Stacy (identity disguised) sat across from me in her usual colorful outfit, her trademark childish enthusiasm filling the space between.
When I signaled the session was running low on time, she was overcome with a puerile poutiness. The pout turned to an impulsive, sarcastic accusation: "Just counting down to when you don't have to hear anymore, huh?"
I didn't take the bait. "Stacy, you contributed a lot of good stuff today, and I want to make sure we have a chance to reflect on a few things to take with you."
Stacy brightened at the compliment like a kid getting a sticker, for she was about to have a positive engagement with someone she felt a bond with.
Personality-interested readers will recognize that Stacy exhibited a mix of histrionic and borderline characteristics. These congealed into an interesting package—the adult version of a little kid, happily showing off, only to stamp and pout when a limit is set, but quickly lured back to amicability when offered a treat.
This childish tempestuousness led her academic advisor, whom she looked up, but to whom she also had an almost dependent attachment, to suggest therapy. The understanding advisor saw Stacy's potential but knew she’d struggle professionally with such an interpersonal style.
The Infantile Adult Explained
Earlier theorists, particularly those of a psychoanalytic bent. referred to interpersonal styles such as Stacy's as an infantile personality. While never classified as a personality disorder, it has generally been considered closely associated with the histrionic (e.g., Ruesch, 1948; Kernberg, 1989; Million, 2011), and Millon went so far as recognizing it as a histrionic subtype.
The infantile personality is perhaps best encapsulated by Hill (1952):
... they're designated infantile personalities... [because] they do not exhibit regression but rather lack of progression (italics added)... the clinical picture is that of functioning like a child... Since he is not a child, some functions are more highly developed... but the attitudes and aims remain that of an infant... Particularly impressive is the persistence of a dependent attitude and a fear of helpless needs—a need, ultimately, to be loved. There is little tolerance for frustration. Denial of his desires appears to the patient as a sign of a lack of love.
Millon (2011) expounded on the above, documenting this as a histrionic presentation seasoned with borderline characteristics he called the “infantile pleasuring personality type.” Millon summarized:
... labile, high-strung, and inclined to express volatile emotions. They display a childlike hysteria, typified by a pouting and demanding attachment to others... Vacillation between moments of childlike agreeableness act enticingly and temptingly, and being sullen or pouty is typical and frequent.
In this light, the similarities to histrionic (hysterical) personality become clearer, and Kernberg (1989) elaborated on the nuances:
They also show the extraverted, exhibitionistic behavior of the hysterical personality, except that this behavior has a childlike, clinging quality rather than an erotic one. Infantile patients convey the impression that erotic seductiveness is a means to gratify clinging and dependent rather than sexual needs.
A good analogy for those who have not encountered this presentation is to imagine a personality with simultaneous arrested development in middle school (histrionic) and the terrible two's (borderline).
Anyone who has worked with histrionic patients knows that the point of therapy is to essentially help them grow up. They’re technically having age-appropriate responses to their environment if viewed as an arrested state of development. Therefore, it’s the therapist’s job to get them developing again and caught up.
Working with an infantile personality isn't much different. We help them learn to relate more effectively by cultivating constructive relationships. A large part of this is examining how their rapidly-shifting affective experiences negatively impact their progress and help them emote more constructively.
For example, in working with Stacy, as we developed the therapeutic relationship, in her more “adult” moments, I let her know that I felt it was easier to relate to her and that we were experiencing a more genuine relationship. Like classical conditioning, these little moments of praise brought about a tendency for her to cultivate more of the material she was rewarded for.
The infantile personality may bring an additional challenge of managing clinginess. Given the strong, problematic emotional components, it can be easy to lose sight of what’s going on in the background. While we want the patient to develop a deep/meaningful relationship with us, we need to be aware of the potential for dependence. Therefore, it is equally important to be cultivating a sense of independence along the way.
One easy tool for this is keeping distinct boundaries and not encouraging any savior image. There may be a propensity, for example, of the patient trying to keep in touch between sessions in a “casual clinical” sense, such as asking for input on handling some minor frustrations. Using this example, we could see some big clinical payout by:
Acknowledging the matter at hand and ensuring it is not a matter of risk.
Reminding them that phone sessions are not part of your practice, but you’d be happy to examine the matter in their next session.
Applying a strengths-based narrative next session: “Earlier in the week, you wanted to talk about X and Y on the phone. How did you end up dealing with those?” Examining what they did and how they arrived at it, showing they managed without your getting directly involved, helps foster a sense of independence.
It will likely come to be that there is a discussion about frustration with the therapist for not saving them at the moment when they called, and this is grist for the ongoing improved relating ability mill.
Lastly, those interested in two detailed accounts of working with this personality may enjoy Otto Kernberg’s 1991 paper, “Transference Regression and Psychoanalytic Technique With Infantile Personalities."
Disclaimer: The material provided in this post is for informational purposes only and is not intended to diagnose, treat, or prevent any illness in readers. The information should not replace personalized care from your provider or formal supervision if you're a practitioner or student.