Efrain Bleiberg, M.D.

Studies of adults with "dramatic" or cluster B personality disorders -- e.g., antisocial, narcissistic, histrionic, and borderline personality disorders -- document that the developmental trajectory leading to maladaptive patterns of coping and relating is shaped by an array of risk factors, including neurobiological vulnerabilities and adverse childhood experiences.

Some of these individual's minds and bodies have been damaged by the destructive intrusions of physical and/or sexual abuse. Others are burdened by neuropsychiatric vulnerabilities, such as mood disorders or attention deficit/hyperactivity disorders. Yet, regardless of the degree of adversity or genetic vulnerability, children who are at risk to develop a dramatic personality disorder seem to share a striking incongruity -- an uncanny sensitivity and reactivity. Thus, their "dramatic" quality to other people's mental states, paradoxically coexisting with remarkable self-centeredness and utter disregard for other people's feelings.

One moment they can be engaging and appealing, the next moment, however, their capacity to manipulate others and their rage, demandingness, and self-destructiveness become overwhelming.

The incongruous coexistence of exquisite sensitivity and brutal lack of concern for others offers clues to the developmental disruptions leading to dramatic personality disorders -- and of the factors that protect other children exposed to similar adversity and vulnerability.

At the heart of these developmental factors is the process of mentalization -- the capacity to interpret and respond to human behavior (that of self and others) in human, meaningful terms. Mentalization allows children and adults to "read" other people's minds and grasp the mental states underlying human behavior. The exercise of this capacity promotes a number of critical developmental achievements:

• The sense of agency or "ownership" of one's own behavior.
• The capacity for social reciprocity and empathy.
• The ability to regulate one's affects, to tolerate frustration and to set one's own goals and ideals.
• The capacity to symbolize.

The crucial maladaptive strategy on the path to dramatic personality disorders is the inhibition of the capacity to mentalize in response to the normal cues for attachment -- i.e., experiences of pain, vulnerability or distress. The strategy may be particularly likely in children with an exceptional disposition to mind-reading whose signals of distress evoke terrified or terrifying responses and misattunement.

When children inhibit their capacity to mentalize, they "loose" the ability to relate to others in a mutual, interactive manner. Instead, their behavior becomes coercive, and aims at evoking stereotypical responses from others that fit children's expectations. Thus, some abused children become proficient at evoking abusive responses while some children who experience disruptions in attachment develop an astounding ability to elicit rejection. Children and parents and other adults, such as teachers and clinicians, become entrapped in coercive cycles of interaction that greatly increase the odds of maltreatment and leave everyone feeling out of control.

As part of the research for my book, Treating Personality Disorders in Children and Adolescents, I reviewed the developmental, clinical and prevention literature to identify the key steps of effective intervention.

1. Treatment of these children requires the "secure base" of a collaborative relationship between parents and treaters. Such collaboration results from emphasizing the importance of interrupting the cycles of coercive behavior; of promoting parental competence, control and mentalization; of providing targeted pharmacotherapy to address dysregulation of arousal, cognition, affect and/or impulse; and ultimately, of promoting a "mismatch" between the children's expectation of parental incompetence, insensitivity and abuse and parents' enhanced capacity to provide support and set limits.
2. A "mismatch" between children's expectations and changes in the environment makes individual psychotherapy productive. The first goal of psychotherapy is the development of a collaborative relationship. The following steps aim at achieving this goal:

1. Avoid confronting vulnerabilities, linking past and present or addressing highly defended internal states
2. Promote verbalization of internal states and convey a view of the children as intentional beings by clarifying their communicative intent
3. Help the patients save face and gain a sense of control and effectiveness (see Case study: Robert).
4. Enhance self-control by promoting mentalization. First, these children need to learn to observe their own emotions without becoming overwhelmed. They need help to understand the relationship between their behavior and internal states, first by focusing attention on the circumstances which lead them, for example, to become aggressive when they feel misunderstood or anxious. Therapists introduce a mentalizing perspective focused both on the children's mind as well as on the mental states of others. The aim is to create a context in which it is safe to experience internal states as mental states rather than concrete actions (see Case study: John, below).

 

1. Children enter an advanced stage of therapy when they can tolerate their attachment to their therapist, as evidenced by their seeking help to find adaptive solutions to day-to-day problems. At this point the treatment is fostered by the exploration of the motives behind maladaptive behavior. Therapists must acknowledge the adaptive function served by maladaptive behavior -- how it has helped them feel safer, less lonely -- while recognizing the tremendous courage needed to relinquish such maladaptive behavior.

 

This review only outlines the demands of carrying on a treatment process with these children and their parents. Clinicians who can withstand their own reactions and help parents and children deal with their own efforts to oppose change are better able to establish a true collaborative relationship. Such collaboration grows from an understanding of the courage children and parents require to relinquish a painstakingly achieved adaptation and face instead the terror and pain of becoming alive in a fully human way.

The treatment model presented here seeks to create the conditions under which coercive cycles and inhibited mentalization can evolve into healing and sustaining connections supported by an enhanced capacity for mentalization.

Dr. Bleiberg is Senior Executive Vice President and the Alicia Friedman Professor of Psychiatry and Developmental Psychopathology of Menninger. His most recent book, Treating Personality Disorders in Children and Adolescents (2001) was published by Guilford Press.