Many patients with a histrionic personality disorder have a habitual defensive strategy of not knowing facts that would be emotionally distressing. They use a variety of inhibitory control processes, ranging from inhibiting contemplation of emotionally complex topics to shifting attention away from external sources of threat. If these avoidance maneuvers are not sufficient, the patient may “short-circuit” to closing a topic prematurely or shift to another state of mind, as already described. The result of the assembly of avoidant control processes is a variety of outcomes that can be called suppression, repression, disavowal, denial, and behavioral avoidance.

The therapist may help the patient by counteracting habitual avoidances and fostering sustained attention to topics that contain irrational beliefs, conflicting motives, contradictions in sense of self, and unresolved dilemmas of choice about what to do.

While promoting the sustainability of working states in the therapy, the therapist can focus attention on topics that are usually warded off and unresolved. As mentioned, these may be signaled, because they tend to lead to a shift into shimmering states of both expressing and warding off ideas and feelings. By discussing these topics, the therapist may help the patient to differentiate reality from fantasy by paying closer than usual attention to what is going on in the immediacy of the therapy situation, in current outside relationships, and in reviews of past situations.

As current, past, and potential future relationships are contemplated, the therapist may help the patient learn to link recognition of emotional responses to what intentions of self and other are occurring in social contexts. Part of this is to encourage translation of nonverbal messages into verbal expressions in the immediate therapy context and to learn to monitor nonverbal messages to others outside of therapy. This will also help the patient to learn to focus attention away from “just now” to what is likely to happen as the present leads to probable futures. In the long run, this will help the patient to counteract the apparent “unreality” of some current real acts and also to counteract the apparent “reality” of living in imagination.

The therapist can help the patient to stay with unresolved topics and to add associations and appraisals just at the moment when the patient might typically short-circuit to an appealingly quick solution to a difficult problem in order to get off the topic. Rationalization of the quick solution and disavowals of what else is important to the patient can be counteracted by calm and supportive challenges. As the patient learns to know when he or she is actively “not knowing,” the therapist can clarify this cloudiness of thinking by exploring how it was learned in the past from emulation of important others, and even how “not knowing” was encouraged within the patient’s family or social context.

Some dilemmas will, especially early in therapy and with more difficult patients, seem too difficult for the patient to address. When these are important in terms of reaching choice points that may reduce repetitions of self-impairing behavioral patterns, the therapist can address them slowly, clearly, and step by step. This provides a useful behavioral model for the patient to copy as a replacement for learned schemas of acting too quickly rather than thinking and planning how and when to act.

In addition to focusing on usually warded-off conflictual and unresolved topics in terms of ideational, emotional, memory, and fantasy contents, the therapist may teach the patient how to focus in terms of time. Patients with histrionic personality disorder often skip around in terms of time frame, as well as in terms of the contents of their attentional focus. The present, past, and future become jumbled, yet patients can learn to alter this with encouragement.

One may proceed in the way that best suits each individual patient. In general, an immediate time frame of the “here and now” is a beginning. This includes expectations about the therapy: How does the patient expect that it will work? Being clear on such expectations allows immediate work on what is realistic and what is unlikely. The patient may expect that he or she is to be emotionally active while the therapist takes care of all ideas and plans, making a transformation in the patient without responsibility by the patient. Work on this focus in therapy can then lead to recognition of patterns leading to maladaptive outcomes in the patient’s current situations outside of therapy.

As present time patterns become clear, the past and the future open up within the framework of attention. How did maladaptive patterns get started in the past? What can be changed in the near future in order to try out, practice, and learn new patterns?

Traumatic events and childhood fantasies play a prominent role in forming the character structure of many patients with a histrionic personality disorder. Through this work in reducing excessive inhibitions that stand in the way of processing meanings well, the patient may recall or more vividly center on traumatic memories. These may include memories that feel real but that contain fantasy components. It is important to take a stance that is not too assumptive on the basis of any theory or any intuition as to what “really happened.” The main goal is to help the patient obtain a here-and-now sense of continuity with the past, with personal identity over time, and with a sense of self as the agent of experiencing and deciding how to act responsibly in the future.

As excessive control processes are reduced and as new, more adaptive processes of self-regulation are learned, the work can be continued by analyzing the cycles of states of mind already considered earlier in the therapy. The reasons for entering dreaded but repetitive undermodulated states and the problems in having desired but seldom sustained states can be examined in relation to other states of mind that serve as defensive compromising, avoiding a “fear script” in which wishes lead to bad consequences. A goal may be clarified to learn in therapy to have desired states of mind without repetition of behavioral patterns that too often led in the past to abusive or abandonment situations. Now that the patient has learned less avoidant cognitive styles, he or she may be able to stop a vicious cycle of states early in the incipient stage. If so, the patient does not need to use avoidant, overmodulated states so frequently and can learn to engage more realistically and openly with others.

To arrive at such useful learning, the belief systems of the patient have to be explored in order to reduce an irrational dread of certain themes and topics. This work on reducing intellectually impairing cognitive styles goes hand in glove with efforts at identifying and modifying troublesome but irrational beliefs. Some of these techniques are summarized in

Table 84-4.