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Real World Clinical Blog: In The Realm of Personality Disorders

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by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way

     Upon preparing to release the DSM 5, there was a large push to shift the way that we think about personality disorders. Rather than understanding the personality disorders as discrete, the hope was that we could move toward thinking about personality disorders as more complex and dimensional. Essentially, the argument was for more dimensional thinking regarding personality disorders. It seems that instead of personality disorders occurring in discrete categories, there is a tremendous amount of overlap between disordered characteristics.

     Without taking too much of a stance on this either way, I want to share some thoughts on how deep work with personality disorders can feel. I also want to address the ways in which one can identify the presence of a personality disorder.

     As social workers, we are loathe to identify personality disorders, because they have long been deemed as untreatable. This is certainly not my experience. However, the identification of the presence of a personality disorder does seem paramount to the possibility of its subsequent amelioration.

     First, let me be clear. I am largely referring to a few different personality disorders in this post: narcissistic, borderline, histrionic, and obsessive-compulsive personality disorder. These personality disorders can best be diagnosed by the studying of one’s own countertransferential response to a client. There is a distinct experience in the countertransference that arises in working with personality disorders. 

     This experience is the byproduct of the developmental arrests in the psychological development of the client. Because personality disorders are largely born out of a failure to maturate, individuals who struggle with them don’t typically have a fully formed sense of self. The fragmented self is held together by a body, but not the mind. Instead, the mind has several distinct entities that the self is not fully comfortable with. The entities that bring the most discomfort, like self-hatred or misanthropy, end up entering the relational environment and often get lodged in the mind of the clinician. The entities that bring the most comfort, like grandiosity or self-righteousness, become inflated in the presence of others, while the others work to metabolize the more difficult aspects of the self.

     From a countertransferential perspective, this means that we can become quite encumbered by the psyches of our clients. During sessions, we might feel confused and disoriented. We often experience tremendous self doubt about our word choices and interventions. In the presence of a person with a personality disorder, we often feel most swayed to bend our boundaries and to shift the frame. We leave sessions feeling hung over. This hangover can lead to the presence of our clients in our unconscious minds, often entering our dreams and distant thoughts.

     The most difficult part of our work with personality disorders is that we are often left with profound feelings of self hatred. These feelings of self hatred are frequently defended against, by individual therapists and agencies as a whole, by dismissing more personality disordered clients as manipulative, incurable, and taxing. 

     So, what is going on when we are working with a client with a personality disorder? Simply put, people with personality disorders feel lost within their own minds. Their minds don’t seem to make coherent sense and are often intruded upon by unwelcome thoughts and feelings. In order to try and regulate these thoughts and feelings, the fragments get launched into the environment and breed in the minds of others. This is why you might go into a session feeling okay and leave a session feeling absolutely horrible, but you are unclear about why or what even happened. A psychological transaction occurred that allowed for the self regulation of the client, at the expense of square footage in the mind of the clinician. 

      What makes all of this more difficult, unfortunately, is what differentiates someone with an Axis 1 disorder from someone with an Axis II disorder. These feelings and thoughts feel completely true and real at all times. For example, someone with major depressive disorder (an Axis I diagnosis) might have extreme disgust at their lack of motivation. However, the lack of motivation bothers them and it feels like something that might not be a fixed aspect of who they are. When someone with an Axis II disorder experiences a lack of motivation, this becomes the entire lens through which they understand themselves.

     Furthermore, while environmental circumstances increase the intensity and furor of Axis I symptoms, Axis II symptoms often persist regardless of environmental relief. In fact, sometimes more supportive environments can make symptoms worse, because one’s sense of self is so distinct from how the supportive environment feels. This means that as we increase our offerings of empathy, our clients can become enraged with us and work to destroy our relationships with them.

     Very simply put, each personality disorder bleeds into the next. However, there are some tell-tale signs of the specific realm you might be operating in.

     Here are some great countertransference clues.

     When working with obsessive compulsive personality disorder, you will likely feel:

     This is because: Obsessive compulsive personality disorder is defined by a collapsed sense of right and wrong and is supplanted by an overactive superego that leads the client to operate in an almost constant sense of shame. This shame is only regulated by extreme attention to rules and boundaries and the excessive regulation of those around them.

     When working with borderline personality disorder, you will likely feel:

     This is because: Borderline personality disorder is characterized by an unwieldy sense of self. The client shifts between extreme feelings of confidence and loathing. Clients feel vacillating distrust in themselves or in their relationships, always struggling to hold ambiguity and complexity.

     When working with narcissistic personality disorder, you will likely feel:

     This is because: Narcissistic personality disorder is characterized by an unending crisis in the sustaining of an even level of self esteem. Most relational decisions are made in the service of regulating one’s idea about one’s own goodness.

     When working with histrionic personality disorder, you will likely feel:

     This is because: Histrionic personality disorder is most characterized by an inability to regulate the level of importance of internal and external stimuli. Every feeling and life event is experienced with the same level of intensity and fear. The client will work diligently to alert you to these crises, hoping to feel less alone in the management of these experiences.

     Uniting all of these disorders are several themes:

     The central treatment tenets for working with personality disorders are: the careful studying of countertransferential data, predictable and constant boundary setting, a guarding against the settling in fragments from the client’s mind into your own, extensive use of supervision, and a steady belief in the possibility of treatment serving to help maturate the mind of the client, allowing for a solid experience of one’s self. 

Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. Read more of her clinical perspective and tips on the most burning questions of developing clinicians in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.

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