Patients begin therapy for a variety of reasons. Those with histrionic personality disorders often begin with a sense of urgency and a belief that presenting symptoms of frightening thoughts and images and out-of-control feelings of anxiety or despair can be quickly dispelled by the therapist. Recent traumatic events or episodes of abuse or loss may be the immediate precipitants of flare-ups of psychiatric symptoms. Even in the midst of such crises there may be a sense, although not one readily expressed in words as a clear complaint, that repetitive interpersonal patterns have led in part to the mixed causes of the current turbulence. In the beginning, it is important to set up and repeat a framework that can address not only chief complaints but also underlying characterological issues over the period of hard and persistent work needed to develop a more mature integration of personality.

Careful listening and questioning about all symptoms and salient interpersonal patterns can lead to a list of salient phenomena that can be explained later by individual case formulations. This is an open-ended list, with revisions indicated as more information is obtained. Empathy to the patient’s suffering resulting from the symptoms is important. The patient’s sense of being out of control over the experiences should also be acknowledged if it is present, without getting into a potentially difficult transference situation of seeming to take over control and rescuing the patient from all distress - a role the patient may offer to the therapist.

The goal is to provide just enough support to reduce the likelihood of self-impairing actions by the patient and help the patient feel less out of control. A plan for step-by-step dealing with problems can be very restorative. A trial of a few weeks of therapy alone may precede the prescription of antidepressant agents if the patient has a comorbidity with a major depressive disorder. Hospitalization may be indicated if there is a risk of suicide or other serious behaviors. Antianxiety agents, if necessary, should be given on a minimal, single-dose basis rather than in a blanketing dosage over weeks.

A therapeutic alliance is built on how symptoms are described by the patient and illuminated as experiences by the therapist. The patient will often present symptoms unclearly and experience them as caused by or even represented outside of the self. By repetitions and questions, the therapist may clarify these experiences, provide everyday labels (not psychiatric jargon) for them, and show the patient an appropriate concern. Early steps can be taken to help the patient recognize that thoughts and moods come from within the self, as well as from social contexts.

This shift of attention from exclusively external to partially internal helps to begin the long process of teaching the patient to regard the self as an agent of action rather than as merely the recipient of actions of others. Gradually, sequences of partial causation may be clarified. For example, a stomachache may be seen as a way of avoiding a threatening interpersonal confrontation. The therapist models calm, persistence, and tentativeness in exploring such possible chains of events. It is also helpful to make links between the sequence of therapy sessions by reviewing the phenomena discussed in the previous session and what was learned about them as part of an inquiry about symptomatic and other experiences since the last session.

Patients with histrionic personality disorder can be very provocative and demanding during the early phase of therapy. The therapist walks a path with the possibility of countertransference and transference enactments on either side. To one side is the error of excessive warmth and seeming to promise more than can be delivered. To the other is the error of excessive coldness, disdaining the patient’s suffering. The middle path may also be difficult. For example, the patient may be about to take a course of action that will be dangerous by impulsive entry into a situation that is likely to lead to further despair or bodily harm. The therapist may have to give firm advice to avoid these dangers. The patient may expect even more rescue from the therapist, or provoke guilt and more interventions, because the advice “did not work” or had “bad effects.” When this type of suggestion is given, the therapist can stay on the middle path by dealing with the transference consequences of the advice, repeatedly clarifying the realistic reasons why the advice was given at that time.

Transference enactments are inevitable and may be useful in therapy; the treatment will not always be on the middle path just discussed. When transference enactments occur, the therapist can identify the sequence of beliefs and feelings already partially identified by hearing about current and past relationship patterns outside the therapy. Clarity about the patterns can be gained by linking interpretations; the pattern noted in the here and now of the transference enactment is like the one in current outside relationships and like ones in the developmental sequence of the patient’s life story. Change can be encouraged by looking back and forth between the beliefs and feelings in the transference pattern and the beliefs and feelings that would differ in a more accurate appraisal of the qualities of patient and therapist in their realistic roles within the treatment context. Some of these techniques are summarized in

Table 84-2.