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:
- Inflexible, pervasive, and long-standing internal experiences
- External behaviors that are inappropriate to one’s culture and which cause internal distress or difficulty functioning
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.
Cluster B Personality Disorders
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.
- Borderline Personality Disorder is characterized by an unstable sense of self, unstable interpersonal relationships, and unstable emotions. These individuals fear abandonment and make frantic attempts to avoid it. They vacillate between idealizing and devaluing others. They have marked impulsive behaviors that can be harmful to themselves or others, such as spending, sex, substance abuse, reckless driving, etc. Frequently, there are recurrent threats or acts of self-harm and suicide. Chronic feelings of emptiness are common, as is emotional reactivity often manifesting in angry outbursts. Commonly, others experience a push-pull style of interaction with these individuals due to their intolerance of being alone, manifesting as anger and blame toward important others.
- Histrionic Personality Disorder manifests as pervasive and excessive emotional expression and seeking attention (i.e., support and care) from others in dramatic ways. These individuals tend to be uncomfortable when they are not in the spotlight. They often use their physical appearance to draw others toward them and tend toward inappropriate, sexually provocative behavior. They can be overly suggestible, shallow, and theatrical in emotional expression, and perceive relationships to be more intimate than they are.
- Narcissistic Personality Disorder is characterized by persistent grandiosity, lacking empathy, and excessive need for admiration from others. These individuals have an inflated sense of self-importance, are often entitled, and exploit others to satisfy their own desires. They tend to be arrogant and believe they are unique and misunderstood by ordinary people, and thereby need to associate with people of high status. They typically fantasize about unlimited success, power, beauty, and ideal love. Beneath their brazen self-confidence, they are very sensitive to criticism, humility, and shame.
- Antisocial Personality Disorder is a diagnosis reserved for individuals who persistently disregard and violate the rights of others. They tend to be deceitful, manipulative, irresponsible, aggressive, and impulsive. They lack remorse and often rationalize their harmful actions. (NOTE: we don’t often work with individuals with Antisocial Personality Disorder at Open Sky, as they typically do not respond well to our relational model.)
My Therapeutic Approach
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 as an Intervention
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:
- Hiking and backpacking
- Bow-drill fire making
- Yoga, meditation, and other mindfulness practices
- Teamwork to complete group tasks and chores
- Managing one’s personal belongings
- Living outdoors under self-constructed shelters
- Processing interpersonal conflicts as they arise
- Supporting and challenging each other emotionally
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.
Parental Support
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!
Successful Intervention
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.
References
- Glasser, W. (1998). Choice Theory: A New Psychology of Personal Freedom. New York: Harper Collins.
- American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th). Arlington, VA: American Psychiatric Publishing.
- Torgersen, S., Myers, J., Reichborn-Kjennerud, T., Røysamb, E., Kubarych, T.S., & Kendler, K.S. (2012). The heritability of cluster B personality disorders assessed both by personal interview and questionnaire. Journal of Personality Disorders, 26(6), 848-866. https://doi.org/10.1521/pedi.2012.26.6.848
- Prochaska, J.O., & DiClemente, C.C. (1983). Stages and processes of self-change of smoking: Toward an integrative model of change. Clinical Psychology, 51(3): 390-395. https://psycnet.apa.org/record/1983-26480-001
- Stoffers, J.M., Völlm, B.A., Rücker, G., Timmer, A., Huband, N., Lieb, K. (2012). Psychological therapies for people with borderline personality disorder. The Cochrane Database of Systematic Reviews, 8(8). https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005652.pub2/full
- Shapiro, F. (2012). Getting Past Your Past: Take Control of Your Life with Self-Help Techniques from EMDR Therapy. New York: Rodale, Inc.
August 18th, 2020