Treating Histrionic Personality Disorder

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Individuals with Histrionic Personality Disorder (HPD) may enter treatment via the criminal justice system or through self-referral. Because of their interpersonal skills and inclination to seek approval through pleasing others, they may initially look like the proverbial "dream client." However, these individuals usually are seeking relief from a crisis in their lives and the accompanying depression. Once the depressed mood is lifted, motivation for change is eliminated or greatly reduced. Turkat (1990, pp. 74-75) is pessimistic about achieving fundamental change in the histrionic personality structure because once the motivation for therapy is gone, change is usually unwanted and treatment is terminated.

Even so, individuals with HPD often have substantial strengths that can be utilized to make progress in treatment. It is not particularly necessary to achieve depth of character or durability in the face of tedium or long-term responsibility. These individuals can thrive in settings and activities that are in harmony with their personalities so long as their value system is not corrupted and they do not engage in illegal behaviors that will ultimately result in negative consequences in the criminal justice system.

Medication Issues

Individuals with Histrionic Personality Disorder should be treated for any concurrent Axis I disorder (depression, anxiety). When this is not needed but cluster symptoms are noted (affective instability or cognitive disorganization) the use of serotonergic blockers (atypical antipsychotics) can be helpful (Sperry, 1995, p. 111).

As with all of the personality disorders, the specific features of HPD can affect compliance with medication. Individuals with HPD may respond to the side effects of various medications with an intense and dramatic overreaction (Ellison & Adler, Adler, ed., 1990, p. 59). Also, medication may not be needed by these individuals but may well be requested. Drug-seeking behavior is a significant issue in the histrionic personality disorder. Refusal to prescribe medication may result in a dramatic scene with the service providers attempting to set limits.

Treatment Provider Guidelines

Early in treatment individuals with Histrionic Personality Disorder may see the therapist as "the all-powerful rescuer who will make everything better." The style of histrionic clients can be very appealing; dramatic renditions of experience can be quite absorbing and amusing (Beck, 1990, pp. 220-221). These individuals often attach easily to service providers, but the attachment is shallow. They are often more concerned with an impressive appearance than substantive identification and resolution of problems. They seek interventions that relieve acute emotional distress and initial motivation and cooperation may be followed by poor dependability (Donat, Retzlaff, ed., 1995, p. 51).

Treatment may be viewed by individuals with HPD as an opportunity to socialize. Treatment providers are seen as valued sources of admiration, attention, and support (McCann, Retzlaff, ed., 1995, p. 147). On the other hand, individuals with HPD are prone to impulsivity and angry tirades with explosive comments. Most of this is outside of awareness and confrontation usually results in denial, resistance, and an unwillingness to be introspective (Craig, Retzlaff, ed., 1995, p. 80). Treatment must involve confrontation of and management of demands for social contact outside of the treatment setting, sexually provocative behavior, and continuous avoidance of relevant issues. Clear treatment goals, focusing, and limit-setting are important for clients with HPD (McCann, Retzlaff, ed., 1995, pp. 147-148).

It is difficult to fully understand clients with HPD because of suppression, repression, and dissociation. These individuals may be aware of their problems but they have difficulty recognizing the manifestations of, or the reasons for, abnormality in their behavior. Unable to accept responsibility for their failures, they tend to blame others (Kantor, 1992, p. 249). The best contribution treatment providers can make to clients with HPD is the confidence that they have the capacity to make competent adult decisions and are capable of accepting responsibility for their own behavior.

Countertransference Issues

Treatment providers may be drawn into a countertransference position of being entertained and enjoying the excitement generated by clients with HPD. These individuals will often communicate to treatment providers that they are idealized, all-knowing persons who have helped their HPD clients to make large and significant strides in treatment in a short amount of time (McCann, Retzlaff, ed., 1995, p. 147). It may be enticing to believe in this rendition of the clinicians' therapeutic effectiveness only to discover that there is little genuine treatment progress.

On the other hand, individuals with Histrionic Personality Disorder can interact with others in a way that actually robs the others of their self-esteem. This happens via the continuous pressure to view these individuals as attractive and appealing. This moves others, including treatment providers, into the admiring observer position. By definition, the anonymous people in the audience are less interesting or exciting people than the beautiful people holding forth on the center stage. The impact is both subtle and cumulative, leaving the people interacting with individuals with HPD inexplicably unsure of themselves. Service providers need to be aware of the potential for esteem-devaluation or their own defenses will be triggered.

Countertransference with clients with Histrionic Personality Disorder may also include defensive distancing and infantilization. It can be difficult to attend respectfully to what feels like pseudoaffect; the self-dramatizing quality invites ridicule (McWilliams, 1994, pp. 314-315).

continue: Treatment Techniques and Goals

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Reviewed: 04/2006