Effective Treatment of HPD?

Very new here. Have read many victim accounts of the incredible pain and suffering resulting from contact with HPDs. Those are exceptionally good, the descriptions and detailed accounts are extremely enlightening! A large audience of victims reading the posts can find excellent examples and gain a total feel for the eerie but similar patterns of pain and turmoil.

Likewise, victim readers can benefit from the collective recorded wisdom stored here on how to go about separating oneself from the chaos of dealing with a HPD, and ultimately recovering from that exceptionally negative and difficult situation, all from a victim’s prospective.

Still I can’t help but feel that more wisdom might be cumulated here on what works to actually reduce, mitigate or completely eliminate HPD altogether.

I’m incredibly impressed with KontrollerX’s “HPD Frequently Answered Questions” and in particular his four really outstanding book suggestions:

1. Emotional Vampires by Albert J. Bernstein
2. The Personality Disorders : A New Look at the Developmental Self and Object Relations Approach: Theory - Diagnosis - Treatment by James F. Masterson
3. Hysterical Personality Style and Histrionic Personality Disorder by Mardi Jon Horowitz.
4. Hysteria by Christopher Bollas

As a newcomer I’m wondering if there are any great prior threads, authors, or leads to materials that actually work in treating the disorder?

For instance, has anyone been through the 2x weekly psychotherapy sessions for at least a year as promoted by the Personality Disorders Institute (Cornell University Medical College / Otto Kernberg)? http://www.borderlinedisorders.com/

Has anyone taken the time to personally work through the Structured Interview of Personality Organization they have posted as a way to start out and get one’s head totally focused where some problem areas might originate? http://www.borderlinedisorders.com/mental-health-professionals-index.php#stipo

The following study compares the clinical effectiveness of three different types of psychotherapy and goes a long way toward proving the effectiveness of their (and other’s) therapy techniques.

Clarkin, J.F., Levy, K.N., Lenzenweger, M.F., & Kernberg, O.F. (2007). Evaluating three treatments for borderline personality disorder: a multiwave study. American Journal of Psychiatry, 164, 922-928

Note – all throughout Kernberg’s work and the Personality Disorders Institute at Cornell Medical they talk about “borderline personality organization” and treatment. However that concept, the way they define it, is much, much broader than BPD itself, and fully encompasses HPD.

One of the key “mechanisms” of change in treating people that they have really documented as “counting” seems to be a rather dramatic expansion in the persons capacity for “Reflective Self Function” (roughly, “being able to sit still for a while and reflect inside your head analytically about your self and your relationships with others”) for more on that specifically look at the descriptive paragraphs in:

http://www.ahealthymind.org/library/Attachment%20and%20reflective%20function--%20Their%20role%20in%20self-organization.pdf

How about HPDs and Nons alike – does any of this stuff actually work, strike a cord, make any sense?

I know HPD is difficult to resolve and often there simply is no solution at all, especially when the HPD just doesn’t see any need or reason to change. However in those “golden” situations where there is an opportunity, a ray of light and the fortitude to trudge though a long tunnel, what is the best advice (even anecdotal) that can be given on what actually can reverse this stuff?

Imagine this forum was giving advice to a bright, promising psychiatrist intern (not me, sorry) that was extremely disciplined, very motivated, and very long-term oriented, one who was going to see a patient population made up exclusively of people suffering from HPD, for his entire career – one's that showed up at his door with the full disorder but at least a glimmer of hope and some recognition that their interpersonal relationships were indeed problematic, and they actually desired change – what would the advice here be for him to read/study/think deeply about? Any books, articles, stories, techniques, trainings, anecdotes, or really any stuff that finally made even a small “break through” for HPD sufferers? All leads very much appreciated!

Hi. lt's very late and l'm rather tired, so l can't reply to your post in detail, but l have had psychotherapy and recovered to an extent. My recovery is very tenuous, three steps forward, two back. lf you read through my posts you will get a bit of an idea of where l am coming from. lt's an ongoing journey, which will never stop. The people on this forum have been a great help and support to me.

I can't speak to psychoanalytic approaches, because my wife would do anything short of chew her own leg off to avoid therapy.

As a partner, I can confirm that (at least in my own case) my wife went from 'crazy' to 'sometimes hard work but always rewarding' when I started a combination of:

• Setting firm, fair, very well enforced boundaries.
• Learning about $#%^ tests, understanding them, and passing them instead of failing them.
• Working on my own enmeshment issues. I still see the roller coaster but I'm not on it, and now I can give her the emotional stability she needs to control the ups and downs.
• Becoming far more assertive, taking the lead in our relationship.

All that stuff is necessary to some degree to have a healthy relationship with any woman. It's essential if you want even a chance at a healthy relationship with an HPD.

(Note: It doesn't guarantee the relationship will last, obviously. Truly pathological HPDs can't get past the first step, because they're literally unable to respect others' boundaries and as such, any healthy partner will leave them and probably initiate 'no contact'.)

Hi, Tattered Knight. l am literally falling asleep at my lap top but this thread is interesting. I would agree with most of what you say, but not necessarily "taking the lead" in a healthy relationship - far better for it to be give and take with necessary compromises! ln a HPD relationship, l can't comment, as l do not know what it is truly like for a man to be in a relationship with a histrionic woman, although reading the threads has given me some insight into the pain the nons go through. HPDs are stuck in a stage of development, with issues that must be worked through before they can grow and mature and in some respects they are like children emotionally, in which case structures and boundaries are necessary, although one has to be careful not to be patronising in enforcing them. CBT is an effective treatment for histrionics who are motivated to change. l am glad you are aware enough to be aware of enmeshment,which can cause a person to beccome entangled in the drama.

Hi Janey. Just to clarify what I meant by 'taking the lead' - I don't mean "taking complete control'. Both partners have an equally important role in making joint decisions, but those roles are different, despite the current feminist assertion that the only difference between men and women is what's between their legs. What seems to work best is the man makes a preliminary decision, then the woman can either accept, or offer an alternative. The man makes the final call which of the two alternatives to take, based on the woman's input. For really important decisions, a few more rounds of debate are usually useful, but for the myriad small day-to-day decisions, this routine decisiveness is part of what the man brings to the relationship. I'm not saying that the woman *can't* make these decisions, just that both of them seem to be happier when the man takes that responsibility (while still giving the woman an equal say).

As for HPDs being stuck at some point in their emotional development (usually seems to be early- to mid-teens), this is true, but they're living, growing human beings just like anyone. I believe that given the right environment, they can re-start and continue that emotional growth. In some cases, there's enough emotional damage to need CBT or similar therapy but I think in many (most?) cases, it may be enough to simply give them the same healthy environment that they should have had in their teens. Loving, safe, secure, but with firm boundaries and with no enmeshment problems, where they will be called on their $#%^ if they step out of line. Basically they need you to be "the grownup" in the relationship, at least a little bit.

I can't really prove this yet but when I say my wife's leaps and bounds ahead of where she was a year ago, I don't just mean the superficial stuff. She's now taking responsibility, making genuine apologies when she knows she's been out of line, doing things for me (massages, hot drinks etc.) that she'd never have done before. I can't take responsibility for all of it, by any means, but I do know there was a clear correlation there: When I fixed myself, she started fixing herself.

Hi Tattered Knight. Think we will have to agree to differ about your first paragraph. l would say that clear negotiations and compromise are important factors in a healthy relationship, irrespective of gender. lt may be that you are a naturally assertive person and this is what works best for you, but no two relationships or dydnamics are the same and dthey cannot be generalised. Anyway, can we agree to differ on that point? What you said in your second and third paragraphs is very true. ln many respects histrionics are like wayward teenagers, and in my case, events that occurred during my teens effectively caused me to be stuck at that stage. Teenagers require clear boundaries and a firm but fair approach. ln many cases, the HPD will not have had clear boundaries during the formative teenage years, when identity is becomming established, maybe because of a lack of discipline from permissive parents, or because of controlling and abusive parents. ln my case, my mother died during those years and l suffered repressed and "complicated" grief. Your posts add a valued input to the forum and l admire your insight about the dangers of enmeshment. It is important to be able to detach sufficiently to remain objective. and to not become embroiled in the game playing and the drama.

Ps - Would you say that your partner has more insight into herself as a result of the boundaries that have been put in place?

I agree that it's not for every relationship. I've just found that since I stopped being such a 'pleaser' and started being more assertive, the arguments we used to have about what to do in the evenings, where to go, what to have for dinner, etc. have completely stopped. She loves it when I take charge (although if I'd described it to her a year ago, she'd have called me a controlling asshole... ), and she knows that if she doesn't like a decision she can always object and unless I have a good reason not to, I'll go with what she wants. It's not a case of me pushing things on her, just me giving a clear decision as a starting point. Either way, that's how my marriage works now, and it's great for us. Your mileage may vary.

I'm glad you found my experiences with enmeshment to be helpful. I'm still working out exactly how much each of the changes I've made have helped, but I'm starting to think that that's one of the biggies, on par with well-enforced boundaries.

I totally agree about the need for the HPD partner to "take the lead". When you have a histrionic personality you are always the one to be doing the talking. Taking the lead. My biggest turn off is going for dinner with someone and me dominating the conversation. There is nothing more refreshing than someone not letting me dominate the conversation. Them taking the lead. I have imediate respect for them.

Janey, TatteredKnight, Sofrance – thanks very much for posting! The “real world” bridge here is really fantastic.

Janey (and any others?) since you specifically mentioned CBT I’m following up with some of the best reference stuff I have in that area for HPD. If you have any direct experience, would love feedback on any therapy you personally find helpful or a waste of time.

Others – on first blush the CBT stuff simple, quick and clear cut – get in there, attack those maladaptive schema and get the reprogramming job done (see below)… Do you think parts or all of this CBT stuff are on target? Any ideas on how to extend, adapt, really get after HPD with CBT? Any way to really immerse a HPD quickly at “seeing the light” and get to relief and self-responsible behavior quickly?

TatteredKnight – very much appreciate your comments and prospective! Would very much love to know much more detail on the $#%^ tests. “Learning about $#%^ tests, understanding them, and passing them instead of failing them.” How about some specific examples of $#%^ tests? Even the name itself, “$#%^ test,” certainly speaks volumes on how they must be exceptionally trying to the uninitiated! Also, how about some details on how do you pass a “$#%^ test”? Any great writes ups from past posts? Please spill!

All – strikes me as TatteredKnight knows his limits of what he is willing to tolerate in terms of bonding with a HPD, and for him it works well! Looks like to maintain some sanity amidst the chaos some limits and a contract need to be established “up front” in dealing with a HPD. What are the limits? When you see HPD how do you strike “the contract” And when the terms are tested or crossed, do you have any other option than full exit with no looking back? Warnings, second chances? Is a best effort good enough? Tolerance? Fall back?

The whole limits topic is indeed fascinating. When you look at the typical psychotherapy techniques used today to treat HPD, they cover a wide range. There is the simple supportive, “hand holding” - sometimes referred to as weekly psychological dialysis – just a soothing emo band-aid to get through to the next week’s session. The therapist doesn’t really do anything other than support the patient. They in essence are merely receptacles for their patients to dump their emotional load off onto each week, with no real goal or promise of substantive long-term change. Limits are not really part of this type of therapy. You go as long as you need, dump as much as you want, as often as you need to, and can afford. Can Non’s be expected to provide this type of emo “dialysis”? Over time its exceptionally draining. However, lucrative, steady income for some therapists.

Other therapists start out by being very direct with a patient, and HPDs might just love that! "I will be your knight in shining armor coming to your emotional rescue. You will be mine, you will be mine, all mine." – Rolling Stones). This would initially appear to be TatteredKnight’s approach. However later, once trust develops you might find that same therapist pulling back the emo support and doing everything humanly possible to rid the HPD of all dependent personality traits and force the HPD to stand up on her own two legs (albeit with some genuine empathy this time around…). Any thoughts on how that might work? Can you swoop in, do a rescue and then later (gradually, over time) wean the HPD over to more “mature” independence?

Also very much on my mind - can a Non work collaboratively with a HPD effectively over time and effect real relief, or is a professional always required? Non’s have so much more contact time, and so much more live, real-time behavioral data to work from. (On the order of 100x or more!) Psychotherapists have great training, have studied disorder patterns, and have focused experience, but they are exceptionally expensive (many times not covered by insurance or subject to limits and high deductibles). Plus, a psychotherapist only has what the HPD voluntarily tells them, verbally (and what they can soak up nonverbally.) They also only operate off-line in non real-time, whereas a Non can catch things right in the moment.

Sorry for being long winded, but hopefully some nuggets here.

How about an eval of these CBT techniques? Are they / could they be effective? Can they be applied by Non’s and Psych’s equally well for the long term benefit of the HPD or do they work only for one or the other? Again, thanks for all the fantastic first person accounts!

***

All Sperry references are to “Cognitive Behavior Therapy of DSM-IV Personality Disorders. Highly Effective Interventions for the Most Common Personality Disorders” By Len Sperry, 1999

Any in-line comments in [brackets] are my own. Bold and underlines are also added.

Generally speaking, the underlying schemas involve a self view of needing to be noticed by others, and a view of the world as a provider of special care and consideration because life makes them nervous (Sperry & Mosak, 1966)

In CBT “schema” are very engrained beliefs and actual thought patterns. However they are thought to be somewhat “plastic” – that is, with lots of observation, data, reflection, conscious thought, it’s felt that maladaptive schemas can be changed permanently. The “plastic” can be re molded with “heat, pressure and a new form to be forced into.” However, absent that significant cognitive effort, the patterns remain the same.

Per Sperry, most frequent maladaptive Schema in HPD…

The entitlement/self-centeredness schema refers to a core set of beliefs that one is entitled to take or receive whatever is wanted irrespective of the cost to others or society
(Sperry, p 153)

The essential feature of this schema is the belief that one is entitled to whatever one wants irrespective to the cost to others or of what might be regarded as unreasonable. This Schema is likely to develop in the context of parents who overindulge or who do not encourage the child to develop self-responsibility. Alternatively, this schema can develop as a compensation for feelings of deprivation, social undesirability, or defectiveness. Subsequently, individuals who develop this schema tend to be self-centered and have an exaggerated view of themselves and their rights. They also tend to have significant empathic deficits and tend to treat others carelessly.
(Sperry, p 31)

Entitlement/self-centeredness schema that must change (see techniques below) to get relief specifically are:

“I’m interesting and exciting”
“Intuition and feeling are more important than rational planning”
“If I’m entertaining others won’t notice my weaknesses”
and, particularly,
“To be happy I need other people to pay attention to me”
(Sperry, p 155 citing Beck, Freeman & Associates, 1990)

Beck, A., Freeman, A., & Associates (1990) Cognitive therapy of personality disorders. New York: Guildford

Per Sperry, the second most frequent maladaptive Schema in HPD (and no others are cited)…

The emotional deprivation schema refers to the core set of beliefs that one’s need for nurturance and emotional support will never be met by others (Sperry, p 153 which refers to Bricker, Young & Flanagan, 1993 and Young, 1994)

Bricker, D., Young, J., & Flanagan, C. (1993) Schema-focused cognitive therapy. A comprehensive framework for characterological problems. In K. Kuehlwein & H. Rosen (Eds.), Cognitive therapies in action. Evolving innovative practice (pp 88-125). San Francisco: Jossey-Bass

Young, J (1994). Cognitive therapy for personality disorders: A schema-focused approach (rev. ed.). Sarasoda, FL: Professional Resource Exchange

The essential feature of this schema involves the core belief that one’s desire for a normal degree of emotional support will not be met by others. Individuals who have internalized this schema tend to be deprived of nurturance, protection or empathy. Deprivation of nurturance involves an absence of attention, affection, and warmth from others. Absence of strength, direction, or guidance from significant others leads to deprivation of protection. In the absence of understanding, listening, self-disclosure, or mutual sharing of feelings and experiences with others, these individuals experience deprivation of empathy. These individuals have usually experienced some emotional neglect in early childhood. They may present as cold, demanding, or withholding, and tend to choose significant others who are unwilling or unable to provide emotional support. [wow, that last phrase about the mates doesn’t sound like the typical Non here…] (Sperry, p 27)

Entitlement/self-centeredness schema that must change (see techniques below) to get relief specifically are:

“I’ll never get enough love and attention”
“I’m only capable of having superficial relationships”
(Sperry, p 155 citing Young 1994)


How to specifically effect change

Could use help interpreting these – Again Sperry in italic, my comments in [brackets]. Any real world examples? Anecdotes? Other ideas to meet the above objective of getting the maladaptive schemas change without snapping back?

HPD and outside helper work … collaboratively to understand the development roots of the maladaptive schemas.
[Involves a trip back to early childhood where the root of the problems seem to be found. However CBT also seems to downplay spending too much time in the past – seems much more interested in reprogramming cognition in the present. My suspicion is the trip to psychoanalyze the past with CBT is indeed brief.]

These schemas are tested through:
[“Tested” is not a mild term here. I think the Non/Psych goes after these “falsehoods” with a vengeance! However what is presented to the HPD is extremely incremental – only building upon what they can handle at the time. A bit more each time, and always backing off at the first sign the HPD is overwhelmed with “nervousness”. I could be wrong here, but the ego strength (sense of self preservation) of the HPD is always taken into account. ]

[On the other hand “total immersion” seems to work in teaching languages, going “cold turkey” in rehab, etc Ideas on how hard and fast to get after the maladaptive schema with a HPD?]

predictive experiments
[I’m guessing - the Non predicts in advance for the HPD how she will act in an upcoming situation. Later, noting the uncanny accuracy in which the Non foretold of the future the HPD begins to see the light and believe…put more earnest effort into changing to the new reality, etc.]

guided observations
[Non “guides” the HPD to see actual examples of the maladaptive schema in action, going from the above generalities down to very specific behavior observation and reflection? Likely, over time, this eventually results in the HPD themselves using much more personal Reflective Self Observation (see prior post in this thread for an intense reference)]

reenactment of early schema-related incidents.
[I’m not sure here I know how far back into childhood CBT typically goes? Perhaps all the way back to childhood where the early injuries took place. Then, really “role play them out again”? Back then you were a child and couldn’t even begin to understand what happened to you. Now that you are an adult you have full faculty to see what happened, interpret it correctly, and start to change the imprint that it surely left on you.]

Finally, histrionic patients are directed to begin to notice and remember counterschema data about themselves and their social experiences.
(all above techniques in italic - Sperry, p 155)
[Instilling the counterschema seems to be critical. The implication seems to be that fallback is exceptionally easy. The key is to build up a powerful “body of evidence” (heat and force) that is actually retained in current memory (and not discarded, repressed, ignored, etc) so it is accessible to “real time” decision making, even specifically under times and situations that produce high levels of emotional stress / nervousness. Therefore, going forward, making new, better behavioral choices in real-time. That’s what Sperry seems to be driving at with “remember the counterschema data”…]

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