Personality Disorders

• Accelerated Learning and Positive Templates by Francine Shapiro, 8/4/97
  
  

In response to Dr. Shapiro's request for a map of "sequential increments of attainment," I suggest that a way to think about the increments is in the gradual transformation of the client's black and white splitting into an ability to see gradations of gray. I believe that much of this can happen using EMDR by processing distortions in self and object representations as the client projects them onto actual events that occur in his or her life. Narcissistic disorders, however, do not respond to this process the way other disorders do.In response to Dr. Shapiro's request for a map of "sequential increments of attainment," I suggest that a way to think about the increments is in the gradual transformation of the client's black and white splitting into an ability to see gradations of gray. I believe that much of this can happen using EMDR by processing distortions in self and object representations as the client projects them onto actual events that occur in his or her life. Narcissistic disorders, however, do not respond to this process the way other disorders do.

James Masterson lays out a sequence of steps necessary for treating a personality disorder, and I think the stages he identifies are among those I would suggest as a model for the therapist using EMDR with personality disordered clients. For any therapy the first step is establishing a rapport and a minimal level of trust between therapist and client. This is not to be confused with therapeutic alliance, which sometimes takes years to establish.

Initially clients go to a therapist for the therapist to do something that will make them feel better. Especially people with personality disorders are not focused on underlying character pathology, but on a symptom from which they want relief. They usually see the problem as originating outside themselves. Rarely do people with a narcissistic disorder, for instance, come to a therapist for treatment of the narcissistic disorder. Narcissistic clients feel bad because they were passed over for a promotion or their husband or wife has left them, and they feel deflated, depressed, a failure and don't know what to do about it. More often than not, independent of the therapist, these clients will rebound from whatever painful event has occurred, reconstitute themselves, feel like their old selves again and terminate therapy, their objective achieved. By most standards, this scenario must be considered a therapeutic success.

Dr. Shapiro's question, however, is about treating the underlying personality disorder. To do this clients must be motivated to address their underlying disorders. Clients must understand that the solution to their problems come from inside themselves rather than from manipulating their environment. Usually, before clients become focused on their underlying disorders, they must be educated about their patterns of repetitive maladaptive behavior and how these are related to the underlying disorder. In the context of the standard phases of EMDR treatment, this comes under the heading of treatment planning after history taking. I believe that for most people with narcissistic disorders under the age of thirty five this step will not be possible to achieve. Even if they are able to see clearly how their internal problems play out in their maladaptive behavior, they will not be able to hold that vision; once they begin to feel better, they will not be sufficiently motivated to stay in treatment. At best their treatment will be episodic, revolving around the periodic disappointments or failures that they encounter.

I would place "motivation" and "rapport" as two essential first steps in treatment. These do not necessarily involve EMDR. Sometimes, however, a client with a personality disorder hears about magical cures of the effects of single incident traumas in two or three sessions and wants to be similarly cured of his or her long-standing depression. After two or three sessions, when the magic has not worked, those people usually become discouraged and see EMDR as a source of failure, rather than a magic source of healing.

The next step in treatment of personality disorders in general is establishing a therapeutic alliance, a shared purpose between therapist and client of identifying and processing the internal sources of the client's dysphoria. I think EMDR can play a bigger role in this stage by reprocessing traumatic memories and maladaptive beliefs related to painful memories. Because EMDR is able to isolate specific traumatic experiences or maladaptive beliefs with extraordinary precision, these clients are usually able to experience some of these changes without having to take on deep-rooted issues. My experience has been that clients feel empowered by their progress in resolving even small issues, and they feel more confident that they can tackle their deeper issues. They also come to view me as someone who can help them to be successful in their personal exploration; they see that I accept them without judgement, that I am able to provide structure for them when their memories are overwhelmingly painful, and that I can help them feel successful in their adaptive reprocessing of early life events and hopeful about future success. There is nothing more convincing that change can come from within than the experience of just that. In these ways EMDR facilitates the development of trust and a therapeutic alliance.

The next step in Masterson's scheme is the working through phase. I believe that EMDR can again be very useful in this phase. As the deep memories come to the surface the affect associated with them is intense. EMDR can have a similar accelerating effect on the processing of these memories as it has on deeply painful childhood memories of physical or sexual abuse. Using EMDR allows these memories to be processed more rapidly and completely so that the periods between sessions are not as painful for the client as they traditionally would be.

Too often in traditional therapy, clients are expected to wade through intensely painful memories without any external structure. The justification for this that I have most often heard is that external structure would encourage passivity in the client. This has not been my experience. I am convinced, and I believe there will be increasing support for my position from results of neurobiological research, that for many clients splitting is anchored in brain chemistry; in the negative part of the split the left hemisphere of the brain, the part responsible for language and reason, becomes inactive. Studies have shown this to be true for clients with Post Traumatic Stress Disorder, and I believe it will also be shown to be true for many personality disorders. For those clients, it is unreasonable for a therapist to expect them to access the painful memories which trigger negative splitting and then to effectively process them when the part of the brain they need to do this has become unavailable to them. EMDR provides a tool to help clients break through this impasse. Certainly a clinician must be alert to the possibility that his or her intervention will contribute to passivity on the part of the client, although with adequate care this possibility can be avoided.

I would call the next stage in this process "reentry." It includes helping the client to adapt to a world that he or she now sees in a very different way and which he or she knows very little about. Those things which people normally learn about intimacy and relationships while growing up must now be learned by the adult client and I believe it is entirely appropriate for the clinician to monitor this process and provide information when necessary. Here the EMDR process of installing future templates is very useful. Clients can imagine situations which are likely to arise and process them using EMDR so that they can identify issues that still need to be processed and they can feel fully prepared to face the actual situations.

A final phase is termination, which brings up any separation issues that have not yet been fully resolved. Actually, I have rarely seen a traditional psychotherapy case study in which this phase appears to be completed. EMDR should be useful in this phase, but time will tell if EMDR therapists are any more successful with this phase than therapists in the past.

• Narcissistic Personality Disorders by Philip Manfield, Ph.D., 8/26/97