Therapy

Histrionics rarely seek therapy for a variety of reasons. First, because our society confuses appearance and essence, high-functioning hysterical personalities readily find reward for good looks and charm. Implicitly or explicitly, they always have a source of rewards. Moreover, because their emotions are more authentic, hysterics are more likely to experience the subtle but nagging feeling that something is missing from life rather than full-blown depressive episodes. If their primary relationships remain solid, they may convince themselves that nothing is really wrong. After all, how could things go awry if all the technical indicators of house, car, and kids all look so good? Second, the more severe somaticizing variants have appropriate sources of attention: the care of their immediate family and the medical community. Because somatization is an unconscious mechanism, this subtype will not seek therapy directly, though they may be unsuccessfully referred. After a breakup, these individuals are usually found in the emergency room with mysterious symptoms or pain. When the couple reunites, the symptoms disappear. Third, histrionics who seek therapy do so mainly in hopes of finding immediate relief for anxiety or depression. Therapy requires introspection and objectivity, both of which are threatening or boring to histrionics; accordingly, when symptoms seem to remit somewhat, they move on. Finally, the demographic trends operating in psychotherapy run counter to what histrionics naturally prefer as their source of attention and support. As more and more women become psychologists, more and more female histrionics are deterred from therapy because they view women not only as contemptible but also as competitors with motives similar to their own. Rather than seek counsel with the enemy, female histrionics naturally seek male therapists.

Therapeutic Traps

Therapy always involves potential unseen problems. For the histrionic, two complicating factors are particularly important to recognize. First, histrionics secure attention and approval by being charming and entertaining. Although they may seem emotionally forthcoming at first, their pseudo-intimate maneuvers betray a secret wish to simply find someone who will take care of them. The same pattern is likely to manifest in therapy. Because histrionics project omnipotence onto prospective mates, unaware therapists are particularly vulnerable. Supportive work comes naturally to many therapists and provides a good starting point for most cases once the patient's histrionic personality has been recognized.

For the patient, however, support can easily indulge pathological neediness. Here, the therapist may lose sight of the client's questions while reflexively dispensing emotional resources and falling prey to the wiles of the histrionic. Eventually the therapist feels drained of attention, support, and nurturance, as is expected, because that is how most individuals eventually experience the histrionic. Not surprisingly, this is the very pattern that therapy must divert; otherwise, when issues of termination arise, histrionics may shift from a demanding to a desperate dependence, featuring flairs of illness and manipulative suicidal gestures. As the client becomes more infantile, the therapist becomes more and more of a magical savior.

Whereas the first complicating factor is primarily interpersonal, the second contains two related themes that originate with the histrionic's feelings of incompetency. Over the course of normal development, most individuals acquire skills that enable them to survive as adults. In contrast, histrionics were reinforced for being attractive, not for developing valuable instrumentalities. As such, histrionic women frequently have a distorted impression of the female role in that their greatest fear is to be less feminine and unattractive—an inevitability for women who engender qualities beyond their appearance. Therefore, independent capacity equals differentiation between self and caretakers, which equals separation. In therapy, the implication is that getting better somehow entails hostile termination. The belief is that if they improve, the therapist may become angry and abandon them. Only slightly different from this is the requirement that therapy focus on the histrionic. Most therapists try to set goals with their patients; however, because histrionics want to be perceived as attractive, they may suggest goals that they feel will be alluring to the therapist (Fleming, 1990). Fortunately, these goals are often easily recognized, being vague and stereotypic of how therapy is portrayed in the media.

Strategies and Techniques

The need for attention and approval with the inappropriate sexualization of interpersonal relationships potentially manifests in therapy. Somehow, therapy must help histrionics give up the manipulative, demanding, and desperate dependence that causes them to orchestrate every social interaction. If subjects could simply be taught adult competencies outright or if their self-esteem could be magically raised, the problem would be eminently treatable. As with all personality disorders, however, the therapeutic mission is complicated by the tightly knit nature of different aspects of the personality, which serve the same functional purpose. In the histrionic, for example, a diffuse, impressionistic, distractible cognitive style merges with the need to keep the self protected from any reflection on its grave vulnerabilities. What is superficial is also protective. If this passive form of nonperception fails, repression is always at the ready.

Accordingly, the usual goals of therapy, which include making the unconscious conscious and producing a deep corrective emotional experience, run up against the needs of the histrionic style.

Writing from a cognitive perspective, Fleming (1990) suggests that histrionics must first learn to focus their attention. Given their flighty thought patterns, a detailed agenda can be invaluable, not only in terms of structuring long-terms goals but also in bringing order to a single session. Otherwise, patient and therapist may become distracted by tangential themes without problem solving anything in depth—talking about everything but doing nothing. Such is their style. Many are content to talk away the hour by reviewing every emotional nuance of their intersession activities. Fleming suggests that a brief period of time be set aside for this, if necessary.

Moreover, he suggests that it is important that goals be desirable to the patient, who may otherwise become threatened or bored and quit, but also reasonable for the pursuit of therapy. Goals that promise more immediate gratification can help keep subjects in therapy while helping them focus on one thing at a time. As noted previously, histrionics want to please their therapists, so it is important that their goals be their own. Globalized items can be further broken down into subgoals by asking patients how their purpose might be achieved. Introspection can be linked to reward by asking them how they would change were their goal achieved and why they chose a particular goal rather than something else. The act of thinking about and setting goals is conducive to identity development. Focusing also helps histrionics learn to identify automatic thoughts and confront impulsive tendencies, though unlike patients who naturally tend to ruminate, histrionics are not likely to record thoughts in a diary without repeated prompting and examples. Because this can be unstimulating, histrionics can be encouraged to write vividly and to challenge dysfunctional thoughts with dramatic defiance.

Interpersonally, histrionics often define themselves in terms of the individuals to whom they are attached. As noted in Benjamin (1996), the development of a personal identity that transcends relationships is a major objective. Assertiveness training can be used to help patients constructively put forward their own thoughts and agendas, rather than seduce others into solving their problems for them. Instruction in active listening skills, paraphrasing, and reflection can be instrumental in helping the client learn to pay more attention to the feelings of others (Turkat, 1990). Focusing on such previously unexamined matters, including major identity choices in adolescence (Benjamin, 1996), often helps integrate past experiences and sets the foundation for recognizing repeating patterns and their futile consequences. For example, many histrionics flit from relationship to relationship, without ever establishing a sense of security that they so much desire. Insight into relationship patterns should lead to less childish coping behaviors as well as greater levels of personal independence.

In addition, patients should understand that their theatrics and sexualization, particularly manifested in group social situations, signal an intense underlying desperation (Benjamin, 1996). If the subject makes this connection, dramatizing behaviors should become ego-dystonic, increasing motivation to change and, therefore, the likelihood that histrionics will remain in therapy long enough for change to occur. Many histrionics experience anxiety when they are no longer controlling the action as the center of attention. Mixing the interpersonal and behavioral, graded exposure may be used to delay enacting impulses to seize social center stage and to tolerate increasingly long periods during which attention is directed at others. Whether these goals are reasonable and whether they are successful depend on subjects' level of insight, which in turn depends on their level of object-relations pathology. More infantile subjects are more impulsive, more egocentric, less able to see themselves in context and, therefore, less able to understand how they perpetuate their own problems. In such cases, it is almost impossible for therapist and client to develop an alliance against the patient's maladaptive behavior patterns. Benjamin, for example, suggests that therapy begin with warmth and support but not indulge a position of neediness. What the therapist supports is change, seeking an alliance with the patient against patterns that perpetuate old problems.

Finally, the psychodynamic perspective assumes that problems have an origin in early family dynamics. Again, excessive dependency is seen as the unresolved unconscious. Fortunately, unconscious patterns of relating are repeated in the transference relationship, where they can be brought to the attention of the subject and related back to childhood dynamics. If the therapeutic relationship is sexually charged, a connection can be drawn between seductive in-session maneuvers and the subject's relationship with potential partners in general. If the therapeutic relationship is one of sexual competition, a relationship can be drawn between contempt for the therapist and the contempt that histrionics feel toward similar others, generally. Any such attempts to induce insight must wait until the therapist-client relationship is solid. Even so, many therapists find themselves frustrated by histrionic pseudo-insights or dramatized episodes during which the subject claims to suddenly understand or put the whole picture together, which are somehow forgotten by the next session. A brief period of review at the beginning of each session helps establish continuity across time and defeat tendencies toward distractibility, diffusion, and, especially, repression of previous gains. Histrionics need high praise for self-reliant and nonsexual behaviors, the reverse of their psychodynamic childhood pattern.

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