1 Family Therapy and Mental Health University of Guelph Open Learning and Educational Support.

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Family Therapy and Mental Health

University of Guelph

Open Learning and Educational Support

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Reflections on the Course So Far

Comments Questions Assignments

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Today ADHD Personality Disorders

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Presentation

ADHD – Stacey and Mark

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Attention-Deficit/Hyperactivity Disorder

Inattention and/or hyperactivity-impulsivity Interferes with functioning or development Occurs in at least two settings Starts young (before 12)

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Inattention (6 or more): Careless mistakes in schoolwork Difficulty sustaining attention Doesn’t seem to listen Doesn’t follow instructions Difficulty organizing tasks Avoids sustained mental effort Loses things Easily distracted Forgetful 6

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Hyperactivity and impulsivity (6 or more): Fidgets Leaves seat Runs around Unable to play quietly On the go, motor-driven Talks excessively Blurts out answers Difficulty waiting in line Interrupts 7

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Six or more of at least one of the categories above

Starts before age 12 Two or more settings Interferes with functioning Rule out schizophrenia

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5% of children and 2.5% of adults Stress may predispose (low birth weight,

smoking, alcohol, child abuse, neglect) Genetic Males:females 2:1

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ADHD - Impact

Reduced school performance Reduced academic attainment Social rejection Poorer occupational attainment Reduced attendance Increased unemployment Increased interpersonal conflict

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ADHD - Treatment

Parent training (positive attending, tokens, response cost, time out, special situations)

COPE Family education and intervention School supports (educational aid) Medication: stimulants, antidepressants,

SNRI, other (including antipsychotics and blood pressure meds)

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Adults Have it Too

Therapy Medication GTD and other techniques

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Presentation

Narcissistic Personality Disorder – Grigoriy and Andrew

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Presentation

Borderline Personality Disorder – Margarete and Amy

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Personality vs. Temperament

Temperament refers to behavioral style, the how of behavior. Personality describes the what or why of behavior. Long recognized as different, researchers have investigated connections between biological aspects of behavior and personality structure and development.

https://www.b-di.com/personality.html, accessed November 17, 2015

https://www.b-di.com/personality.html



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Personality Traits

Currently, one of the most popular personality theories is the Big Five theory of Paul Costa and Robert McCrae. Based on repeated factor analysis of personality traits, these authors have concluded that personality is comprised of five universal dimensions: Extroversion, Agreeableness, Neuroticism, Openness, and Conscientiousness. They believe that these five factors can be found in self-ratings of personality in youngsters as soon as they are able to rate themselves, and remain invariant through adulthood.

https://www.b-di.com/personality.html accessed November 17, 2015



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OCEAN Traits

Open to Experience (Thinking) Conscientious (Conscience) Extraverted (Relating) Agreeable (Willfulness) Neurotic (Emotional Stability)

E.g. my friend D, male, 56, believes that because one group of terrorists belongs to a particular religious group, therefore all members of that religious group are predisposed toward violence

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Other views of personality

Myers-Briggs Personality = temperament + character

Temperament = inclinations = predisposition Character = habits = disposition

“Foxes are predisposed – born – to raid hen houses…unless arrested in its maturation by an unfavorable environment, develops the habit appropriate to its temperament: stealing chickens” David Keirsey (1998), Please Understand Me II:

Temperament, Character, Intelligence (Del Mar, California: Prometheus), p. 20

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Carl Jung

People have a multitude of instincts or archetypes, all equally valid

Naturally inclined toward extraversion or introversion

Prefer one of four basic psychological functions: thinking, feeling, sensation, intuition David Keirsey (1998), Please Understand Me II:

Temperament, Character, Intelligence (Del Mar, California: Prometheus), p. 3

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David Keirsey (1998), Please Understand Me II: Temperament, Character, Intelligence (Del Mar, California: Prometheus), pp. 4-5

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3 Axes, 16 Combinations

Thinking – Feeling Sensing – Intuiting Perceiving – Judging Extraverted – Introverted SPs: ESTP, ISTP, ESFP, ISFP SJs: ESTJ, ISTJ, ESFJ, ISFJ NFs: ENFJ, INFJ, ENFP, INFP NTs: ENTJ, INTJ, ENTP, INTP

David Keirsey (1998), Please Understand Me II: Temperament, Character, Intelligence (Del Mar, California: Prometheus), pp. 11-12

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Myers-Briggs, 4 personality types

Artisans (SPs) or Concrete Utilitarians Ernest Hemingway, Winston Churchill, Dylan

Thomas, Ronald Reagan, foxes Guardians (SJs) or Concrete Cooperators

George Washington, Hobbits, Harry Truman, beavers

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Myers-Briggs, 4 personality types

Idealists (NFs) or Abstract Cooperators Mohandas K. Gandhi, Plato, (Socrates?), dolphins

Rationals (NTs) or Abstract Utlitarians Einstein, Professor Higgins (Pygmalion), owls

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Maybe personality can be defined on the basis of life goals

Strategies, plans and concerns Behaviour desired goals Personal projects, life tasks, strivings Dynamic, goal-directed The journey we take in life

Robert A. Emmons (1999). The Psychology of Ultimate Concerns: Motivation and Spirituality in Personality. New York: Guilford

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Personality as Story

Narrative the story that I tell about myself integrity vs. despair (Erickson)

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Personality Disorder

“An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” DSM-5, p. 645

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No longer “Axis II”

Personality Disorders, Developmental Disorders, maladaptive personality features and defense mechanisms used to have a separate niche in the DSM

The Axes have been removed and PD’s return to the mainstream (Section II)

They also have an “Alternative Model” for PD’s in Section III of the DSM-5 (p. 761)

Section II is very similar to the DSM-IV Section III is a new model emerging...

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Paranoid – distrust, interprets others as malevolent

Schizoid – detachment, restricted range of affect

Schizotypal – discomfort in relationships, cognitive distortions, eccentric behavior

Cluster A (odd, eccentric)

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Cluster B (dramatic, emotional, erratic)

Antisocial – disregard for, and violation of, the rights of others

Borderline – unstable relationships, self image, affects, and impulsive behavior

Histrionic – excessive emotion and attention seeking

Narcissistic – grandiosity, need for admiration, lack of empathy

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Cluster C (anxious, fearful)

Avoidant – social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation

Dependent – submissive, clinging, need to be taken care of

Obsessive-Compulsive – preoccupied with orderliness, perfectionism, and control

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Clusters are not validated(then again, nothing is) Individuals may present with co-occurring

personality disorders from different clusters Prevalence

Cluster A 5.7% Cluster B 1.5% Cluster C 6.0% Any personality disorder, 9.1%

Approximately 15% of U.S. adults have at least one personality disorder

Approximately 70% of high-conflict post-divorce couples have at least one partner with a personality disorder

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General Personality Disorder Enduring pattern of inner experience and

behaviour that deviates in two or more ways Thinking Feeling Interpersonal functioning Impulse control

The enduring pattern is inflexible and pervasive (i.e. enduring)

Causes distress or impairment Stable (i.e. enduring) 32

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1. Traits that tend to put the person in conflict with others

Not so open (or too open) to new experiences Not so conscientious (or too conscientious) Not so extraverted (or too extraverted) Not so agreeable (or too agreeable) Not so neurotic – i.e. emotional instability (or

too neurotic, i.e. lack of emotional range)

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2. Goals that tend to put the person in conflict with others

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3. Stories that tend to put the person in conflict with others, or that tend to put others in conflict over the person

Good vs. evil (splitting) Story about the client

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Cluster A

Odd, eccentric

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Paranoid Personality Disorder

Pervasive distrust and suspiciousness (interprets others’ motives as malevolent) beginning in early adulthood, 4 or more of: suspects others are exploiting or harming doubts loyalty or trustworthiness of friends reluctant to confide in others reads hidden threats in benign remarks or events bears grudges perceives attacks from others doubts fidelity of sexual partner 37

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Schizoid Personality Disorder

Pervasive detachment and restricted affect beginning in early adulthood, four or more of: no joy in close relationships almost always chooses solitary activities little interest in sexual experiences pleasure in few, if any, activities lacks close friends apart from close relatives appears indifferent to praise or criticism emotionally cold, detached, flattened affect

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Schizotypal Personality Disorder

Pervasive social deficits, acute discomfort and reduced capacity for close relationships, cognitive distortions and eccentric, 5 or more: ideas of reference odd beliefs unusual perceptions odd thinking and speech paranoid ideation constricted or inappropriate affect peculiar behaviour lack of close friends; social anxiety r/t paranoia

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Cluster B

Dramatic, emotional, erratic

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Antisocial Personality Disorder

Pervasive disregard for and violation of the rights of others since age 15, 3 or more: repeatedly acting s.t. grounds for arrest deceitful, lying, conning for personal profit impulsive or failure to plan ahead irritable, aggressive, fights and assaults reckless disregard for safety of self or others consistent irresponsibility lack of remorse

at least 18; history of Conduct Disorder before age 15

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Borderline Personality Disorder

Pervasive pattern of instability in relationships, self-image, affects, and marked impulsivity. Five or more: frantic efforts to avoid abandonment pattern of unstable and intense relationships unstable self image impulsivity in two areas potentially self-damaging suicidal or self-mutilating behaviour affective instability chronic feelings of emptiness 42

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Borderline Personality Disorder

Pervasive pattern of instability in relationships, self-image, affects, and marked impulsivity. Five or more: inappropriate, intense anger transient, stress-related paranoid ideation or

severe dissociative symptoms

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Histrionic Personality Disorder

Pervasive pattern of excessive emotionality and attention-seeking, five or more: likes to be centre of attention sexually provocative rapidly shifting, shallow emotions uses physical appearance to draw attention impressionistic style of speech theatrical suggestible thinks relationships are intimate 44

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Narcissistic Personality Disorder Pervasive grandiosity, need for admiration

and lack of empathy, five or more: self-importance fantasies of unlimited success special requires excessive admiration sense of entitlement interpersonally exploitative lacks empathy envies others arrogant and haughty

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Cluster C

Anxious, fearful

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Avoidant Personality Disorder

Pervasive social inhibition, feelings of inadequacy, hypersensitivity to criticism, 4 +: avoids jobs with people avoids people in general unless they like him/her well behaved in intimate relationships preoccupied with rejection inhibited in new situations sees self as inferior to others reluctant to take risks

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Dependent Personality Disorder

Pervasive and excessive need to be taken care of, submissive, clingy, five or more: difficulty making decisions needs others to be responsible difficulty disagreeing with others difficulty initiating projects goes to great lengths to get support feels helpless when alone serial relationships afraid of being left alone 48

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Obsessive-Compulsive Personality Disorder

Pervasive preoccupation with orderliness, perfectionism, control, four or more: details, rules, lists perfectionism that prevents task completion workaholic overconscientious (morals, ethics, values) pack rat can’t delegate miserly rigid and stubborn 49

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Family Etiology

PDs defined as a pattern of relationship that doesn’t work in the patient’s current setting

Why would anyone develop a pattern of relating that doesn’t work?

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Family Etiology

A: It did work, at one time, in a different setting

Biopsychosocial pattern Affect regulation Cognitive perception Interpersonal relations (In)appropriate behaviour Impulse control

Malcolm M. MacFarlane, ed. (2004), Family Treatment of Personality Disorders (New York: Haworth), p. 5

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Family Etiology

Object Relations Self Psychology Attachment

“Those who endure abusive, extremely inconsistent, and neglectful attachments fail to develop a sense of object constancy and mastery of basic ego functions, such as affect regulation, impulse control, and the ability to develop trusting attachments. Instead, they tend to rely on primitive defenses, such as splitting good and bad elements of the self and others, projection, acting out, have a tendency for emotional dysregulation, and have unstable interpersonal relations.”


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Biology

Doubtless genetics plays a role Some evidence: borderline, anti-social, OCD Cloninger 1986, 1987

Novelty-seeking = dopamine Harm-avoidance = serotonin Reward-dependency = norepinephrine “In effect, these systems set the constraints for

personality, and combining these tendencies allows for the individual differences in personality as well as explaining disorders.”


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Treatment

Joining (with limits) Understanding Educating Intervening

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Tailor the Treatment to the Deficiency Understand and appreciate client’s limits (e.g.

don’t expect OCPD to express emotion, do expect BPD to have frequent crises)

Attend to safety Step a little outside the client’s comfort zone

(e.g. OCPD promote exposure, discourage compulsive behaviour; BPD be a disappointing helper)

See more below (DBT) Feinberg, R., & Greene, J. T. (1997). The Intractable Client: guidelines for working with

personality disorders in family law. Family and Conciliation Courts Review, 35(3), 351–365.

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Object Relations Theory

MFT Applications

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Object Relations Theory

The ‘object’ of object relations: a “human” object Internal or external Fantasied or real

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Object Relations Theory:A Brief History

Melanie Klein (1882–1960): Contemporary of Freud’s First direct work with children Children devote more energy to interpersonal

relationships than to libidinal impulses They create internal and play representations of

their important relationships Intensely studied mom & infant

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Klein in continuation with Freud believed in a

destructive inner force (death instinct) inner struggle of live v death projected on the

outer world external destructive objects (bad objects: giants,

monsters, villains) external life objects (good objects: mothers,

fathers, heros)

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Klein, cont

Resolving Good and Bad in Relationships Positions

Paranoid (0-3 months) birth is stressful, the child feels persecuted and attacked takes it out on the breast splitting good v bad persecutory anxiety

Depressive (4 months - 2 years) splitting is reversed and mom is whole object again appreciate good and bad instead of good or bad anxiety about harming the parent with guilt comes empathy 60

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William Fairbairn (1889 – 1964) Continued to shift focus from pleasure to

relationships Developmental scheme

early infantile dependency transitional period mature dependence

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Fairbairn cont

Early infantile dependency child merged with caretaker poorly developed sense of self

Transitional stage lifelong process away from one-way dependency

Mature dependence mutuality and exchange healthy interdependence

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Fairbairn: three types of objects Good becomes ‘ideal object’ Bad becomes

‘exciting object’ (formed from teasing or tempting child) - makes child feel frustrated and empty

‘rejecting object’ (formed by hostile or rejecting caregiver) - makes child feel unloved and unwanted

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Fairbairn Three ego states Exciting object → libidinal ego

Always thirsting, never satisfied, deprived Rejecting object → anti-libidinal ego

Hateful and vengeful, longs for acceptance Ideal object → central ego

Results in conforming behaviour

The first two states are repressed: psychopathology

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Margaret Mahler

Normal Developmental Stages of Infants Autistic Symbiotic Separation-individuation

Differentiation Practicing Rapprochement Libidinal object constancy

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Differentiation

6 - 10 months mother is separate stranger anxiety increasing differentiation of self and object

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Practicing

10 - 16 months quadruped locomotion physical distance from mother

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Rapprochement

15 - 30 months language interaction with other adults (father) self-assertion and separateness strong need for help and reassurance crisis: need for parent v need for separation need a balance of support and firmness

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Libidinal Object Constancy

30 months - 3 years stable internal representation of the mother enables the child to function on its own develops relationships with others integration of positive and negative, good

and bad, objects if not completed, in later life tend to see others as

either punitive and rejecting or unrealistically gratifying

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Otto Kernberg (1928- ) Bipolar representations

self other affective colouring

e.g. mother-child-positive and fulfilling or mother-child-frustrating and depriving

Various bipolar representations are “metabolized” to form foundation of personality

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Kernberg, cont

Development Introjection

primitive experiences, undifferentiated splitting good v bad

Identification more mature, beginning of self-object understanding more control over affective colouring

Ego Identity synthesized bipolar representations integrated sense of self

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Kohut

self psychology parents and significant others are selfobjects

“distinct, objectively separate individuals in the child’s life who eventually become incorporated into the self”

praise from a selfobject is internalized as pride

shame is internalized as guilt

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Kohut cont

children are naturally narcissistic develop a positive and rewarding structure of self

children have two basic needs to show off (If others see me as good, then I must

be good) - healthy omnipotence - mirroring selfobject

to merge with an ideal selfobject (My mother is good, and I am my mother, so I am good) - healthy connectedness - idealizing selfobject

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Kohut

Mirroring I am perfect and you must admire me

Idealizing You are perfect and I am a part of you

Normally, these two continue through life in increasingly mature and complex ways, and you become a selfobject for your children, your spouse, and your clients

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Dialectics

• Everything is made of opposing forces• Gradual changes lead to turning points,

where one opposite overcomes the other• Change is evolutionary• There is truth on both sides• Balance of acceptance and change


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The Biosocial Model

emotionallyvulnerable

person

invalidatingenvironment

BEHAVIOURALLYDYSREGULATED PERSON


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What is emotion regulation?

• Ability to decrease (or increase) physiological arousal associated with emotion

• Inhibit mood-dependent action• Experience emotions without escalating or blunting• Organize behaviour in the service of external,

non-mood dependent goals

(Gottman & Katz, 1989)


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DBT Assumptions

1. Clients are doing the best they can2. Clients want to improve3. Clients need to do better, try harder, be more

motivated4. Clients may not have caused all of their

problems, but they have to solve them anyway

5. Clients lives are currently unbearable6. Clients must learn new behaviours7. Clients cannot fail in DBT


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Behaviour change strategies

• Antecedents, Behaviour, Consequences• Diary cards (self-monitoring form)• Behaviour chain analysis• Contingency management

• Reinforcement (“Scratch the good dog, not the bad one” – Buddha)

• Punishment – immediate, consistent, firm• Shaping – guiding toward new behaviour


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DBT Skills Training

• Mindfulness• Mindfulness is the awareness that emerges through

paying attention on purpose, in the present moment, and non-judgmentally to things as they are

• Mindfulness is intentional• Mindfulness is experiential, and it focuses

directly on present moment experience• Mindfulness is non-judgmental• The practice of mindfulness teaches us to shift

into being mode so that we can be more at peace with our emotions

(Williams et. al., 2007)


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DBT Skills Training: Mindfulness

• Three states of mind:• Reasonable Mind

• Left hemisphere• Rational, logical, facts, observable data• Cause effect, consequences

• Emotion Mind• Right hemisphere• Impulsive• Creative, passionate, empathy

• Wise Mind• Synthesis of both• Need both to make decisions• Less impulsive


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DBT Skills Training

• Practicing mindfulness:• WHAT Skills

• Observe (being aware, noticing)• Describe (“just the facts”)• Participate (completely, in the moment)

• HOW Skills• Non-judgmentally• One-mindfully (be present)• Effectively (do what works!)


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DBT Skills Training

• Distress tolerance skills• For how to survive a crisis without making it

worse • Crisis survival skills:

1. STOP skill

2. Distract with Wise Mind ACCEPTS

3. Self-soothing with the five senses

4. IMPROVE the moment

5. Pros/Cons of engaging in behaviour


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DBT Skills Training

• Distress tolerance skills• Acceptance skills

1. Observe the breath

2. Awareness of the body

3. Half-smile

4. Radical Acceptance• Turn the mind• Willingness vs. wilfulness


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• Distract with Wise Mind ACCEPTS• Activities• Contributing• Comparisons• opposite Emotions• Pushing away (leave it for a while)• with other Thoughts• use other intense Sensations (e.g. holding ice)

DBT Skills Training: Distress Tolerance


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• Self-soothing• Using the five senses• Comfort, nurture, be gentle w/self• Developing compassion for the Self• 5-4-3-2-1 technique (Yvonne Dolan)• Incorporate mindfulness skills• Not making it worse• Being creative (e.g. using playlists or slide shows

on iPod)• Exercise: create a self-soothing collage/scrapbook



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• IMPROVE the moment• Imagery (safe place, relaxing scene)• Meaning• Prayer/spiritual beliefs• Relaxation• One thing in the moment• Vacation• Encouragement



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• Radical Acceptance• Accepting completely and fully situations,

circumstances, and/or people• “Pain is inevitable, suffering is optional”

- Buddha• Accepting completely and fully one’s genetic

predisposition to body shape, size, metabolism• Accepting that they are in treatment• Includes “turn the mind” and “willingness vs.

willfulness”



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DBT Skills Training: Interpersonal Effectiveness Skills

• Asking for things & making requests• Saying “No”’ to requests, staying firm• Focus on being effective• Reviews myths to IPE and helps to challenge them• Objectives effectiveness: DEAR MAN• Relationship effectiveness: DEAR GIVE• Self-respect effectiveness: DEAR FAST


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• DEAR MAN• Describe the current situation• Express feelings and opinions• Assert by asking or saying no• Reinforce the person ahead of time• Mindful of objectives without distraction

• Broken record• Ignoring attacks

• Appear effective and competent• Negotiate alternative solutions

• Turn the tables

DBT Skills Training: IPE Skills


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DBT Skills Training: Emotion Regulation

• Goals of emotion regulation skills• Understand emotions• Identify, observe & describe (mindful),

understand function • Reduce emotional vulnerability• Decrease negative vulnerability (emotion mind)• Decrease emotional suffering• Being mindful of painful emotions and letting go• Acting in a manner opposite to painful emotion


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• Understanding emotions• Emotions communicate to (and influence) others• Emotions organize and motivate action

• Don’t have to think everything through

• Emotions communicate to ourselves• can be self-validating• Provides us with information about a situation• Can be a signal or an alarm that something is happening


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• Reduce emotional vulnerability (staying out of emotion mind)• treat PhysicaL illness• balance Eating• avoid mood-Altering drugs• balance Sleep• get Exercise• build MASTERy


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• Decreasing emotional suffering• Observe your emotion

• Be aware of it, step back, get unstuck

• Experience your emotion• As a wave, don’t block or suppress it• Don’t hold on to or amplify it

• Remember: You are not your emotion• Practice loving your emotion

• Don’t judge it, radically accept it


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• Acting opposite to the current emotion• Not trying to mask or hide emotions• Throw your entire self into acting opposite to the

emotion, go all the way!• Works best when your emotions are not realistic

for the situation• e.g. fear – doing what you are afraid of, over and over

again anger – “be kind, and if you can, be a little bit

nice” or gently avoid (vs. attack)

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Kohut reprise: Twinship

The parent partners with the child in significant tasks

The child develops empathy, creativeness, humor, wisdom and acceptance of his/her transience

Innate skills and talents

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Narcissistic Injury

The parent repeatedly fails the child Mirroring failure – inability to consistently reflect

pride in the child’s accomplishments Inadequacy, emptiness, despair, meaninglessness,

need for reassurance Idealizing failure – e.g. parent who is a drug

addict, “don’t use me as a role model” Defective self-soothing, inability to pursue goals with

commitment (what’s the use? Look where I came from)

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Twinship Failure

Child lacks experiences of joining with the parent in activities Defective empathy, creativeness, humor, wisdom,

acceptance of one’s own transience Lack of skills and competence

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Narcissitic Injury and Rage

The self develops through selfobject provisions of mirroring, idealizing and twinship

The self attempts to protect itself at all costs Selfobject failures lead to narcissitic injury The child feels and is afraid to express rage

(for fear of destroying the parent) The therapist gets to deal with the rage

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In spite of selfobject failure and narcissistic injury, the self protects its integrity through defenses, and where the parents failed, hope springs eternal that the partner will make everything right

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Relationship Management

David Dawson and Harriet MacMillan Look at the process of the personality

disorder: what is the client trying to accomplish?

How does this make sense developmentally? What is a developmentally appropriate

intervention?

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Be helpful by being different

avoid your assigned role position assume a warm but benign, neutral posture be paradoxical discuss the new social contract overtly always assume the client is a responsible,

competent adult but overtly set appropriate limits and

consequences you are prepared to deliver be carefully honest

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1 Family Therapy and Mental Health University of Guelph Open Learning and Educational Support.

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Transcript of 1 Family Therapy and Mental Health University of Guelph Open Learning and Educational Support.