9. Working with People with Personality Disorders Flashcards
What is the revolving door problem with regard to clients with BPD?
Patients go in and out of care. BPD previously thought to be untreatable.
What is personality and what are the 3 aspects of personality?
The reliable way you organize and regulate yourself and your relationships.
1) regulation of emotions and behaviors
2) predictability of social interactions
3) integrated self
According to the DSM-V, what is the focus of personality disorders?
Significant impairments of self and interpersonal functioning.
What are the 2 elements of the self that may dysfunction?
1) self-identity: unique self, boundaries between self and others, stability of self esteem, accurate self-appraisal, emotional regulation
2) self-direction: coherent and meaningful short and long term goals, productive and prosocial internal standards of behavior, self-reflection
What are the 2 elements of interpersonal relations that may dysfunction?
1) Empathy: understand others’ experiences and motivations; tolerance of differing perspectives; understand effects of one’s behavior on others
2) Intimacy: depth and duration of connection with others, desire and capacity for closeness
What are the 5 different pathological personality traits?
1) negative affectivity
2) detachment
3) antagonism
4) disinhibition
5) psychoticism
What is negative affectivity?
Frequent and intense experiences of a wide range of negative emotions (eg. anxiety, depression, guilt/shame, worry, anger) and their behavioral and interpersonal manifestations (eg. self-harm, dependency)
What is detachment?
Avoidance of socio-emotional experience
- withdraw from interpersonal interactions,
- restricted affective experiences and depression (limited hedonic capacity ie. capacity to feel joy)
What is antagonism?
Behaviors that put the individual at odds with other people
(eg. exaggerated sense of self importance and expect special treatment, unawareness of others’ needs and feelings, use others for self-enhancement)
What is disinhibition?
- Impulsive behaviors due to orientation towards immediate gratification, without regard for past learning and future consequences.
- Excessive constraints of impulses (risk avoidance, perfectionism, rigid and rule governed behavior)
What is psychotism?
Exhibit wide range of culturally incongruent, eccentric behaviors and cognitions, including process (eg. perception, dissociation) and content (eg. beliefs)
People with Borderline Personality Disorder should have impairment on personality functioning in 2 or more of the following aspects: (4)
1) identity
2) self-direction
3) empathy
4) intimacy
What does an impairment on self-identity entail? (4)
- unstable self image
- excessive self-criticism
- chronic feelings of emptiness
- dissociative states under stress
What does an impairment of self-direction entail?
instability in goals, aspirations, values, or career plans
What does an impairment in empathy entail? (3)
- Inability to recognise feelings and needs with others
- interpersonal hypersensitivity (proneness to feeling insulted)
- biased negative perception of others
What does an impairment in intimacy entail? (3)
- Intense, unstable, and conflicted close relationships
- relationships marked by mistrust, neediness, and anxious preoccupation with real or imagined abandonment
- close relationships viewed in extremes of idealization and devaluation and alternating between over-involvement and withdrawal.
People with BPD have pathological personality traits in 4 or more of the following: (7)
1) emotion lability (negative affectivity)
2) anxiousness (negative affectivity)
3) separation insecurity (negative affectivity)
4) depressivity (negative affectivity)
5) impulsivity (disinhibition)
6) risk-taking (disinhibition
7) hostility (antagonism)
What is emotional lability?
- unstable emotional experiences and frequent mood changes
- intense emotions that are easily aroused
What is anxiousness?
intense feelings of nervousness, tenseness, or panic in response to interpersonal stresses
threatened by uncertainty
What is separation insecurity?
fears of rejection and/or separation from significant others, associated with fears of excessive dependency and complete loss of autonomy.
What is depressivity?
- Frequent feelings of being down, miserable, and hopeless
- difficulty recovering from such moods
- inferior self-worth
- thoughts of suicide and suicidal behavior
What is impulsivity?
Acting on the spur of the moment in response to immediate stimuli without consideration of outcomes.
What is risk taking?
Engagement in dangerous and potentially self-damaging activities without regard for consequences
What is hostility?
Persistent or frequent angry feelings and irritability
What are the core features of BPD? (3)
1) Emotional Dysregulation
2) Self-harming behaviors/impulsive behaviors to cope with emotions. Immediate reduction of emotional pain and distraction from emotions using physical pain.
3) Relational difficulties. Due to early family history that is invalidating to their emotions. Difficult to build rapport in the clinic as they are less trusting and less able to build interpersonal relationships.
According to NICE guidelines, which therapy is recommended for patients with BPD?
Dialectical Behavioral Therapy (DBT)
Besides consideration of NICE guidelines, what other considerations should you keep in mind before deciding on the therapy?
1) the person’s ability to remain within the boundaries of the therapeutic relationship
2) choice and preference of service user; their willingness to engage with therapy and motivation to change.
3) degree/severity of impairment
What should always be the first target of treatment for BPD patients?
High risk behaviors!
Must keep patient alive before you can do anything else.
Why is the choice and preferences of client especially important in BPD patients?
Because they have relational difficulties and it’s difficult to engage them! Must figure out what kind of life is worth living for them.
BPD clients can get quite aggressive when they get upset, what should you do as a therapist?
Make sure you are safe. Take necessary precautions.
eg. panic button, sit near door
What does the biosocial theory of DBT propose?
Biological vulnerability + Invalidating Environment -> Pervasive Emotional Dysregulations
How do you explain emotions in BPD patients?
Emotions are like waves…
- Typical individuals: when we experience something negative, emotions will go up and down quickly
- BPD patients: emotions shoot up much higher and faster, and stay up there for a long period of time before coming down again. very slowly
- staying up there is very emotionally painful. So BPD patients do silly things like self-harming behaviors to bring emotions down quickly.
- the way their emotions work make them more susceptible to emotional difficulties.
What are the benefits of using the wave diagram in explaining to the client?
1) validates the client’s emotions. lets them know you can understand why they are self-harming because it is like a way out of hell for them.
2) build rapport and alliance
As a therapist working with BPD patients, it can be easy to get emotionally affected by them, because they have relational difficulties. What should you do?
Empathise with them, don’t be defensive.
After letting them know that emotions are like waves that will come and go, what is the final aim of that?
To help clients learn that they are able to cope with the emotion without extreme behaviors.
What are the mechanisms of an invalidating environment that perpetuates pervasive emotional dysregulation? (5)
1) Poor emotion knowledge
2) Parents modeling and reinforcing poor skills of regulating emotions
3) Develop assumptions that emotions will be overwhelming and expressing emotions are maladaptive
4) No ‘emotional skin’ - increased sensitivity to invalidation in the present
5) Start to invalidate themselves (self-blame and self-hatred)
What does it mean to have poor emotion knowledge?
- lack understanding of how emotions come about and their functions
In what ways can parents model and reinforce poor skills of emotional regulation in the individual?
- parents putting child down a lot, telling them to stop crying and suppress their emotions. Creates an invalidating environment that does not help them learn emotional regulation
- parents never model to their child better ways of self-soothing
What does it mean when we say a BPD patient does not have ‘emotional skin’?
Tend to be more sensitive to invalidation in the present. They are quick to take offense to the smallest things you say.
After being invalidated so much in their early childhood, what do they subsequently do over time?
They start to internalize the invalidation and invalidate themselves. Self-blame and self-hatred. (eg. “I’m weak, I’m useless). Creates a vicious cycle of invalidation and poor emotional regulation.
What is the meaning of risky behaviors in BPD?
viewed as consequences of emotional dysregulation and attempts to cope.
Dialectical Behavioral Therapy (DBT) draws heavily on what theories?
Behavioral theories
Identifying triggers and maintaining factors for maladaptive behaviors
- Antecendent triggering events (eg. invalidation)
- Behaviors
- Consequent reinforcing events
Dialectical Behavioral Therapy (DBT) is very structured and manualised. Why is this useful?
Because sometimes when the therapist is using his/her interpersonal relationship with the client as part of the therapy, it can make the therapist lose their way without structure. Good to make things clear cut so it provides direction.
What are the primary targets of DBT? (3)
Primary Targets
1) Pretreatment - agreement on goals and commitment (contract)
- duration & freq of therapy
- can’t miss how many sessions in a row
- can’t withdraw unless discussed first
- must attend sessions sober
- goals must be realistic and explicit
2) Stage 1 - controlling risky behaviors (eg. suicidal or self-harm behaviors); therapy-interfering behaviors
3) Stage 2 - emotional experiencing and cognitive restructuring
- dealing with emotional avoidance
- challenge maladaptive beliefs (“I am unloveable and unwanted”)
What are the secondary targets of DBT? (5)
1) Increasing emotional regulation
- skills group. what to do when she is in distress.
- selfcare and being engaged with the world through community activities :) (depression)
2) Increase self-validation
3) Increase realistic decision making & problem solving
4) Increase emotional experiencing (outside clinic)
5) Increase accurate communication of emotion
What are the 4 distinct aspects of DBT sessions?
1) individual sessions
2) group skills training (2h)
3) in between sessions (24h phone coaching, self-monitoring using a diary card)
4) peer supervision for therapist
During individual sessions in DBT, what is done?
- Behavioral Chain Analysis
- CBT informed treatment (eg. exposure, contingency management, cognitive restructuring)
What does the behavioral chain analysis focus on? Describe the chain. (5 steps)
Causes of problem behavior. DBT suggests that we should focus on helping clients change the causes of the problem, which can reduce unhelpful responses (problem behavior)
1) vulnerability
2) triggering event
3) thoughts, emotions, subevents, bodily sensations
4) problem behavior
5) consequences
What is the purpose of tracking the behavioral chain?
Helps them to see a pattern in causal events. The triggering event may have happened a lot earlier but recalled and affect them at a later point in time. Help them to take active steps in changing the causes of the behavior so they perform the problematic behaviors less. Very behavioral and skills focused.
Why is behavioral and skills focused intervention more beneficial than cognitive intervention for BPD patients?
Because when distressed, it’s difficult to think rationally about anything
In skills training sessions in group settings, what are the key aspects of intervention? (4)
1) mindfulness (acceptance based)
2) emotional regulation
3) distress tolerance
4) interpersonal effectiveness
How does acceptance based strategies such as mindfulness work for clients with BPD?
- make them more aware of their self-criticising thoughts so they can choose not to respond to them in unhelpful ways. Help them to stop engaging in impulsive behaviors which are automatic ways of behaving for them (taking them out of autopilot mode)
Describe emotional regulation strategies taught during skills training.
- psychoeducation: learning the normal and adaptive functions of emotions. help clients be more accepting of emotions rather than avoid them.
- practical techniques to prevent emotional dysregulation: learn a different strategy each session
What skills are being taught with regard to distress tolerance?
- Taught what to do in a crisis. Since can’t think straight, just take out a paper with list of all the skills learnt. Encourage them to create techniques for themselves (eg. ice bucket challenge to cool body down)
1) sit on the wall until thighs ache / other intense exercise - similar mechanism of inflicting physical pain on herself but at least this is not dangerous.
2) progressive muscle relaxation (TIP) - go through different muscle groups, flex and relax. physically causes a relaxation. bring attention to the present.
- get them to practice these skills and behaviors so it comes more naturally to them when they are distressed.
With regard to interpersonal effectiveness, what is being taught in skills training sessions?
Learning how to manage interpersonal conflict. (eg. assertiveness, self respect, FAST rules - fair, avoid apology, stick to values, truthful)
Avoid the 2 extremes - passive vs aggressive. being very passive and saying yes to everything that people ask, but get upset about being abused and become super aggressive. help them be more balanced.
Describe the ABC PLEASE approach in emotional regulation.
Accumulate positives Build mastery Cope ahead of time (plan and mentally prepare yourself) Physical Illness (Treat it) Eat well Avoid mood altering drugs Sleep well Exercise
In skills training sessions, what acceptance strategies are used?
Emotional validation
- showing empathy and validation of client’s perspective
As a therapist, what are the 6 steps you must engage in to show emotional validation?
1) listen with awareness
2) accurately reflect client’s views
3) articulate non-verbal emotions, thoughts, behaviors
4) communicate how their behaviors make sense in context of past circumstances
5) communicate how their behaviors make sense in context of present circumstances
6) be radically genuine (share similar experiences)
What does ‘dialectical’ mean?
- Means a balance between being ‘change oriented’ and ‘acceptance oriented’
- Work through opposing forces for need for acceptance and change for movement to occur.
- too much focus on change –> conveys to client that problem and fault lies in client. client may respond with aggression.
- too much focus on acceptance –> client feels that this is not helping in a practical sense. finding a solution.
- hence balance is key!! depends on what client is ready for. if client is ready for change, do change. If not focus on acceptance and validation of emotions.
In suicidal risk assessment, which areas of risk must you assess?
1) risk to self (suicide, self-harm)
2) risk to others (sexual, aggression, risk to children)
3) risk from others (neglect, physical/sexual abuse, financial inability, medication, service providers)
When assessing suicidal risk levels, what risk factors must you consider?
- history of self-harm
- current suicidal ideation or plan
- means for self-harm (eg. medication)
- low moods
- current circumstances
When assessing suicidal risk levels, what protective factors must you consider?
- social support
- employment
- engagement with treatment
- commitment not to act on suicidal thoughts
- emotional regulation skills
- religious faith and the meaning of suicide
What is risk and protective factors useful for?
Risk management
After collecting risk and protective factors, what should you do with the information?
- inform social services
- speak to supervisor
- immediate risk cases: consider A&E visit or home visit with responsible adult
- contact all professionals working with the client
- consider increasing frequency of meetings
- develop a crisis plan with client
- update clinical notes on the system
What goes into a crisis plan that clients bring home?
- short term strategies to ensure safety
- plan in advance of high risk situations. what to do in a crisis.
- plans for further therapy and support
- contact details. therapist, 24h helplines, friends and family.
What are the 4 core diagnostic features of patients with BPD?
1) Disorder of the self
- poor self identity. change according to relationships and environment.
2) Emotional instability
- intense, rapid, dramatic fluctuations in mood
- when stressed, may become angry, depressed, and anxious, or even dissociate
3) Behavioral instability
- impulsive decision making and self-destructive behaviors
4) Interpersonal instability
- unstable relationships
- intense fears of abandonment and active attempts to stop others from leaving them
- take a long time to build trust
- highly sensitive to change and unpredictability in others’ behavior
Why should ending of therapy be discussed in advanced for patients with BPD?
Because the client may misinterpret this ending or break as a rejection.
What kind of attachment patterns characterises those with BPD?
Insecure disorganised attachment patterns.
- Infant learns that their attachment figure is a source of terror. At times of stress in adulthood (eg. relationship breakups, conflict at work etc.), the activation of the attachment system in itself becomes a source of destabilised and dysregulated emotions.
How does their attachment pattern link to their current relations with others in times of distress?
- Not that they don’t want to accept help from others, but they simply CANNOT. In times of stress, it is impossible to see others as a potential source of comfort and help. People become a source of fear.
- end up wanting to control others
- Common to see a repeat of abusive relationship patterns in current relationships
In what ways are patients with BPD ‘biologically vulnerable’?
Have an emotional system that is quickly over-aroused. May never have learned skills to regulate their emotional system (social).
In an invalidating environment without good corrective relationship experiences, what do these ‘biologically vulnerable’ individuals do?
The individual ends up looking for extreme ways to manage extreme emotions that emerge when trying to deal with people.
What are 7 characteristics of good BPD treatments?
1) well structured
2) devote time and effort to enhance motivation and adherence
3) have clear focus which both sides have agreed
4) theoretically coherent for both therapist and client
5) relatively long term
6) powerful attachment relationship between therapist and patient so therapist can make use of the relationship to positively influence patient
7) well integrated with other services
