Using Art Therapy for Clients with Personality Disorders

The DSM-5 categorizes personality disorders into 3 main clusters:

• Cluster A (odd, bizarre, eccentric) – Paranoid, Schizoid and Schizotypal
• Cluster B (dramatic, erratic, emotional) – Antisocial, Borderline, Histrionic and Narcissistic
• Cluster C (anxious, fearful) – Avoidant, Dependent and Obsessive-compulsive

We can all exhibit behaviours that would fall under all clusters, however, these behaviours are typically short-lived and may be in response to a specific situation that is eventually resolved. Individuals who are diagnosed with a personality disorder often exhibit these behaviours over a longer period of time. The behaviours are considered enduring patterns and typically have a significant negative effect on the daily functioning of the individual in terms of social, interpersonal and work situations.

Our personality is essentially based on how we think, feel, and behave. Working with personality disorders can be complex work as we are all made up of varying personality traits and we react differently to life events that we experience along the way. With this in mind, it can be difficult to come up with a standard approach to treatment for personality disorders because the variables are so broad. 

Art therapy and psychotherapy treatment is especially helpful for clients with personality disorders as they focus on the individual sitting in the room with their unique and varied experiences.

Although we all have a personality, the rate of those who are classified as having a personality disorder is currently about 7-10% with most classified as cluster B/C.

Our personalities develop over time based on our experiences as we mature. We may experience single traumatic events that shape our personality, however, it is often the cumulation of our experiences that shape our overall personality.

As we develop our personalities based on learning experiences, it is impossible to identify a single point in anyone’s life and clearly state that an individual has a personality disorder. Instead, those who have a personality disorder are often untreated for years.

Along the way behaviours may be simply dismissed as normal reactions to events and we may not seek help when it’s most crucially needed to deal with difficult life experiences when they occur. Often what does occur is we experience a series of life events and only realise the true impact of these events later in life once we have exhausted all previous coping skills of avoidance, denial, anger, and other maladaptive techniques.

Personality disorders develop based on the combined influence of biology, psychological, and social factors through the biopsychosocial model. Defining the specific causes of personality disorders is made difficult by the diagnostic comorbidity that exists in clients with personality disorders. Often clients who are diagnosed with a personality disorder have received additional psychological diagnoses and labels throughout their life.

For example, a client may have been dealing with alcohol addiction for many years, only to discover later that their drinking was masking a personality disorder. When seeking a reason for a client to be diagnosed with a personality disorder, it often required peeling back many layers within the individual’s life to reveal a series of connected diagnoses. In this situation, it is difficult to isolate each disorder to determine it’s own origins in the client’s life.

Given the difficulty in determining a cause for personality disorders, it is therefore difficult to identify specific treatment protocols. Furthermore, personality disorders by definition are known to be enduring, pervasive, and resistant to change. This can mean any treatment process is often focused on management instead of permanent change.

Furthermore, often clients diagnosed with a personality disorder will present with more than one disorder which can become difficult to address in the treatment process of defining problems the client would like to work on and set goals around. Treating a client with a personality disorder can become a process of integrating different approaches.

Clients with personality disorders also experience a higher rate of interpersonal problems in their lives and this can often affect the client/therapist relationship. It can be especially difficult for clients to develop trust for their therapist, especially for individuals who have a high degree of paranoia.

Clients who have narcissistic or antisocial personality disorders often don’t view their behaviour as a problem which can be difficult to explore in therapy if the client is focused on denying specific behaviours. In most cases, it is difficult to get cluster B clients into therapy given their propensity to deny there are any problems with their behaviour. In many cases, those who are diagnosed as antisocial personality disorder are often forced into therapy through mandatory sentencing given the prevalence of this disorder in prison inmates.

Clients with borderline personality can often interpret therapy discussions as personal attacks which can, in turn, exacerbate behaviour and intensify emotions. It can also lead to the client resenting their therapist and rejecting any attempts to provide treatment.

With all of these difficulties in mind, the therapist should work with the client on developing a treatment plan and series of goals. These can include:

• Reducing immediate distress
• Addressing interpersonal problems of conflict/volatility
• Developing the client’s awareness and insight into their behaviours
• Changing any behaviours
• Identifying personality traits that create significant disruption

Once these treatment goals are defined, it is useful to regularly remind the client of their goals when therapy sessions feel difficult. A client with a personality disorder can often lose track of an overall larger picture in terms of what bought them to therapy and how they wish to use the resources they have in therapy to improve their life.

For individuals diagnosed under Cluster A, art therapy is typically best delivered in group sessions and utilized as a process of encouraging social inclusion. In this case, art therapy would prove beneficial in a mental health unit setting.

Art therapy is beneficial for the B & C Cluster personality disorders in private therapy settings. Personality disorders under Cluster B are often considered resistant to therapeutic treatment as the behavioural traits are considered an inherent part of the individual’s personality. Someone in the Cluster B category can have insight into the dysfunction of their behaviour and attempt to find ways to commit to treatment.

Typically individuals who are diagnosed with a personality disorder believe their daily behaviour is ‘normal’ and may only seek treatment at times of heightened stress. This can often mean there are long breaks between therapy sessions. It can also mean that the session may focus specifically on a high-stress situation rather than focus on long-term behavioural insight and change.

For Cluster B disorders that exhibit overly emotional behaviours, art therapy can present as an opportunity to disengage dramatic and emotional verbal conversations and instead engage in mindful, mood-regulating activities that focus on creating focused art. Artistic expression can be cathartic and provide valuable insight through personal reflection. This process is integral in helping an individual with a personality disorder to focus on personal behaviours instead of focusing on external influences that distract the individual from reflecting on personal behaviour.

For Cluster C disorders, art therapy enables the individual to explore internal conflicts that stem from fear based thought patterns. Individuals diagnosed with Cluster C personality disorders may be reluctant to discuss obsessive and compulsive thoughts or behaviours. Art therapy helps circumvent these feelings of embarrassment by allowing free expression through less confronting non-verbal techniques.

Self-expression through art therapy techniques can provide the client with a process of exploring identity and also help formulate a positive self-image through reflection and insight gained from this self-expression. This insight can have a positive impact on the ability of the client to self-regulate emotional distress.

RESEARCH – FURTHER READING

ARTICLE (OPEN ACCESS): Perceived effects of art therapy in the treatment of personality disorders, cluster B/C:A qualitative study

In this study, patients with personality disorder experienced an improvement in sensory perception, emotion regulation and personal integration. Patients also gained insight into their emotional experiences and behavioural change. Using art therapy was considered a more direct approach to accessing emotions as well as providing a constructive pathway for regulating emotions and developing awareness about emotions.

ARTICLE (OPEN ACCESS): Art therapy for patients diagnosed with personality disorders cluster B/C: A thematic analysis of emotion regulation from patient and art therapist perspectives

This study focused on cluster B/C personality disorders and found that art therapy helped facilitate therapeutic effects through the experience of sharing emotions. Participants in the study were able to explore and understand internally held images and emotions through art expression. Participants felt safe in exploring previously hidden emotions and experiences so that they could bring light to the intense feelings. Participants felt more in control of their personal exploration and ability to develop insight then they did with previous talk therapy.

Despite some of the art activities being exposing the participants to confronting painful memories, they were able to develop a sense of security in their treatment process through art expression.

ARTICLE: Efficacy of Art Therapy in Individuals With Personality Disorders Cluster B/C: A Randomized Controlled Trial. 

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