Text adapted from: "The adult patient with a personality disorder," in Psychiatry in primary care by Michael Rosenbluth, Matthew Boyle & Lucille Schiffman (CAMH, 2019).
For primary care practitioners, the main issue is often whether they have the time, interest or training to do psychotherapy.
Dialectical Behavioural Therapy
Dialectical behavioural therapy (DBT) is the most researched psychotherapy for people with BPD. This form of cognitive-behavioural therapy emphasizes validation and acceptance, while focusing on change. DBT views these patients as having temperamental irregularities that when combined with an invalidating environment result in affective dysregulation (Linehan, 1992).
The goal of DBT is to learn functional strategies to modulate the reactivity, intensity and duration of responses to stress. The focus is on validating the “kernel of truth”—that is, in reviewing when patients have their characteristic meltdowns, the clinician searches for the trigger and motivation for the response, which might be expressed as “You wanted to escape the pain.”
Primary care practitioners may not have training or interest in using DBT or other therapeutic modalities that psychotherapists use with these patients. However, understand that you are uniquely situated to contribute to the care of patients with personality disorders.
In supportive therapy, it is important to “go with the flow” (Frances, 2005)— that is, to admire the patient with narcissistic personality disorder, to provide information to the patient with obsessive-compulsive personality disorder and to allow and maintain a distance from the patient with schizoid personality disorder.
These strategies meet the patient’s needs and support necessary defences. Trying to change personality in people with a longstanding character structure is a more challenging task that most primary care practitioners will be willing to defer.
You can help patients learn how to develop an “owner’s manual” so they can better understand their personality. Patients need to consider how their core vulnerabilities can be managed. You can help them to understand and manage their reactivity, using the mnemonic TAACO as a guide:
- Triggers that cause the emotional overreactivity
- Antecedents that make those things the triggers (e.g., why did the boss’s criticism trigger such a reaction and what might that reflect from earlier in life?)
- How the triggering situation could have been Anticipated so that it could have been managed better
- Consequences of the overreaction
- Options that could have been used to avoid the reaction and the negative consequences.