Reliance on Primitive Defenses

Decreased autonomy and increased mutual interdependence are both normal and expectable as people grow old. In older age, people come to need and rely more on others, need more actual care, and need to cooperate more with this care. Interdependence and cooperation requires the ability to relate reasonably well to others and to be able to tolerate a degree of intimacy. Being hardy, flexible, and resilient relies on more mature defenses, such as altruism and humor, and the ability to change. Individuals with personality disorders present with profound limitations in these areas. They rely on immature defenses such as repression, denial, and projection. They are vulnerable rather than hardy, rigid rather than flexible—and they have difficulty considering themselves as agents of change; to them, "things" (over which they do not perceive they have much control) just happen. This is why the challenges of aging are so problematic for them, and why they are typically poor candidates for psychological treatments, despite their desperate need.

Understanding these constraints, and recognizing the real and many challenges of aging, it becomes clear that the older individual with a personality disorder is at significant risk of experiencing increased distress and failures in functioning. They may become aware of the need to make a change, but do not know how to go about doing this; generally, they are not people for whom change is congruent or comfortable. Older adults with a personality disorder seek help only when they perceive that change is inevitable, their needs are unmet, or they are be-

Core Features of Personality Disorder Affecting Treatment 267

coming increasingly distressed or developing a mental illness. Thus, responding in their usual ways (i.e., resisting change) no longer works for them. In their schema, others are perceived as responsible for their distress, and they typically expect others, or the world, to change for them.

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