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HANDOUT: PERSONALITY TRAITS SEEN IN THE HARD-TO-SERVE CLIENT: CHALLENGES FOR THE TREATMENT TEAM

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HANDOUT: PERSONALITY TRAITS SEEN IN THE HARD-TO-SERVE CLIENT: CHALLENGES FOR THE TREATMENT TEAM. Stella L. Blackshaw M.D. FRCPC Professor of Psychiatry University of Saskatchewan. Outline. Case History #1, “Kevin” Defense mechanisms used by clients with severe personality disorders

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handout personality traits seen in the hard to serve client challenges for the treatment team
HANDOUT:PERSONALITY TRAITS SEEN IN THE HARD-TO-SERVE CLIENT: CHALLENGES FOR THE TREATMENT TEAM

Stella L. Blackshaw M.D. FRCPC

Professor of Psychiatry

University of Saskatchewan

outline
Outline
  • Case History #1, “Kevin”
  • Defense mechanisms used by clients with severe personality disorders
  • Recognizing Splitting and Projective Identification
  • Managing Splitting and Projective Identification
outline3
Outline
  • Case History #2, “Margaret”
  • Help-seeking / help-rejecting
  • Chronic suicidal ideation and it’s management
kevin personality characteristics
“Kevin” - PERSONALITY CHARACTERISTICS

BORDERLINE:

  • Intense, unstable relationships.
  • Unstable self-image.
  • Recurrent suicidal threats.
  • Unstable mood (intense but brief episodes of dysphoria).
  • Difficulty controlling anger.
kevin personality characteristics5
“Kevin” - PERSONALITY CHARACTERISTICS

NARCISSISTIC:

  • Pre-occupied with fantasies of success or brilliance.
  • Believes he is special or unique.
  • Requires excessive admiration.
  • Has a sense of entitlement.
  • Shows arrogant, haughty behaviours or attitudes.
borderline personality organization kernberg
Borderline Personality “Organization” (Kernberg)

Characterized by :

  • “Poor ego function” (impulsivity, poor reality testing)
  • Predominant use of immature or primitive defenses:

- Denial

- Splitting

- Projective Identification

splitting an unconscious defense against anxiety
SPLITTING - An Unconscious Defense Against Anxiety
  • Splitting of self or others into “all good” or “all bad”.
  • Less anxiety-provoking than viewing self or others ambivalently.
  • Is manifested as polarized attitudes:

- towards different people

- towards the same person but at different times

- towards the self at different times

projective identification
PROJECTIVE IDENTIFICATION

3-Step interactive process (Ogden):

- projection of a (strongly negative or positive) mental representation onto the other person,

- believing it to be true (in the moment) and acting towards the other as if it were true,

- thus inducing the other person to act in a way consistent with the projection.

(a self-fulfilling prophecy)

recognizing splitting and projective identification
Recognizing Splitting and Projective Identification
  • The Client:

- presents him or herself differently to the same person at different times.

- presents differently to different people.

  • The Helping Professional:

- may be idealized at one time, devalued the next.

- hears the client idealizing or devaluing other staff members.

- has intense feelings and may find themselves reacting to the client in ways “not like me”.

recognizing splitting and projective identification cont
Recognizing Splitting and Projective Identification (cont.)
  • Members of the Treatment Team:

- have polarized opinions of the client (“are we talking about the same person?”).

- take polarized positions about management (“rescue and nurture” vs “confront and set limits”).

- have strong feelings about the client and feel strongly about their therapeutic position.

minimizing adverse effects on the team
Minimizing Adverse Effects on the Team
  • Be aware of strong countertransference feelings, either nurturing or punitive.
  • Do not get caught up in the patient’s idealization (or devaluing) of you.
  • Do not collude with the client’s devaluing (or idealization) of other team members.
  • Discuss as a team and assume that each member of the team is a reasonable and competent clinician.
chronic suicidal ideation
CHRONIC SUICIDAL IDEATION
  • Often seen in clients with a history of sexual abuse and Complex PTSD (Herman).
  • A way out, keeping suicide as an option is a comfort, suicidal ideation is a coping mechanism.
  • A communication strategy, (“I feel desperate,- do something!”).
  • Often will not contract for safety, “I can’t promise”, (usually honest!).
management of chronic suicidal ideation linehan
Management of chronic suicidal ideation (Linehan)
  • Validate feelings of distress, reduce need for patient to prove their distress.
  • Give hope, but minimize polypharmacy and dependency.
  • Problem-solve around other coping strategies and focus on patient’s strengths.
  • Note: easier said than done because of help-seeking / help-rejecting pattern.
chronic suicidal ideation when to worry more
Chronic suicidal ideation - when to worry more:
  • Change from usual presentation.
  • Recent loss, especially of supportive relationship.

NOTE: Document reasoning for admitting or not admitting to hospital, e.g. “chronic suicidal ideation with no known change in circumstances, history of hospitalization resulting in regression”.

work as a team
Work as a Team
  • Resist the urge to be overly critical of others’ management of these challenging patients and difficult situations!
references
References
  • 1. Gabbard,Glen O. “Psychodynamic Psychiatry in Clinical Practice” 4th Edition. American Psychiatric publishing Inc. 2005
  • 2. Herman,Judith L. “Trauma and Recovery”. Basic Books 1992
  • 3. Linehan,Marsha M. “Cognitive-Behavioral Treatment of Borderline Personality Disorder”. Guilford Press. 1993
  • 4. Livesley,John W. “Principles and strategies for treating personality disorder”. Can J Psychiatry, Vol 50, No 8, July 2005
  • 5. McWilliams,Nancy “Psychoanalytic Diagnosis”. Guilford Press 1994
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