Patients with borderline personality disorder (BPD) or narcissistic personality disorder (or both) can feel entitled to special treatment and often seek only approving forms of attention from those who treat them. Such appeals for special treatment may prompt clinicians to worry that gratifying them can reinforce unrealistic interpersonal expectations, but that withholding may elicit reactive worsening of symptoms or dropping out.
Questions to consider when reading the case:
1. In what ways might the therapist help the patient address her problems?
2. If therapeutic efforts fail, how much time should transpire before the therapist advises the patient s/he is unable to help?
Kathy is a 52-year-old divorced woman who is referred for treatment following a suicide attempt related to losing her job. Kathy began therapy with the goal of developing more close relationships. Her children don’t speak to her and her family reports walking on eggshells around her because of her volatility.
At the start of treatment, Kathy made multiple requests to have her appointment times adjusted to accommodate her schedule and frequently needed to move the furniture in the office to suit her better. The therapist managed this by saying that she understood why such changes were preferred but that she was unfortunately not able to meet Kathy’s requests. The therapist also reminded Kathy that she was very much interested in helping her meet her treatment goals.
The greater difficulty was that Kathy used up quite a bit of time in therapy dwelling on how she was doing better than other people she knew. She reported only her successes in hopes of being praised. Her therapist had a hard time getting Kathy to focus on the problems that brought her into treatment.
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