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


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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

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Handout personality traits seen in the hard to serve client challenges for the treatment team l.jpg

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


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Outline

  • Case History #1, “Kevin”

  • Defense mechanisms used by clients with severe personality disorders

  • Recognizing Splitting and Projective Identification

  • Managing Splitting and Projective Identification


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Outline

  • Case History #2, “Margaret”

  • Help-seeking / help-rejecting

  • Chronic suicidal ideation and it’s management


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“Kevin” - PERSONALITY CHARACTERISTICS

BORDERLINE:

  • Intense, unstable relationships.

  • Unstable self-image.

  • Recurrent suicidal threats.

  • Unstable mood (intense but brief episodes of dysphoria).

  • Difficulty controlling anger.


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“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.


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Borderline Personality “Organization” (Kernberg)

Characterized by :

  • “Poor ego function” (impulsivity, poor reality testing)

  • Predominant use of immature or primitive defenses:

    - Denial

    - Splitting

    - Projective Identification


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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


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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)


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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”.


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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.


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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.


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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!).


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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.


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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”.


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Work as a Team

  • Resist the urge to be overly critical of others’ management of these challenging patients and difficult situations!


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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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