessarily need to change careers, but treatment can be useful in adjusting how they perceive these roles. To beat a dead horse, these are treatable disorders and these clients are as worthy of treatment as any other population.
Ashleigh: How can family and friends best provide support for people with personality disorders?
Rachel: They often need their own support from a therapist. Most therapists, even if they don’t specialize in personality disorders, can help support someone who is being affected by a loved one’s personality disorder. They need to be taught about boundaries and self-care. They need to know the difference between support and enabling. It can take a devastating toll on families. I often refer to Al-Anon, individual therapy, or bibliotherapy, such as the book Walking on Eggshells. I encourage them to do research and focus on educating themselves.
It’s key that they maintain low reactivity. Basically, do not take the bait! Taking the bait makes it worse because they’re buying into their agenda and proving them right, increasing mental and physical behaviors. It’s hard to do/maintain because they’ll get push back, but it’s essential to stay neutral. That doesn’t mean they can’t have feelings or should ignore them, it’s like responding to a child having a temper tantrum. You want to be ready to talk when they calm down but getting reactive doesn’t calm them down and only makes the situation worse. Natural consequences are fair and should be consistently enforced. Effectively interacting with people with personality disorders really is quite similar to authoritative parenting; balancing boundaries with compassion. Do not let them hold you hostage, do not let them run the show and be careful about setting a healthy example to the best of your ability.
Judgment has to go out the window for family, friends, and practitioners. The question isn’t if the clients are right or wrong, it’s whether their personality disordered behaviors work for them. Our job is not to jump into their narrative or validate their disordered behaviors/perspectives. Keep in mind that it’s usually not actually about anything outside of themselves; that’s the hidden agenda. They’re going to try to make it about you because that is less painful than looking in the mirror and taking ownership, but it rarely is truly personal. If it is, take accountability, make amends, and move on.