Personality Disorders: Separating Myth from Fact Part 2

Personality Disorders: Separating Myth from Fact Part 2

Last week we presented the first part of my interview with Rachel McMurray, MA, LMFT, who specializes in working with cluster B personality disorders. The following is the second of three parts of my interview with Rachel. I hope you continue to find the information personally and professionally valuable!

Ashleigh: What is it like to work with this population as a therapist?

Rachel: It is 100% qualitatively different than working with other populations. It is challenging, never boring, and for me it’s exciting because I like meaningful conflict and I like working with a challenging and emotionally charged individual. Their minds fascinate me. Many people are drawn to the aberrant or fringe elements in society like serial killers or stalkers, and more often than not these are people with personality disorders; serial killers often have antisocial personality disorder and most of the well-known stalkers through time would qualify for borderline personality disorder. I have the privilege of getting to know them and seeing the intricacies that make-up who they are and how they operate in the world. For example, I was working with someone diagnosed with histrionic personality disorder who expressed feeling confused about “what to do with my face” in social situations, like what facial responses to use. We were able to identify her issue not as a lack of understanding social cues, but to a lack of interest in what most people have to say if it’s not about her or exciting to her. She only pretends to listen and then has to pretend to respond with concern. It’s a different side of humanity.

As a therapist working with personality disorders, I’m always on my toes. You have to be really on it. It’s a specialization that requires very strategic interventions and tools that demand that you’re 100% on your game. For the most part, there’s no relaxing and no chit-chat; everything you do has to be strategic. Every conversation is a discussion with the personality disorder and not with the person; they don’t talk TO you, they just talk. At the same time that you’re engaging with them, you’re having a conversation with yourself; you’re plotting, monitoring, assessing. You hear what they’re saying but are always looking underneath for the real message, analyzing. Content is not important, it’s all about process – what your body is feeling in reaction to theirs and always keeping the work contained within the treatment frame. Each session needs to be conducted through the personality disorder lens.

Unlike many other forms of therapy that involve collaboration and going on a journey together, working with personality disorders demands that the therapist is the “bigger dog in the room” so to speak. You establish alpha through solid rapport and then buy-in from the client. I hold a strong treatment frame (boundaries), am directive, and when necessary, will be blunt or what some might call “harsh” for a therapist. It’s essentially authoritative parenting in that I have absolute unconditional positive regard for my clients, or I wouldn’t work with them, but I will also be firm with them because of this care; I am not a “paid friend” as I like to say. I definitely adore them, and I care about them because I know that even though they can hurt people that they’re not monsters. Sadly, a lot of people think they are, that they act the way they do just to hurt people. I think it’s important to remember they’re just people and their brains are wired differently.

You’re always working on rapport knowing that you’re going to have to say certain things that they do not want to hear. I establish during this process that I am the expert and am very direct, clear, and precise because they will not listen or stick around very long otherwise. If you specialize in this area you typically don’t have a big practice or at least limit the amount of them you will work with at one time because they require a lot. Being seen as the “bigger dog in the room” or “the expert” is important because they know they’re not going to hurt my feelings as they do with most people in their lives, that I can handle them, and thus I’m going to stick with them and help them get better (not abandon). I educate them on their diagnosis constantly because knowledge is power, and they have to do the true work here, be active participants in their care (as with all therapy). I can’t do the work for them, aka enable them, or they get sicker and it doesn’t teach them anything.

You have to constantly be their observing ego, which is important because you’re trying to teach them how to observe their own ego. Role-modeling this processed of detached self-observation is key; taking accountability for your own missteps when warranted. You have to practice self-reflection between sessions (and during if possible). If you notice a misstep, you have to let them know and process it together to maintain their respect. As mentioned above, if they respect you and see your services as valuable (buy-in) they are more likely to stay in treatment. This is key because they do not typically like staying in treatment altogether, or at least in one specific setting for long. A caveat is that they may stay in treatment for the purpose of having a captive audience and/or a (false) sense of intimacy (difficult to achieve in their outside lives), but they will not be able to do core work specific to their disorder. If they are not challenged, they’ll stay. I am not that therapist. What we do is really hard work, so for continued successful treatment, I have to keep that really strong treatment frame and actually give them something they can work with.

Essentially, I’m holding up a mirror and they are being faced with the fact that most of their struggles begin and end with them; not a fun process to say the least, which makes me, according to my adolescent clients, “Rachel the Ruiner”! I know all that sounds intense, but my goal is to help them change instead of just sitting with them and taking their money, so to speak. I’m challenging their core beliefs and sense of self and helping them to see the hidden agendas they use to navigate the world. That said, I am a Rogerian therapist so I always, always, operate from a client-centered perspective and show unconditional positive regard for my clients. These “tough love” interventions do not work from any other framework. In addition, I don’t get escalated and react to their level of emotionality and/or provocation with the same. I’m locked down on every level. When they’re first experiencing this response and baiting me via defense mechanisms (calling me names, deflecting, etc.), I respond with something neutral like “I hear you and I understand that you’re suffering.” I can empathize vs. apologize unless I agree that a breach occurred, and repair is needed. The difference is crucial during those moments. I have years of data backing up my premise that the ones who can tolerate this specific work get better, and the ones who cannot tend not to. Those who drop out early see me as the “perpetrator” and themselves as the “victim”, referencing The Karpman Triangle and Transactional Analysis (key education). They’ll often then go on to find another therapist who may not see the underlying personality disorder or is less challenging than I am, and I never judge that choice despite my concern that the personality disorder will continue to run their lives and possibly become stronger.

Ashleigh: What would you want people with a personality disorder to know?

Rachel: They need to be taught how to be good to those who are good to them, to not take advantage of others, and to stop assuming that they’re more important than others and that other people need to know this. Again, while personality disorders are not curable, they are definitely treatable, and I’ve seen that it’s absolutely worth the effort to make some changes. However, some people with personality disorders will fare better in treatment than others.

Dr. Lester shares 10 signs of treatability that serve as indications that improvement is likely. I read these to clients to help inspire hope because they often come into therapy feeling fairly hopeless. These 10 signs include:

  1. The ability to form a relationship with the therapist
  2. High intelligence (except antisocial personality disorder, which makes prognosis worse)
  3. An unusual talent (this often leads them to value themselves and provides for an enjoyable hobby)
  4. Being attractive (draws in social support)
  5. Obsessive or compulsive traits below level of OCD/OCPD (e.g., organized, conscientious, aware)
  6. If substance abuse history, they’re in treatment or recovery (very important)
  7. Motivated (it’s hard work and they need to stick with it for a successful outcome)
  8. They can talk about their own weaknesses (fairly rare, but it happens as treatment progresses)
  9. They can trust and/or be loyal (major factor that prevents many from attending)
  10. Ability to weigh contingencies (people with borderline personality disorder often struggle here)

One of my clients recently shared that she told someone else, “if you met my therapist, she’d kick your ass and you’d have no idea who you are anymore. She’ll ruin your life, but in the way you need her to.” I felt that summed up life as a personality disorder therapist well (laughs). I’m here to make big changes. People with personality disorders should know that they need an overhaul. It’s intense and it’s hard to tolerate. It’s painful because their whole world, their whole self-concept, shifts. It’s pretty incredible to see when it works, and I really love it.

Check-in next week for the third and final part of my interview with Rachel McMurray, MA, LMFT to learn more!

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