Working with Individuals Diagnosed with Personality Disorders

Transcription

1 Working with Individuals Diagnosed with Personality Disorders Presented by: Malcolm Horn, LCSW, MAC, SAP January 10, 2018

2 Thomas Durham, PhD Director of Training NAADAC, the Association for Addiction Professionals

3 Produced By NAADAC, the Association for Addiction Professionals

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6 Cost to Watch: Free CE Hours Available: 1.5 CEs CE Certificate for NAADAC Members: Free CE Certificate for Non-members: $20 CE Certificate To obtain a CE Certificate for the time you spent watching this webinar: 1. Watch and listen to this entire webinar. 2. Pass the online CE quiz, which is posted at 3. If applicable, submit payment for CE certificate or join NAADAC. 4. A CE certificate will be ed to you within 21 days of submitting the quiz.

7 Using GoToWebinar (Live Participants Only) Control Panel Asking Questions Audio (phone preferred) Polling Questions

8 Webinar Presenter F. Malcolm Horn 1231 N 29 th Billings, MT mhorn@rimrock.org Your

9 Webinar Learning Objectives LO #1 Know the diagnostic criteria for personality disorders LO #2 Gain understanding of the theory behind the etiology of personality disorders LO #3 Gain awareness of basic counseling strategies to work with individuals diagnosed with personality disorders

10 Agenda Brief review diagnostic criteria Key PD that we will focus on: Borderline Antisocial Narcissist Psychopaths Sociopaths Treatment Goals & Techniques

11 The Four Core Features of Personality Disorders The DSM-5 (APA, 2013) identifies and describes ten specific personality disorders. These ten diagnoses represent ten specific enduring patterns of thoughts, feelings, and behavior. However, each of these ten patterns can be distilled down to four core features of personality disorders: 1. Rigid, extreme and distorted thinking patterns (thoughts) 2. Problematic emotional response patterns (feelings) 3. Impulse control problems (behavior) 4. Significant interpersonal problems (behavior) To diagnose a personality disorder a person must exhibit at least two of these four core features.

12 DSM-5 Criteria: 1. A personality disorder is enduring pattern of inner experience and behavior. This pattern manifests in two or more of the following areas: a. Thinking b. Feeling c. Interpersonal relationships d. Impulse control 2. This pattern deviates markedly from cultural norms and expectations. 3. This pattern is pervasive and inflexible. 4. It is stable over time. 5. It leads to distress or impairment

13 Borderline personality disorder Pervasive fear of abandonment Unstable perception of self Difficulty with stable relationships Mood swings Black and white" Constantly seek a higher level of caretaking from others as adults Manipulation of others, leaving them often feeling empty, angry, and abandoned, which may lead to desperate and impulsive behavior Antisocial personality disorder Characteristically disregard the feelings, property, authority, and respect of others for their own personal gain May be violent or aggressive acts involving or targeting other individuals, without a sense of regret or guilt for any of their destructive actions.

14 Narcissistic personality disorder Histrionic personality disorder Severely overly-inflated feelings of self-worth, grandness, and superiority over others. May exploit others who fail to admire them Overly sensitive to criticism, judgment, and defeat. Overly conscious of their appearance and are constantly seeking attention Behave dramatically in situations that do not warrant this type of reaction Emotional expressions are often seen as superficial and exaggerated

15 Psychopaths All of the APD traits but not limited to criminal bx; manipulative, insincere. Lack of guilt; think the white collar criminals (Madoff, Enron) Many psychopaths never get to prison More likely to be violent Values relationships only as they benefit them Criminal: likely to take calculated risks to minimize exposure-premeditated

16 Both Sociopaths and Psychopaths have: A disregard for laws and social mores A disregard for the rights of others A failure to feel remorse or guilt A tendency to display violent behavior How insightful are these people to want to change??

17 Causes of Pathology

18 Since we cannot change reality, let us change the eye that see reality Mikos Kazantizakis Only 3 ways to view these disorders: 1. Born that way Causes of Pathology 2. Not born that way the environment did it 3. Born that way and the environment made it worse.

19 The Ultimate Attachment Disorder Uncompleted developmental tasks lead to complex defense mechanisms: irresponsibility, impulsivity, thrill-seeking, poor decision-making, undeveloped value and moral structure They are stuck in an underdeveloped age & emotional deficits..acting like a child The absence of needs being met leads to emotional deficits which leads to disorders

20 What We See in Clients Chameleon bx (can behave well when it suits them; usually not sustainable) Blaming Creative splitting They are calm and compliant until confronted.. When you speak logic, it destroys their reality and they may become explosive Charming

21 Complex Defenses Excuse making (lying) Justifying/Rationalizing Intellectualizing Victim stance Self-serving acts of kindness Asserting power over others/manipulation Getting away with anything/above the law Views self as superior/harmless Lazy thinking

22 If you didn t have to hold yourself accountable, empathize with others, feel guilt or remorse, would you change?

23 Thinking Errors People don t react emotionally, or behaviorally to the events they encounter, rather people cause their own reactions to the way they interpret or evaluate the events they experience. Albert Ellis This implies that the thought pattern is dysfunctional or bad..but where do we get our thought patterns from?

24 Goals of Therapy & Interactions Create safety & structure: without this nothing will happen Help gain insight Help client understand their behavior Harm reduction Help them navigate their world This only works if there is insight and desire to change

25 It is not about you When working with PDs.. MI is helpful for helping them gain insight which is necessary for change You goal is to provide safety and trust (with some exceptions) Personality Disorders are classified on the same axis as mental retardation in DSM-IV Would you ask a developmentally disabled person to be fixed or would you help them to better navigate their world?

26 Techniques Find their strength Don t worry about getting them to like you; don t focus on building rapport Do not worry about getting the truth; do not focus on factfinding Ask yourself what the goal is; stick to it DBT MET SFBT

27 Dialectical Behavioral Therapy Specifically for BPD Reactive attachment Suicidal behaviors Eating Disorders/Substance Use Clients change behavioral patterns Clients increase emotional regulation and subsequent reactive behaviors by identifying triggers and emotional states Assumes that clients are doing the best they can with the poor skills that they have Mindfulness Observation without judgment Grounding Emotional Regulation Use Distress Tolerance skills Awareness and acceptance of uncomfortable feelings Interpersonal Effectiveness Assertive Communication Distress Tolerance Radical Acceptance Weigh the pros & cons

28 The ABC process.. 1. Activating Event Immediate Environment 2. Belief System Filters our perception of the Activating event Memory 3. Consequences Fight, Flight, or Freeze Positive Negative

29 Change Requires Safety.what if you don t know what safe feels like? Sense of necessity for change which means insight Willingness or readiness to change (which means being uncomfortable & vulnerable) Awareness of the problem Confrontation of the problem Effort towards change Hope for change Support for change

30 Listening Skills are Key Active Listening Be aware of non-verbal communication (esp tone and volume) Clarify, repeat, and validate Non-threatening Non judgmental Respect Low emotion People can change only if they feel that they are basically liked and accepted as they are. When people feel criticized, disliked, and unappreciated they are not able to change. Instead, they feel under siege and dig in to protect themselves. ~~John Gottman

31 Techniques for Change Admire negative traits and behaviors. reframe it into a strength and skill Redirect/reframe the skill in a positive manner Find out the values of the client and help them align their behaviors with them Praise: it takes courage to confront these issues You are very resilient to have survived that

32 Techniques for Change Leave your ego at the door Empathize even when it hurts to do so. Establish empathy prior to confronting Courtesy and permission; ask permission to confront or give feedback Roll with resistance Set boundaries

33 Techniques for Change Use scaling to help them identify & see change (or lack thereof). Reframing can help them feel more in control Ask hypothetical questions; ask open-ended questions; use the Miracle Question Help them to see their strengths and what they are doing right Role play; gets them out of the client role

34 Porcupines Don t get into power-struggles; when we win we undermine the idea that they can make choices AND who wants to admit that they are wrong? These patients have to have a hard shell to survive remember that when you are taking that away, you are leaving them vulnerable.

35 How do we Instill Hope? Avoid black/white thinking: open up the possibility of exceptions to the problem Put the problem in the past: recently I ve seen.so far.lately.. Reframe: encourage a different perspective of the problem Help them to make good decisions for themselves Find and capitalize on their resilience and strengths

36 Give choices State facts Parenting. Meditation Anger management Grief/Anger work Trauma work DBT Skills: Other Techniques Emotional Regulation Interpersonal Communication Core Mindfulness Distress Tolerance

37 To keep in mind. Personality Disorders are classified on the same axis as mental retardation..both are mental disorders. PDs impact the affected personality. DD impacts the cognition. Would you ask a developmentally disabled person to be fixed? People that have problems can have hope that they can solve them. People who ARE problems see themselves as fundamentally flawed and unchangeable.

38 Don t Go it Alone You want them to have several people that they can go to (especially if they are BPD) Probation officer Case manager Additional counselor Family Psychiatrist But make sure that you have a release of information so that you can communicate with your other team-mates

39 References: Brown, Sandra. Women who love psychopaths. Harlow, H. (1959). Monkey Love Hanna, Fred. Dissolving Resistance in Difficult Clients: Techniques for motivation and change. (PESI) NAR Associates. Solutions for the treatment resistant client; Samenow, Stanton. Inside the Criminal Mind: Understanding the resistant, Antisocial Client.

40 Thank You! F. Malcolm Horn 1231 N 29 th Billings, MT mhorn@rimrock.org Your

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42 Cost to Watch: Free CE Hours Available: 1.5 CEs CE Certificate for NAADAC Members: Free CE Certificate for Non-members: $20 CE Certificate To obtain a CE Certificate for the time you spent watching this webinar: 1. Watch and listen to this entire webinar. 2. Pass the online CE quiz, which is posted at 3. If applicable, submit payment for CE certificate or join NAADAC. 4. A CE certificate will be ed to you within 21 days of submitting the quiz.

43 Upcoming Webinars January 24, 2018 February 28,,2018 Brief Intervention: Process and Techniques By Rebecca Bullion, LCSW, CIP, SAP, MAC February 14, 2018 The Role of Collegiate Recovery Programs and the Continuum of Care Journey Through Grief and Loss By Lisa Connors, LCPC, NCC, MAC, ABD March 14, 2018 Cultural Aspect of Trauma and Substance Use Disorders By Amy Boyd-Austin, MMS, LSW and Susie Mullens, MS, LPC, AADC-S, MAC By Gladys Smith, PsyD, LPC, MAC, CCMHC, RYT

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