The word personality describes deeply ingrained patterns of behavior and the manner in which individuals
perceive, relate to, and think about themselves and their world. Personality
traits are conspicuous features of personality and are not necessarily pathological,
although certain styles of personality traits may cause interpersonal problems. Personality disorders are rigid, inflexible, and maladaptive behavior
patterns of sufficient severity to cause significant impairment in functioning or
internal distress. Personality disorders are enduring and persistent styles of
behavior and thought, not atypical episodes.
Several alcohol and other drug
(AOD)-induced states can mimic personality disorders. If a personality disorder coexists
with AOD use, only the personality disorder will remain during abstinence. AOD
use may trigger or worsen personality disorders. The course and severity of
personality disorders can be worsened by the presence of other psychiatric problems
such as mood, anxiety, and psychotic disorders.
The personality disorders
include paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial,
borderline, avoidant, dependent, obsessive-compulsive, passive-aggressive, and self-defeating
personality disorder. Many features of the personality disorders may occur during
an episode of another mental disorder. Individuals may meet criteria for
more than one personality disorder.
Four personality disorders have been
selected for detailed discussion: borderline, antisocial, narcissistic, and passive-aggressive.
These are among the greatest challenges to treatment providers. This
TIP provides information about engagement, assessment, crisis stabilization,
and longer-term care, and describes a continuum of care for patients with personality
disorders.
Antisocial personality disorder involves a history of chronic antisocial behavior
that begins before the age of 15 and continues into adulthood. The disorder
is manifested by a pattern of irresponsible and antisocial behavior as indicated
by academic failure, poor job performance, illegal activities, recklessness,
and impulsive behavior. Symptoms may include dysphoria, an inability to tolerate
boredom, feeling victimized, and a diminished capacity for intimacy. Borderline
personality disorder is characterized by unstable mood and self-image, and unstable,
intense, interpersonal relationships. These people often display extremes of overidealization
and devaluation, marked shifts from baseline to an extreme mood or anxiety
state, and impulsiveness.
Narcissistic personality disorder describes
a pervasive pattern of grandiosity, lack of empathy, and hypersensitivity
to evaluation by others. Passive-aggressive personality disorder
involves covertly hostile but dependent relationships. People with this disorder
commonly lack adaptive or assertive social skills, especially with regard to authority
figures. They often display a passive resistance to demands for adequate social
and occupational performance. They generally fail to connect their passive-resistant
behavior with their feelings of resentfulness and hostility toward others.
Exhibit 7-1 describes the characteristics of passive-aggressive, antisocial,
and borderline personality disorders.
Avoidant personality disorder includes social discomfort, hypersensitivity to both criticism and rejection, and
timidity, with accompanying depression, anxiety, and anger for failing to develop
social relations. Obsessive-compulsive personality disorder describes
a disorder of perfectionism and inflexibility. Symptoms may include distress
associated with indecisiveness and difficulty in expressing tender feelings, feelings
of depression, and anger about being controlled by others. Hypersensitive
to criticism, these people may be excessively conscientious, moralistic, scrupulous,
and judgmental.
Histrionic personality disorder is characterized
by a pervasive pattern of excessive emotionality and attention seeking. Behavior
may include constant seeking of approval or attention, striking self-centeredness,
or sexual seductiveness in inappropriate situations. Paranoid personality
disorder is characterized by a pervasive and unjustified proclivity to interpret
the actions of others as intentionally threatening, demeaning, and untrustworthy.
Dependent personality disorder is characterized by a pervasive
pattern of dependent and submissive behavior and an intense preoccupation with
possible abandonment. Persons with this disorder often feel anxious and depressed,
and may experience intense discomfort when alone for more than a brief time.
Schizoid personality disorder involves a pervasive pattern of indifference
to social relationships and a restricted range of emotional experience and
expression. Schizotypal personality disorder entails deficits in interpersonal
relatedness and peculiarities of ideation, appearance, and behavior and dysphoric states
such as anxiety and depression. Self-defeating personality disorder
is characterized by a pattern of self-defeating behavior in work and personal
relationships, often with complaints of exploitation by others; these persons are often unaware
of their contributions to the outcomes of their behavior.
Personality
disorders not otherwise specified (NOS) include disorders of personality functioning
that are not classifiable as specific personality disorders. Instead, individuals
do not meet the full criteria for any one personality disorder; yet their
symptoms cause significant impairment in social or occupational functioning, or
cause subjective distress. Personality disorders NOS include impulsive, immature,
and sadistic personality disorders.
Diagnoses should be clinically based,
and not influenced by professional, personal, cultural, or ethnic biases.
For example, in the past some African Americans were stereotyped as having
paranoid personality disorders; women have been diagnosed too frequently as being
histrionic, but they are seldom diagnosed as antisocial or psychopathic; Native Americans
with spiritual visions have been misdiagnosed as delusional or having borderline
or schizotypal personality disorders.
People with a personality
disorder often use AODs for purposes that relate to the personality disorder: to
diminish symptoms of the disorder, to enhance low self-esteem, to decrease feelings
of guilt, and to amplify feelings of diminished individuality.
People
with borderline personality disorder often use AODs in chaotic and unpredictable
patterns and in polydrug patterns involving alcohol and other sedative-hypnotics
taken for self-medication. People with personality disorders often develop problems
with benzodiazepines that have been prescribed for complaints such as anxiety,
which may lead to relapse to the primary drug of choice.
Many people
with antisocial personality disorder use AODs in a polydrug pattern involving
alcohol, marijuana, heroin, cocaine, and methamphetamine. The illegal drug culture
corresponds with their view of the world as fast-paced and dramatic, which supports
their need for a heightened self-image. Consequently, they may be involved in
crime and other sensation-seeking, high-risk behavior. Some may have extreme
antisocial symptoms. They tend to prefer stimulants such as cocaine and the amphetamines.
Rapists with severe antisocial personality disorder may use alcohol to
justify conquests. People with less severe antisocial personality disorder may
use heroin and alcohol to diminish feelings of depression and rage.
People with narcissistic personality disorder are often polydrug users with a
preference for stimulants. Alcohol has disinhibiting effects, and may help to diminish
symptoms of anxiety and depression. Socially awkward or withdrawn people with narcissistic
personality disorder may be heavy marijuana users. One group of people with narcissistic
personality disorder uses steroids to build up a sense of physical perfection. When
not using AODs, people with narcissistic personality disorder may feel that
others are hypercritical of them or do not sufficiently appreciate their work,
talents, and generosity. During a crisis, these people may be severely depressed
and upset.
Drug preference among people with passive-aggressive and self-defeating
personality disorders often varies according to gender. Women may prefer alcohol and
other sedative-hypnotics to sedate negative feelings such as anxiety and depression.
Although men may use these AODs, they may also use stimulants to disinhibit
aggressive or risk-taking behaviors. People with passive-aggressive personality disorder
often complain of somatic problems, such as migraines, muscle aches, and ulcers.
They may seek over-the-counter medications as well as cocaine and amphetamines
to relieve somatic symptoms.
Progress with patients who have personality disorders can
be slow. Therapists should be realistic in their expectations and should
know that patients will try to test them. To respond to such tests, therapists
should maintain a matter-of-fact, businesslike attitude, and remember that people
with personality disorders often display maladaptive behaviors that have helped
them to survive in difficult situations. These behaviors may be called "survivor
behaviors."
It is important to educate patients about their AOD use and psychiatric disorders.
Patients should learn that recovery from AOD use is not synonymous with
treatment for personality disorders. Written and oral contracts can be a useful
part of the treatment plan. They should be simple, clear, direct, and time-limited.
Contracts can help patients create safe environments for themselves, prevent
relapse, or promote appropriate behavior in therapy sessions and in self-help meetings.
Treatment of people with personality disorders requires attention
to several particular issues, such as violence to self or others, transference
and countertransference, boundaries, treatment resistance, symptom substitution,
and somatic complaints.
All
suicidal behavior, from threats to attempts, must be taken seriously and assessed
immediately to determine the type of immediate intervention needed. Special attention
must be given to previous attempts and their seriousness, previous intervention
strategies, whether the failure of the attempt was intended or accidental, the relation
of previous suicidal behavior to psychiatric symptoms, and current psychiatric
symptoms. All suicidal behavior should provoke the following questions:
Management of self-harm can be accomplished by creating
written or oral contracts with patients. In these contracts, a patient may promise
to avoid certain self-harm or high-risk behavior (such as suicide or relapse),
or may promise to engage in a specific healthy behavior (such as calling his
or her 12-step sponsor or a suicide prevention hotline) when self-harm or a
high-risk behavior appears imminent.
Therapists should attend to the patient's
need for safety. Safety may range from the need for safe shelter to escape
domestic violence to the need to reside in a controlled environment in order to
remain abstinent.
Transference and countertransference can present problems in group and individual therapy.
Therapists should be prepared to manage these issues. Transference refers
to positive and negative feelings and perceptions that the patient projects
onto the therapist. Countertransference refers to distortions in the therapeutic
process due to the therapist's unresolved conflicts. Both transference and countertransference
rely on the mechanism of projection.
Projection is a combination of
personal past experiences along with feelings experienced during the course of therapy.
Being aware of transference issues and commenting on them when appropriate
is extremely important when working with these patients.
Boundaries are clear expectations regarding limitations
or requirements in roles or behavior. Boundaries are ethical and practical
ground rules that help therapists to be therapeutically helpful to patients.
The clinician and patient must establish and maintain clear boundaries. Boundaries
must also be set in group therapy sessions. For example, therapists should
not lend money to patients or involve them in financial deals. Patients should
not establish intimate relationships with others in group therapy.
People with personality disorders often
assume certain roles or ways of social interaction. They may shift from one role
to the next, depending upon the situation. Some of these roles include:
the victim, the persecutor, and the rescuer.
As these patients assume
a specific role (such as the victim), other people may be prompted to assume
a complementary role (such as the rescuer). Therapists should be aware of
the roles that people with personality disorders may assume. They should resist
assuming dysfunctional complementary roles themselves and become aware when they
do assume such roles.
Patients
with personality disorders often exhibit acting-out behaviors that were developed
as psychological defenses and survival techniques. The patient may be reenacting
a response learned during experiences of abuse or trauma. Resistances are
defenses and coping mechanisms that help patients survive in situations confronted
in therapy which are perceived as threatening.
Confronting a patient's
resistance without helping the patient develop other strategies for safety will probably
escalate the patient's tension. Therapists should view and use resistance as a
therapeutic issue, not as a challenge to treatment.
It is becoming increasingly clear that alcohol and most other drugs of abuse
produce acute and subacute withdrawal syndromes. Depending on the specific drug,
subacute withdrawal may include mood swings, irritability, impairment in cognitive
functioning, short-and long-term memory problems, and intense craving for AODs. Subacute
withdrawal syndromes often trigger relapse and exacerbate existing psychiatric symptoms
During periods of abstinence
from AODs, some people will engage in other types of compulsive behaviors. Some
of these behaviors include eating disorders, and compulsive spending, gambling,
and sex. Relationship problems may also increase.
Patients with addictions to prescription drugs often
seek treatment because of somatic complaints. Therapists should watch for use
of prescription and over-the-counter drugs and for drug-seeking behaviors.
Therapists should be mindful of
their own well-being, which can be compromised when working with patients with
personality disorders. Clinicians can be drawn into playing certain roles in the lives
of patients with personality disorders. To prevent this, therapists should
care for themselves by seeking outside supervision. Therapists should join
or develop support systems with others in the field through 12-step program
participation, regular meetings with other therapists, grand rounds, and the like.
The following sections describe specific strategies and techniques that therapists
can use when working with patients who have an AOD use disorder and a borderline,
antisocial, narcissistic, or passive-aggressive personality disorder.
Each section
describes techniques for assessing patients and engaging them in treatment, stabilizing
crises, providing long-term care, and creating a continuum of care. Each section
concludes with a case example in which the reader is asked to make a treatment decision.
Where appropriate, clinical tools are provided.
Key Issues and Concerns in The Treatment of Personality Disorders
Safety is an anchor for patients with borderline
personality disorder, for whom abandonment and fear of rejection are often core issues.
To engage and assess these patients, the therapist should acknowledge
and join with the patient's need for safety. The therapist's absence, even
for brief periods, can prompt acting-out behavior.
Acting-out behavior
is a maladaptive survivor response that expresses a need for safety. Therapists
should identify each patient's motivation for recovery, which may be rooted in
safety. Further, therapists should discover what safety means to the patient.
Therapists can learn how patients create their own feelings of safety by asking them
about safe spots, magic getaway places, closet-sitting, rocking or other repetitive
movements, or other techniques the patient may use to generate a sense of security.
To help patients with borderline personality disorder establish and maintain
a sense of safety, therapists can continually ask patients: "What do you
need right now?" "What do you want right now?"
Therapists may work with
patients to develop a patient-generated list of the conditions that they need in
order to feel safe. Therapists may ask patients: "What would have been helpful
(in a specific situation) to make you feel safe?" Through teaching cognitive
skills to promote patients' sense of safety, therapists can help patients with
borderline personality disorder to assume personal responsibility for their own safety.
Written and verbal contracts can identify specific ways to help
patients stay physically and emotionally safe and to prevent relapse. Written and
verbal contracts for safety should be developed during the assessment process
with simple and clear behavioral responses regarding the management of unsafe
feelings and behaviors. These contracts can be very simple and direct:
"If I feel like I want to get drunk, I will call my sponsor."
"If I
feel like getting loaded, I will go to the next NA meeting."
"If I
feel like hurting myself, I will call a crisis hotline and go to my sister's
house."
"I will report self-harm thoughts and behaviors to the therapist at the next
session."
When assessing a patient, the therapist is
attempting to understand and view the patient within a holistic framework. Areas
of assessment may include a history of AOD and mental health treatment, suicidal
planning, dissociative experiences, psychosocial history, history of sexual abuse,
and a history of psychotic thinking. Some patients may also require a neurological
examination.
The assessment of patients with borderline personality disorder should look
for a history of self-harm. Behaviors such as AOD use should be described
as unsafe behaviors. However, clinicians should help people with borderline
personality disorder to avoid black-and-white thinking, such as right/wrong and good/bad,
and all-or-nothing styles of thinking. Specifically, the assessment should
include the following:
A history of previous treatment, including psychiatric
medications administered, and a description of what worked and what did not work in
treatment, as well as information on why the patient left earlier treatment. Patients
are not always a reliable source of information about themselves, and therapists
should evaluate this information accordingly. The treatment history can help
the therapist avoid unnecessary repetition of treatment strategies, such as
skill-building activities in which the patient is already competent (for example, relaxation
strategies). The history taking is an opportunity to examine patients' strengths and
weaknesses.
A list of potential means available to patients
to injure themselves in their own homes, such as a large supply of medication.
History and evidence of dissociative experiences,
such as trance states, rocking, flashbacks, nightmares, and repressed memories.
Any and all parts of a memory can be repressed. One model for assessing
dissociation and identifying repressed memories is the BASK model. The BASK model is
a quick way to check what part of the memory is missing, and whether or not
it is Behavior, Affect, Sensation, or Knowledge. Survivors of abuse may detach
themselves from their feelings so that they recall memories of abuse in a robot-like
fashion.
Attachment to a special object. Anniversary reactions are
also common to survivors of abuse, whose memories or feelings may be triggered
by certain dates, events, or objects. For no apparent reason, the survivor
may become sick or suicidal when faced with a situation similar to a past reminder
of abuse.
History of fugue states and losing time.
For example, patients with borderline personality disorder might start
watching a movie and suddenly reorient later in the middle of another movie, with
no clear memory of the elapsed time.
Psychosocial
history and history of sexual abuse. It is common for people to feel as if they
were sexually abused without having any actual memories of the abuse or trauma.
Questions should be framed in a manner that facilitates the acquisition
of all relevant information. By asking open-ended questions while paying
attention to the patient's body language, the therapist may be able to draw useful
conclusions.
Neurological workup of individuals who have
a history of self-mutilating behaviors that could have resulted in cognitive
impairment such as head-slamming. Some psychologists will conduct neurological screening;
in other cases, a neurologist should be consulted.
Psychotic-like
thinking and history of suicidal behavior, especially under intense stress. Psychotic-like
thinking may be evident during episodes of trauma and stress. For example, a patient
may state, "The walls are bleeding."
Safety issues are at the core of crisis stabilization.
To ensure the patient's safety or to detox a patient, a brief psychiatric
hospitalization may be necessary. Issues to be addressed during crisis stabilization might
include an unwillingness or inability to contract for safety. A written release
of medical information is important to coordinate care with physicians and
addiction counselors.
At this stage, therapists should avoid psychodynamic
confrontations with patients and should not engage patients in further therapy for abuse
or trauma. The treatment focus should be on addressing the patient's need
for safety, especially important with patients who have borderline personality
disorder. More complicated and emotionally charged material should be deferred until
the patient has better skills to manage emotional pain.
It may be helpful
to describe out-of-control crisis behavior as a survivor response. Therapists
and patients should avoid rigid black-and-white thinking. Describing events
or issues as being more helpful or less helpful may circumvent the inflexibility
of seeing life's challenges and problems only as black and white, while ignoring
the numerous grey areas of experience.
During crisis stabilization, the
continued use of written and verbal contracts is critical. These contracts should
be rooted in the here-and-now, and should offer patients practical ways to
manage crisis behavior. The contracts must focus on safety. Contracts written
on 3-by-5-inch cards that they can carry and read when necessary are very
helpful for patients with borderline personality disorder. Contracts should be
simple and concrete and should emphasize problem-solving skills.
Therapists
should work on relapse management strategies that are clear and concrete, such
as: "Before I use cocaine, I will call my sponsor." At the same time, therapists
should encourage patients to be honest about relapse. Therapists should assume
a posture of concerned support about relapse and view it as an opportunity
to learn from past mistakes and strengthen relapse prevention skills and the
therapeutic relationship.
The family -- as defined by each patient -- should
take part in this process. It may be useful to encourage contracts with family
members. These contracts can dissuade family members from assuming dysfunctional
roles such as the victim, the persecutor, and the rescuer. The family should
learn how to set boundaries with the patient, and should learn not to play certain
roles, especially the role of rescuer.
In individual therapy, issues
stemming both from borderline personality disorder and from AOD use may emerge.
Issues related to unsafe behavior or AOD use will continue to be important.
Longer-term care is a stage in which teaching the patient skills, such
as assertiveness and boundary setting, can be useful.
Patients may need
to be educated about survivor issues without exploring more psychodynamically
based issues. Patients should be oriented to a survivor framework, but therapists
must build slowly before engaging patients in retrieving painful memories.
The abuse survivor should demonstrate the necessary skills to benefit from
psychotherapy. Patients should tell the therapist when they are not ready to discuss certain
issues. Once patients are ready to do so, the integration of psychodynamic material
and trauma therapy may begin. There is no pressing need for the retrieval
of early memories of trauma. Rather, the focus of therapy may be on behavior
rather than memory.
Therapists might try to frame acting-out behaviors as
survivor behaviors. Complications at this stage can include a variety of compulsive
and impulsive behaviors, such as eating disorders (obesity, anorexia, bulimia),
compulsive spending and money mismanagement, relationship problems, inappropriate
sexual behaviors, and unprotected sex (in regard to STDs and pregnancy). Other
maladaptive behaviors include sexual impulsiveness, which can cause confusion about
sexual identity dramatized in experimental sexual relationships, adding to the
crisis and drama on which people with borderline personality disorder often thrive.
Therapists may want to consider limiting access to educational material about adult
children of alcoholics (ACOAs) for patients with borderline personality disorder.
Reading some ACOA material and self-help books and participating in self-help
support groups may be detrimental to some patients' recovery. For some patients,
self-labeling can become counter-productive -- and in worst-case scenarios, it can lead
to self-fulfilling prophesies.
For example, books suggesting that
some people self-mutilate in order to relieve pain may teach patients with borderline
personality disorder to self-mutilate. Some books offering "inner-child work" lead
the patient through age-regressive exercises that can cause an overwhelming
flood of feelings the abused patient may not yet be ready to manage.
Therapists
should remember that progress in treating patients with borderline personality
disorder and AOD problems can be slow. There may be many setbacks. Rather than
looking for enormous changes in personality or behavior, therapists should look
for small, measurable signs of improvement.
In addition, therapists may
want to consider the following in treating patients with borderline personality
disorder:
Using mini-contracts for each session to encourage the patient to stay focused.
Immediately asking patients about any crises that have occurred,
reviewing the entire week, not just a particular day.
Stating the purpose
of each session.
Running through a checklist can be helpful. A list
might include: homework, failing tests, arguments with others, interactions
with the criminal justice system, problems in school or work life, family relationships
and friends, relapses, thoughts of self-harm, nightmares, flashbacks, painful
situations, and bad memories. Questions should be specific.
Encouraging patients
to keep mood and dream journals (especially during survivor work) between
sessions for brief comments on mood.
Conducting survivor work only after
daily living skills are successfully demonstrated.
Keeping and dating
all correspondence and notes from telephone conversations. Having previous
conversations documented can help to remind the patient of earlier agreements and conversations.
There are special issues concerning work
with people with borderline personality disorder in group therapy. Therapists
should consider the following:
Making contracts for all members to stay
in the room.
Making contracts for group rules that promote safe behavior
and not hurting oneself or others.
Working with transference and countertransference
issues.
Discussing thoughts and feelings about other group members as they arise.
Setting time limits at the start of each session.
Making mini-contracts
for those who have issues to work on in each session.
Having group
members sign contracts for abstinence and reporting self-harm and AOD use to the
group.
Making contracts for confidentiality.
Disallowing participants
to form intimate or exclusive relationships. Supportive activities, such
as calling one another during crises or attending 12-step meetings together,
are acceptable and should be encouraged.
Evaluating safety issues in
screening people with borderline personality disorder for group therapy. Patients
should be safe from predatory, manipulative behavior of others, and should not
engage in such behaviors themselves.
Although 12-step involvement
is important for patients with borderline personality disorder, some may not
be immediately able to attend 12-step meetings. Some patients may find it
more helpful to participate in pre-12-step practice sessions. These patients
should be helped to organize their thoughts, to practice saying "pass," and to
create safety in a 12-step meeting. Counselors may want to use the step work
handout as a treatment tool for working with people with borderline personality
disorder (see Exhibit 7-2 and Chapter 6
on use of 12-step meetings).
Patients should be encouraged to join
same-sex 12-step groups when possible. People with borderline personality disorder
may find it helpful to use same-sex sponsors as guides to recovery. When possible,
therapists should educate the sponsor about survivor behaviors. The sponsor may even
attend a therapy session to learn why the patient is taking medications. Antidepressants
or lithium may be an important part of the patient's recovery. Explaining
how medications are helpful may enable sponsors to help improve medication
compliance.
Some sponsors may have problems setting boundaries. Such sponsors
should not be paired with borderline patients. If they must be paired, however,
they need to understand how important boundaries are in helping borderline patients
feel safe. Understanding this may keep them from taking on borderline patients,
who may be more than they can handle. Material in the step program should
be limited to the here-and-now. Patients should not engage in dealing with
sexual abuse issues until they are ready.
Longer-term care should include
specialized 12-step work. In using step one ("We admitted we were powerless over alcohol
-- that our lives had become unmanageable.") with patients who have borderline
personality disorder, therapists should encourage patients to recognize that powerlessness
does not mean helplessness. Instead, patients should focus on gaining personal
control over AOD use. Faith and hope concepts used in 12-step work may also be
difficult for this group to comprehend or integrate.
An aftercare plan for patients with dual disorders is essential.
This plan should integrate rather than fragment strategies for treating
the patient. It should include methods to coordinate care with other treatment
providers. Relapse prevention is critical and should be managed through careful planning
throughout treatment. Relapse should be defined as engagement in any unsafe behavior
such as AOD use, self-harm, and noncompliance with medications. Relapse prevention
should focus on preventing AOD use and recurrence of psychiatric symptoms.
Patients should be encouraged to participate in 12-step groups and other self-help
and support groups such as Adults Molested As Children (AMAC), Incest Survivors
Anonymous (ISA), and Survivors of Incest Anonymous (SIA).
Acute hospitalization
may be necessary during suicidal crises. Again, the emphasis of treatment
should remain on safety. Outpatient therapy should continue. AOD treatment should
be obtained when appropriate. Therapists should be wary of triangulation
in coordinating with other professionals.
Rachel was 32 years old when she was taken by ambulance
to the local hospital's emergency room. Rachel had taken 80 Tylenol capsules
and an unknown amount of Ativan in a suicide attempt. Once stable medically,
Rachel was evaluated by the hospital's social worker to determine her clinical
needs.
The social worker asked Rachel about her family of origin. Rachel
gave a cold stare and said, "I don't talk about that." Asked if she had ever
been sexually abused, Rachel replied, "I don't remember." Rachel acknowledged
previous suicide attempts as well as a history of cutting her arm with a razor blade
during stressful episodes. Rachel reported that the cutting "helps the pain."
Rachel denied having "a problem" with AODs but admitted taking "medication" and
"drinking socially." A review of Rachel's medications revealed the use of Ativan
"when I need it." Rachel used Ativan three or four times a week. She reported
using alcohol "on weekends with friends" but was vague about the amount. Rachel
did acknowledge that before her suicide attempts, she drank alone in her apartment.
This last suicide attempt was a response to her breakup with her boyfriend.
Rachel's insurance company is pushing for immediate discharge.
Question -- Should Rachel be discharged? Where should she be sent? Exhibit 7-3 shows a recovery model for treatment of borderline personality
disorder.
Clinicians should be careful
to avoid mislabeling patients. Although some women may have antisocial personality
disorder, they receive this diagnosis less often than men. Instead, they may be
misdiagnosed as having borderline personality disorder. Among the male prison population,
20 percent may have antisocial personality disorder. However, once they are
abstinent, many AOD-using offenders may not meet the criteria for antisocial personality
disorder.
In engaging the patient with antisocial
personality disorder, it is useful to join with the patient's world view, which may
include a need for control and a sense of entitlement. In this context, entitlement
refers to people who believe their needs are more important than the needs of
others. Entitlement may include rationalization of negative behavior (such as
robbery or lying). People with antisocial personality disorder may evidence little
empathy for their victims. If incarcerated, they may believe they should be released
immediately. In an AOD treatment program, they may describe themselves as being unique
and requiring special treatment.
The primary motivation of the patient
with antisocial personality disorder is to be right and to be successful. It
is useful to work with this motivation, not against it. Although this motivation
may not reflect socially acceptable reasons for changing behavior, it does
offer a point from which to begin treatment. Wanting to be clean and sober,
to keep a job, to avoid jail, and to become the chair of an AA meeting are
reasonable goals, despite a self-serving appearance. Therapists may help patients
by working with patients' world view, rather than by trying to change their
value system to match those of the therapist or of society.
Patients should
understand their role in the process. In engaging patients, therapists may want to
use contracts to establish rules for conduct during treatment. The contract
should explicitly state all expectations and rules of conduct and should be honored
by all parties. Such an approach can be useful with people with antisocial
personality disorder, who often view relationships as unfair contracts in which one
person attempts to take advantage of the other. Therapists may find that once
a level of interpersonal respect has been established, working with antisocial
patients can lead to important gains for the patient.
In addition to an objective psychosocial and criminal history, the following
steps may be useful in assessing the antisocial patient:
Taking a thorough
family history.
Finding out whether or not the patient set fires as a
child, abused animals, or was a bed-wetter.
Taking a thorough sexual history
that includes questions about animals and objects.
Taking a history
of the patient's ability to bond with others. Therapists can ask: "Who was
your first best friend?" "When was the last time you saw him or her?" "Do
you know how he or she is?" "Is there any authority figure who has ever been
helpful to you?"
Asking questions to find out about possible parasitic
relationships and taking a history of exploitation of self and others. In this context,
parasitic refers to a relationship in which one person uses and manipulates another
until the first has gotten everything he or she wants, then abandons the relationship.
Taking a history of head injuries, fighting, and being hit. It may be useful
to perform neuropsychological testing.
Testing urine for recent AOD
use.
HIV testing.
The assessment should consider criminal thinking
patterns, such as rationalization and justification for maladaptive behaviors. There
is a special need to establish collateral contacts and to assess for criminal
history and the relationship of AOD use to behavior.
Useful assessment
instruments include the Minnesota Multiphasic Personality Inventory (MMPI), the Millon
Clinical Multiaxial Inventory (MCMI), the PCL-R (Hare Psychopathy Checklist-Revised),
and the CAGE questionnaire.
People with antisocial personality disorder may enter treatment profoundly depressed,
feeling that all systems have failed them. Often, their scams and lofty ideas
have failed and they feel exposed, feel like losers, and have no ego strength.
They are at risk for suicide, especially during intoxication or acute
withdrawal. They may require psychiatric hospitalization and detoxification.
They may become acutely paranoid. Containment in the form of a brief hospitalization
may be indicated for patients experiencing acute paranoid reactions to avoid
acting out against others. For less acute paranoid reactions, therapists should
try to avoid cornering patients, disengage from any power struggle, offer lower
stimulus levels, and create options, especially if those are supplied by the antisocial
patient. During this phase, clarification without harsh confrontation is recommended.
When patients with antisocial personality disorder have crises, therapists should
become cautious and careful. During crises, these patients may engage in dangerous
physical behavior in order to avoid unpleasant situations or activities, and therapists
should avoid angry confrontations.
It is helpful to view the process
of working with antisocial patients as a process of adaptation of thinking
rather than the restructuring of a patient into a person whose morals and values
match those of the therapist or society. Therapists may benefit from modifying
their own expectations of treatment outcomes, and realize that they may not help
some patients to develop empathic and loving personalities. It is enough to
guide patients to lead lives that follow society's rules.
Individual therapy
offers the therapist an opportunity to point out patients' errors in thinking
without causing them to feel humiliated in the presence of the therapy group.
Other issues for individual therapy may include continued relapse management
and identity of empathy. Three key words summarize a strategy for working
with people with antisocial personality disorder: corral, confront, and consequences.
Corral.
Corralling with regard to patients with antisocial
personality disorder means coordinating treatment with other professionals, establishing
a system of communications with other professionals and with the patient,
contracting patients to be responsible for their AOD use in the recovery program, monitoring
information about the patient, and working toward specific treatment goals. Patients
may benefit by signing agreements to comply with the treatment plan and by
receiving written clarification of what is being done and why. Interventions and
interactions should be linked to original treatment goals.
One approach to
treatment that adds to the notion of "corralling" is to "expand the system." Spouses,
family members, friends, and treatment professionals may be invited to participate
in counseling sessions as a way to provide collateral data. This is sometimes
called "network therapy."
Confront.
In confronting antisocial
patients, therapists can be direct without being abusive. They can be clear in pointing
out antisocial thinking patterns. They can remark on contradictions between
what patients say and what patients do. Random AOD testing is essential for
monitoring patients. Honest reporting of AOD use should be an active part of treatment.
Consequences.
Patients should bear the consequences of their behavior. For instance,
violation of probation or rules should be recorded. Patients who are offenders should
be encouraged to report behavior that violates probations, thus taking responsibility
for their own actions. Positive consequences that demonstrate to patients the
benefits of appropriate behavior should also be designed and incorporated into the
treatment plan. Financial incentives and opportunities for power or recognition
can be a key element of treatment.
Case management may involve coordinating
care with a variety of other professionals and individuals, including those
in the criminal justice system, AOD counselors, and family members. Therapists
need to make it clear to patients that the therapist must talk to other providers
and to family members. Thus, it is helpful for patients to sign releases of
information for all people involved in their treatment.
The question of terminating
therapy can be a puzzling one for therapists treating antisocial patients. The
patient may frequently express a desire to end treatment. This desire should be
closely examined to determine whether it is a manifestation of patient resistance
or whether it is a valid request. There is some question about whether it
is appropriate to terminate therapy with patients who have antisocial personality
disorder who may need ongoing treatment. Reasons for termination may include noncompliance
with treatment, continued drug use without improvement, any aggressive behavior,
parasitic relationship with other patients, or any unsafe behavior.
Patients
with antisocial personality disorder compulsively try to break rules. If a
treatment plan is not devised to work with a person who wants to redefine rules,
termination should be considered and transfer to more appropriate care should be arranged.
Continued thinking-error work, as described in Exhibit 7-4, may help patients to
identify various types of rationalizations that they may use regarding their behaviors.
Group therapy is a useful setting in
which people with antisocial personality disorder can learn to identify errors
not only in their own thinking, but in the thinking of others. The group can
help identify relapse thinking. For example, when an individual begins to glamorize
stories of AOD use or criminal and acting-out behaviors, the group can help to
limit that grandiosity. Therapists may also ask people with antisocial personality
disorder to discuss feelings associated with the behavior being glamorized.
Role play exercises can be useful tools in group therapy. However, therapists
should be careful to prevent patients with antisocial personality disorder from
using newly learned skills to exploit or control other group members. In group
therapy, patients with antisocial personality disorder can be encouraged tomodel
prosocial behaviors and learn by practicing them. Role play exercises can help these
patients to focus on their shortcomings rather than on the faults of others.
AOD
therapists should avoid creating groups that consist entirely of patients with antisocial
personality disorder. Such groups are best conducted in very controlled settings in
which therapists have control over the environment.
Patients with antisocial
personality disorder may be asked to sign contracts that establish healthy and nonparasitic
relationships with other group members. This means not becoming romantically involved
with other members, not borrowing money from them, and not developing exploitive
relationships.
Therapists themselves should try not to become obsessed with being
manipulated or tricked by group members. Such power struggles are not helpful.
Counseling Tips for Patients With Antisocial Personality Disorder
Corral:
Coordinate treatment.
Communicate with other providers.
Make contracts with patients.
Confront:
Be direct, not abusive.
Identify antisocial thinking.
Conduct random AOD testing.
Consequences:
Make patients responsible for their behavior.
Record violations of rules.
Allow patients to experience consequences of their behavior.
A key to treating people with antisocial
personality disorder is to be flexible within an array of containment interventions.
Therapists should have the ability to quickly move a patient from a less
controlled environment to a more controlled environment. Patients benefit from sanctions
that match the degree of severity of behavior. Sanctions should not be "punishments"
but responses to the need for containment and more intensive treatment. Antisocial
patients need a range of treatment and other services: from residential to outpatient
treatment, from vocational education to participation in long-term relapse prevention
support groups, and from 12-step programs to jail.
When patients with antisocial
personality disorder shed aspects of the disorder, they may become more dependent.
Therapists often try to limit such dependence. However, with regard to
antisocial patients, such a transition should be allowed rather than confronted.
It often represents a healthy change. Feelings of dependency are easily frustrated
at this stage, and disappointment may result in relapse.
Mark was 27 years old when he was arrested
for driving while intoxicated. Mark presented himself to the court counselor
for evaluation of possible need for AOD treatment. Mark was on time for the
appointment and was slightly irritated at having to wait 20 minutes due to the counselor's
schedule. Mark was wearing a suit (which had seen better days) and was trying to
present himself in a positive light.
Mark denied any "problems with alcohol"
and reported having "smoked some pot as a kid." He denied any history of suicidal
thinking or behavior except for a short period following his arrest. He acknowledged
that he did have a "bit of a temper" and that he took pride in the ability to
"kick ass and take names" when the situation required. Mark denied any childhood
trauma and described his mother as a "saint." He described his father as "a real
jerk" and refused to give any other information.
In describing the situation
that preceded his arrest, Mark tended to see himself as the victim, using statements
such as "The bartender should not have let me drink so much," "I wasn't driving
that bad," and "The cop had it out for me." Mark tended to minimize his own
responsibility throughout the interview. Mark had been married once but only briefly.
His only comment about the marriage was, "She talked me into it but I got
even with her." Mark has no children and currently lives alone in a studio
apartment. Mark has attended two meetings of Alcoholics Anonymous "a couple of years
ago before I learned how to control my drinking."
Question -- What might
the court counselor recommend to the judge as an appropriate treatment plan
for Mark?
Exhibit 7-5 shows a treatment tool
for use with patients who have antisocial personality disorder.
In trying to engage and assess patients, therapists should remember that patients
with narcissistic personality disorder will have certain traits that should
be addressed therapeutically. Therapists should try to join with patients'
hypersensitivity and need for control by saying such things as "I'm impressed with what
a bright and sensitive person you are. If we work as a team, I think we
can help you get out of this spot."
Patients with narcissistic personality
disorder often have a need to be the center of attention and to control events.
They crave affection and admiration from others. They are perfectionists
(about themselves). They may try to create dramatic crises to obtain attention
to return the focus to themselves. As with patients with antisocial personality
disorder, entitlement issues are very important. Patients with narcissistic personality
disorder feel as if everyone and everything owes them -- without any contribution
on their part.
It is helpful for therapists to work with these personality
traits in therapy. Working with narcissistic motivations for recovery, such as
an improved appearance or a desire to continue in a job or to make romantic
and sexual conquests, may help the patient to change inappropriate behaviors.
Therapists may benefit from working with, rather than against, ego inflation.
Therapists who try to squelch the narcissistic ego may be met with rage.
Therapists should position themselves as trying to help the narcissistic
patient reach his or her goals.
Therapists may work with patients to identify
thinking errors that interfere with the patient's ability to work. These errors
may include beliefs such as "Everybody loves me." Therapists may need to work
with patient's victim-stance thinking. An example of such thinking is "Everybody
is out to get me." The antisocial thinking-error work described in the previous
section (see Exhibit 7-4) can be a very effective tool
for working with the narcissist.
To manage narcissistic rage and depression,
therapists may contract for patient safety as well as for the safety of others. The
therapist may offer the patient a combination of empathy and reality testing. For
example, when patients say, "Everything is messed up," or "Everybody is causing
me trouble," therapists may empathize with patients, while also indicating
the reality of the situation and the need for behavior change.
Therapists may need to assess
patients' defenses, and to put those defenses to therapeutic use. For example, when
a patient blames the police for "setting me up," the therapist can mention
that the best way to avoid being set up again is to not drink and drive.
Patients with narcissistic personality disorder have a central concern with being
perfect. For these individuals, the disease concept approach can assist in recovery
by removing blame from the patient and conceptualizing the illness as a biochemical
disorder. This can help to lessen the feelings of failure which can be a barrier
to treatment.
People with narcissistic personality disorder may become
depressed when they feel deeply wounded, when their systems have failed them, and
when they sense that their world is falling apart. When wounded, they are at
the highest risk for acting out against themselves and others. When in a narcissistic
rage, patients may become homicidal, feeling a need to seek revenge. This rage
comes from the intensity of the narcissist's wound. The counselor needs to work
carefully with this rage and to avoid getting into power struggles.
When these
patients are in suicidal crises, patients should sign contracts for safety. Safety
may include brief psychiatric hospitalizations that are goal oriented and designed
for stabilization.
When working with HIV-positive patients with narcissistic
personality disorder, therapists may establish contracts with them to engage in safer-sex
practices. Often sexual prowess is part of the narcissistic ego-inflation. Their
need to see themselves as great lovers, coupled with self-centeredness, puts
them at high risk for sexually transmitted diseases.
There will
be an ongoing need to manage the rage and depression of patients with narcissistic
personality disorder and their need for attention, control, and admiration. Continued
attention to self-centeredness and the need to work the 12 steps is essential. Step
work designed for people with antisocial personality disorder (as previously
described in Exhibit 7-5) can be helpful for patients with narcissistic personality
disorder. Similarly, the individual and group approaches to the treatment of patients
with antisocial personality disorder can be used for patients who have narcissistic
personality disorder. Indeed, it may be helpful to view the patient with narcissistic
personality disorder as a hypersensitive patient with an antisocial personality disorder.
People with narcissistic personality
disorder may benefit from group therapy. In group therapy, therapists may need
to set time limits in a firm but pleasant manner, pointing out the need for
all patients to have group time. At the start of each session, therapists
should make a contract with patients with narcissistic personality disorder to
encourage prosocial behaviors and to avoid attempts to dominate, control, or compete
for attention with other group members. Some behaviors to contract for might
include:
To limit the time that they can speak during group sessions
To not
interrupt others while they speak
To respect other group members' time and
feelings
To give responses to other group members
To receive responses and
feedback from others.
It is important not to smash the narcissistic
ego or to attack the narcissistic patient within the group. It is more useful
to comfort and confront the narcissist simultaneously: "I understand that
the part of you that is sensitive is wounded to hear that the group does not
believe everything you are saying." Continue to work with the narcissist's defenses,
not against them.
For patients with narcissistic personality disorder, the least restrictive
treatment environment is preferable. It permits patients to feel that they are in
control. These patients should be moved quickly from inpatient to outpatient levels
of care. If they do not like the treatment, they will stop participating.
Thus, it is critical not to overpathologize the patient's disorder with
constant criticism. However, acute hospitalization for psychiatric emergencies
(such as homicidal or suicidal plans) may be necessary.
Narcissistic patients
generally enjoy the attention they receive through involvement in outpatient treatment;
retention in the program is easily accomplished. Long-term outpatient
involvement is critical to maintain narcissistic patients' prosocial behavior and sobriety.
Therapists who strive to build narcissistic patients' strengths and who
pay close attention to them in therapy will find them active participants in
the recovery process. In addition to their personality disorder and AOD use
disorder, some patients may engage in compulsive sexual or spending behaviors that
should be addressed therapeutically.
Tip for Narcissistic Patients
A helpful exercise for patients with narcissistic personality disorder is
to ask them not to say anything during a specific number of 12-step or self-help
groups, but to simply listen. Once this has been done, narcissistic patients should
discuss their feelings with the therapist in response to the exercise.
Bill is a 45-year-old male who was referred
by his employer to the company's employee assistance program (EAP). The employer
was concerned about Bill's temper, his difficulty accepting criticism, and
his difficulty in getting along with other staff. At the EAP appointment,
Bill's appearance was that of an extremely well-groomed man who paid exceptional
attention to his dress and attire. His manners were impeccable, although he was
critical of the receptionist at the EAP's office for not offering him coffee when
he came in. Bill was friendly but cool toward the EAP counselor, tending
to gloss over the importance of his boss's concerns.
When the EAP counselor
asked him for more specifics about his problems with his coworkers, Bill became
extremely defensive and hammered away in a raging attack on his coworkers and their
jealousy of his success. Bill felt that his boss was a well-intentioned but incompetent
person who frequently made mistakes. Bill also felt that his boss didn't appreciate
the caliber of his work or the time he put into his work. Bill took pride
in his perfectionism, attention to detail, and firm and inflexible beliefs.
Bill was not married, although he reported that he had come close a few times
only to discover that these women had "fooled him" in one way or another. Bill
reported to have only one male friend and indicated that he much preferred the company
of women to men. Bill denied having any "problem with drugs" but did indicate
that he uses marijuana and cocaine recreationally. Bill reported using alcohol
most weekends and occasionally drinking to the point where he "forgot" what
happened.
Question -- What should the EAP counselor suggest as a treatment plan to address
employer concerns over Bill's behavior?
As in working with all patients with personality
disorders, therapists should attempt to join with the world-view of patients with
passive-aggressive personality disorder, rather than work against it. Therapists may try to
work with patients' need for safety and with their ambivalence toward recovery.
Therapists should work with patients' indirect displays of anger and assertiveness.
Passive-aggressive patients try to avoid commitment and responsibility. All interventions
should be focused on the patient's needs, wants, and desires, a strategy that
promotes treatment compliance.
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