Treating Emerging Cluster B Personality Disorders in Wilderness Therapy
Kirsten Bolt, MEd, LMFT | Senior Clinical Therapist | Adolescent Girls
People with personality disorders historically have been misunderstood and pathologized as having character faults. In reality, it’s not that one has a “broken” personality, as the name might suggest. Rather, this diagnosis typically results from childhood coping strategies that eventually become entrenched behavioral and emotional patterns if not otherwise interrupted. Individuals who don’t believe their needs will be met positively often gravitate toward unhealthy actions to meet those needs, resulting from a fragile sense of self and low emotional resilience. If these behaviors become more fixed in one’s persona over time, the result is a personality disorder.
Personality disorders are characterized by:
One’s genetic profile can also be a factor in developing cluster B personality disorders and a difficult life situation(s) can trigger development. These triggering situations might include traumatic childhood experiences, attachment issues, or intergenerational behavioral patterns, for example.
There are currently ten personality disorders recognized by the American Psychiatric Association in its Diagnostic and Statistical Manual of Mental Disorders (DSM). These disorders are clustered together by similar behavioral patterns, though the clusters are not entirely distinct. “Cluster B” disorders include narcissistic, borderline, histrionic, and antisocial personality disorders, which are categorized due to their dramatic, erratic, or emotional commonalities.
A significant number of my adolescent female students at Open Sky have what we call “emerging cluster B personality disorders.” Full personality disorders are typically not ascribed to teens, as they are in the process of identity formation and development. In rare cases, the patterns of behavior are so clear in minors that they might be given a full personality disorder diagnosis—usually for the sake of receiving necessary mental health support.
Below, I describe each Cluster B personality disorder to distinguish its traits using the criteria from the DSM-5.
At Open Sky, we combine copious observation on many levels: social, familial, academic, personal, interpersonal, psychiatric, emotional, physical, etc. We often combine these observations with a professional psychological evaluation to deepen our understanding of how to best support each individual, as well as psychiatric assessments when necessary to explore psycho-pharmacological support.
While each person is unique, there are a few common practices we utilize to support students with emerging Cluster B personality disorders. When one first arrives at Open Sky, the initial priorities are stabilization and assessment. We begin by sorting through the surface behaviors and distractions to access the true underlying issues. In this way, I often feel like a detective, weeding through what is real and what is distraction. We help students develop insight into why they are here, coach them to manage overwhelming emotions, and encourage them to engage in the program.
The next step is helping these students move through the precontemplation stage of change, in which they either don’t see the problem or blame others for the problem. Typically, individuals with personality disorder traits do not see them as clearly as others do. They require consistent, compassionate confrontation and firm, loving boundaries to develop self-awareness and motivation to change. Because we authentically care about our clients, we can help them begin to experience hope and the belief that they are worthy and capable of change. Additionally, basic program elements intrinsic to living in wilderness with an intimate peer group provide inherent opportunities for students to develop emotional resilience, healthy interpersonal relationships, and self-efficacy.
In addition, I am highly skills-focused in my approach. We teach clients at Open Sky many principles of DBT (Dialectical Behavior Therapy), which continues to be recognized as one of the more effective treatment approaches, particularly for borderline personality traits. Many of my students come to Open Sky with prior DBT experience, often saying it wasn’t helpful and they don’t want to use it, or they might be able to recite the myriad skills but not apply them when needed. With these students, I can be covert with the DBT approach, sliding skills into daily programming, and simplifying the sometimes-confusing approach. With students who loved their prior DBT experiences, I will use that language with them to convert skills they already have into practical interventions – teaching them how and when to use them. And for some individuals, there might be an underlying traumatic experience(s) needing to be addressed, so I sometimes begin working with them using EMDR (Eye Movement Desensitization and Reprocessing).
Wilderness therapy is a unique and highly effective setting for helping this population because we create a contained and supervised microcosm of the home environment. Students with emerging Cluster B personality disorders show their problematic behavioral patterns so clearly in this environment, allowing us to address them on a daily basis. Therefore, these students have the opportunity to experience success beginning in the early stages of treatment in wilderness therapy. In addition, they are living a healthy lifestyle (exercise, sleep, diet), are engaged in a therapeutic process, and are free from substance use and other unhealthy behavioral patterns (e.g., promiscuity, self-harm, disordered eating, spending, phone and internet use). In this unique setting, we are able to provide an incredibly thorough assessment process, help clients stabilize, create motivation for change, and start the healing process.
The basic programming of Open Sky Wilderness Therapy helps clients develop self-efficacy, interpersonal effectiveness, and emotional resilience through activities such as:
Wilderness therapy offers many opportunities for unique and creative interventions. While we have an agenda for each day, we are also flexible and can alter the plan at any point to address personal and interpersonal issues occurring in the moment, a level of intervention that is nearly impossible to replicate in more traditional therapeutic environments. Our field guides and therapists collaborate to facilitate unique and personalized challenge activities throughout the week, empowering students to put the skills they’re developing into practice, foster identity strength, and nurture healthy relationships.
Once students acknowledge their underlying problems and start experiencing success by interrupting their unhealthy patterns, they tend to build momentum. They start to feel and express tremendous relief and gratitude at seeing a way forward that was previously unfathomable. I find such satisfaction and enjoyment in working with this population for this reason.
As a program that emphasizes systemic change, we also work extensively with parents and the greater family system to facilitate more lasting change. Just as we do with the student, we spend the first few weeks assessing the needs of the family system and exploring potential areas of growth for parents to address. Often, parents also struggle to manage difficult emotions, feel hopeless and unworthy as parents, and get stuck in futile interpersonal patterns with their children. We offer them the same set of skills their children are learning, thereby providing the family with a common language and skillset for improving communication and relationships. We coach parents in letter-writing, family phone calls, and Family Quest™ workshops in person with their child.
For anyone connected to someone with an emerging or developed cluster B personality disorder, you probably feel some mixture of loving them intensely … and struggling at times to like them, to manage your own emotional reactions to them, and to stay connected in relationship with them. We provide education about personality disorders and work to instill hope. Contrary to the old perspective of personality disorders, there is hope! People can change!
Most of us don’t change until it is too difficult not to change. Wilderness therapy provides such an environment.
In addition to the change process begun here, we help families develop long-term plans for success, as these personality traits tend to take time to effectively address. To be clear, success at Open Sky is not the absence of the problems with which one arrived. It is acknowledgment of the problems, awareness of the negative impacts on oneself and others, increased readiness for change, and sometimes just hope that change is possible. Success also typically includes better connection with one’s family and other important relationships, motivation to seek additional support, and engagement in the recovery process. Over time, the therapeutic benefits individuals make in wilderness therapy become more and more irrefutable, supporting them to feel hopeful, proud, and capable, eventually leading to internalized change.