Working with Individuals Diagnosed with Personality Disorders · PDF fileWorking with...
46
Working with Individuals Diagnosed with Personality Disorders Presented by: Malcolm Horn, LCSW, MAC, SAP January 10, 2018
Transcript of Working with Individuals Diagnosed with Personality Disorders · PDF fileWorking with...
Working with
Individuals
Diagnosed with
Personality Disorders
Presented by:
Malcolm Horn, LCSW, MAC, SAP
January 10, 2018
Thomas Durham, PhD
Director of Training
NAADAC, the Association for Addiction Professionals
www.naadac.org
Produced By
NAADAC, the Association for Addiction Professionalswww.naadac.org/webinars
www.naadac.org/webinars
www.naadac.org/personality-disorders-webinar
Cost to Watch:
Free
CE Hours Available:
1.5 CEs
CE Certificate for
NAADAC Members:
Free
CE Certificate for
Non-members:
$20
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
www.naadac.org/personality-disorders-webinar
3. If applicable, submit payment for CE certificate or join
NAADAC.
4. A CE certificate will be emailed to you within 21 days of
submitting the quiz.
CE Certificate
Using GoToWebinar – (Live Participants Only)
Control Panel
Asking Questions
Audio (phone preferred)
Polling Questions
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
1 32
• Brief review diagnostic criteria
• Key PD that we will focus on:
Borderline
Antisocial
Narcissist
Psychopaths
Sociopaths
• Treatment Goals & Techniques
Agenda
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.
The Four Core Features of Personality Disorders
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 control2. 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
DSM-5 Criteria:
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.
Narcissistic 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.
Histrionic personality
disorder
• 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
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
Psychopaths
• 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??
Both Sociopaths and Psychopaths have:
Causes of Pathology
“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
2. Not born that way—the environment did it
3. Born that way and the environment made it
worse.
Causes of Pathology
• 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
The “Ultimate Attachment Disorder”
• 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
What We See in Clients
• 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
Complex Defenses
If you didn’t have to hold
yourself accountable,
empathize with others,
feel guilt or remorse,
would you change?
“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?
Thinking Errors
• 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
Goals of Therapy & Interactions
• It is not about you
• 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?
When working with PDs…..
• 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 fact-
finding
• Ask yourself what the goal is; stick to it
• DBT
• MET
• SFBT
Techniques
• 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
Dialectical Behavioral Therapy
• 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
1. Activating Event
Immediate Environment
2. Belief System
Filters our perception of the Activating event
Memory
3. Consequences
Fight, Flight, or Freeze
Positive
Negative
The ABC process…..
• 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
Change Requires Safety
….what if you don’t know what safe feels like?
• Active Listening
• Be aware of non-verbal
communication (esp tone and
volume)
• Clarify, repeat, and validate
• Non-threatening
• Non judgmental
• Respect
• Low emotion
Listening Skills are Key
“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
• 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”
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
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
Techniques for Change
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.
Porcupines
• 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
How do we Instill Hope?
• Give choices
• State facts
• Parenting…….
• Meditation
• Anger management
• Grief/Anger work
• Trauma work
• DBT Skills:
Emotional Regulation
Interpersonal Communication
Core Mindfulness
Distress Tolerance
Other Techniques
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.
To keep in mind….
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
Don’t Go it Alone
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.
References:
www.naadac.org/personality-disorders-webinar
Cost to Watch:
Free
CE Hours Available:
1.5 CEs
CE Certificate for
NAADAC Members:
Free
CE Certificate for
Non-members:
$20
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
www.naadac.org/personality-disorders-webinar
3. If applicable, submit payment for CE certificate or join
NAADAC.
4. A CE certificate will be emailed to you within 21 days of
submitting the quiz.
CE Certificate
January 24, 2018 February 28, ,2018
February 14, 2018
The Role of Collegiate Recovery
Programs and the Continuum of
Care
By Amy Boyd-Austin, MMS, LSW
and Susie Mullens, MS, LPC,
AADC-S, MAC
March 14, 2018
Upcoming Webinars
www.naadac.org/webinars
Brief Intervention: Process and
Techniques
By Rebecca Bullion, LCSW, CIP,
SAP, MAC
Cultural Aspect of Trauma and Substance Use
Disorders
By Gladys Smith, PsyD, LPC, MAC, CCMHC, RYT
Journey Through Grief and Loss
By Lisa Connors, LCPC, NCC, MAC, ABD
www.naadac.org/webinars
Over 145 CEs of free educational
webinars are available. Education
credits are FREE for NAADAC
members.
WEBINAR SERIES
In each issue of Advances in
Addiction & Recovery, NAADAC's
magazine, one article is eligible for
CEs.
MAGAZINE ARTICLES
NAADAC offers face-to-face
seminars of varying lengths in the
U.S. and abroad.
FACE-TO-FACE SEMINARS
Earn CEs at home and at your own
pace (includes study guide and
online examination).
INDEPENDENT STUDY COURSES
NAADAC Annual Conference, October 6-8
2018, Houston, TX
www.naadac.org/2018annualconference
CONFERENCES
Demonstrate advanced education in diverse
topics with the NAADAC Certificate Programs:
• Recovery to Practice
• Conflict Resolution in Recovery
• National Certificate in Tobacco Treatment
Practice
CERTIFICATE PROGRAMS
www.naadac.org/education
Contact Us!
NAADAC
44 Canal Center Plaza, Suite 301
Alexandria, VA 22314
phone: 703.741.7686 / 800.548.0497
fax: 703.741.7698 / 800.377.1136
www.naadac.org
NAADACorg
Naadac
NAADAC
