Understanding Personality Disorders and Attachment Styles

1. Personality Disorder: What is it? Jackie Moon Val Gorbould Wednesday 22nd October 2014

2. PERSONALITY DISORDERS • Disturbances in personality and behaviour, difficulties in relating, distress and impairment • Characterised in clusters A, B, and C • Useful but crude and not consistently validated • Clients may present with co-occurring personality disorders from different clusters

3. CLUSTER A May appear odd or eccentric • Paranoid: distrust or suspicion of others, unforgiving, sensitive to setbacks • Schizoid: detachment from social relationships, emotional expression limited, solitary • Schizotypal: discomfort in close relationships, cognitive or perceptual distortions

4. CLUSTER BCan be dramatic, emotional, erratic • Antisocial: disregard for others, lack of concern for their feelings • Borderline: instability in interpersonal relationships, self-image and affects. Feelings of emptiness. Marked impulsivity, tendency to self-destructive behaviour

5. CLUSTER B • Histrionic: excessive emotionality and attention seeking. Shallow and labile affectivity • Narcissistic: grandiosity, need for admiration, lack of empathy

6. CLUSTER CMay appear anxious or fearful • Avoidant: social inhibition, feelings of inadequacy, hypersensitivity, wants to be liked and accepted • Dependent: submissive and clinging behaviour, passive reliance on others and therefore compliance, feelings of helplessness, • Obsessive-compulsive: pre-occupation with orderliness, perfectionism and control. Feelings of doubt. Checking.

7. CO-MORBIDITY Examples: • Personality disorder with mood disorder • Dual diagnosis: substance misuse and diagnosis of personality disorder

8. TREATMENT • Diagnosis- Discussion of difficulties with clients • Medication or Not?-Not recommended as first line of treatment • Psychotherapy • MBT-Mentalization Based Therapy • DBT- Dialectical Behavioural Therapy • CAT- Cognitive Analytical Therapy

9. Community and Inpatient • How to think about admissions • Care coordination or not • Intensive therapy or not • Management with GP • Management with CMHT • Family and Friends

10. Attachment • First Attachment relationships • Phenomenon in Mammals • Infant/Child seeks comfort from caregiver; Caregiver has an equally instinctive reaction to signals of unease and responds • Being ‘emotionally regulated’ leads to inner image of attachment person • Infant/child works towards ability to self-regulate through someone else making sense of their emotions

11. Attachment Styles • Secure Attachment • Insecure Attachment- Ambivalent/Overinvolved/Resistant; • Distanced/Insecure Avoidant; • Disorganised • Strange situation

12. How Attachment Styles Develop • With the help of the caregiver, infant learns that difficult and distressing feelings can be tolerated and managed. • Marked Mirroring- Mother recognises distress and conveys this to the baby through tone of voice and facial expression • Infant experiences own emotional experience being accurately reflected back to them. • Leads to development of sense of self

13. Strange Situation http://www.youtube.com/watch?v=s608077NtNI

14. When marked mirroring does not occur sufficiently… • Infant does not develop a representation of his own emotional experience • Instead internalises an image of the caregiver as part of his self representation • Leads to establishment of what is known as ‘alien self’; not congruent with true self

15. Disorganised Attachment http://www.youtube.com/watch?v=8BA8CcEUP84

16. Impact on parents and children • Insecure avoidant children do not orientate to their attachment figure, while investigating the environment/ Are very independent of the caregiver both physically and emotionally • Insecure Ambivalent- Clingy and dependent behaviour, but rejecting of attachment figure when they engage in interaction/Difficult to soothe/This behaviour results in inconsistent responses from the caregiver • Disorganised- High levels of confusion as child both comforted and frightened by attachment figures

17. Mentalisation • is when we attribute intentions to each other • when we understand each other and ourselves as driven by underlying motives • and when we recognise that these take the form of thoughts, wishes and various emotions

18. Having mind in mind • Mentalising involves being able to think about our own thoughts and feelings • Developing the capacity to think about, wonder about the thoughts and feelings of others • Being held in mind, holding others in mind

19. Impact on parents and children • Lack of marked mirroring and developing sense of self-regulation means child is not having the experience of being held in mind by the caregiver; difficult feelings are catastrophic rather than potentially manageable; no containment • Unless addressed leads to difficulty helping own child to self-regulate; parent may experience child’s distress as persecutory and overwhelming

20. Lack of Marked Mirroring http://www.youtube.com/watch?v=apzXGEbZht0

21. Making Assumptions • We all make assumptions all the time • Mentalising involves developing the capacity to question our own assumptions • This means entertaining different perspectives and different points of view; to tolerate this rather than experience it as threatening and persecutory

22. Different Perspectives • People interpret the same event in different ways • Some interpretations are more plausible that others • Some observations about another or about an event are mentalising while others are not: describing or reflecting

23. Why Mentalising is Important • To understand what is taking place between people • To understand yourself, who you are • To communicate well with close friends and family • To regulate your own feelings • To regulate other people’s feelings • To avoid misunderstandings • To see connection between emotions and actions

24. Mentalising Culture in the Family Home • Points to consider about the culture people grew up in/are living in: • Caregiver perceived as unavailable? • Caregiver lacking skills and empathy? • Oppressive silences? • Taboo areas? • Some form of abuse? • Chaotic and unpredictable? Leading to:

25. Attachment Conflict • Difficulties and problems in attachment relationships • Impact on the child’s developing mentalising abilities • Inhibiting or exaggerating signals about own emotional states: child fears or is insecure about response of attachment figure • Impulse to get closer inhibited e.g. by fear of punishment or wanting to punish

26. Why do we often misunderstand each other and ourselves? • Non-transparency of mind: we cannot know what is going on in another’s mind • Our tendency to attribute thoughts to others: the same as ours • Experience that others understand us without having to tell them • Defensiveness • Difficulty in expressing thoughts and feelings

27. How this might relate to parenting • Assuming the intentions in a child’s behaviour and communication based on own difficult feelings e.g. feeling persecuted, rather than being able to hold the child in mind and think about him or her • Difficulty in recognising and owning own difficult feelings and seeing them as separate from what is going on in the child’s mind

28. What characterises a mentalising stance? • Curiosity about one’s own mind and the minds of others, our own and others’ thoughts and feelings • Openness to different perspectives • Developing a capacity to tolerate not knowing • Pause, reflect back on what has happened; think before you speak

29. Some characteristics of poor mentalising • Black and white thinking • Feeling certain about the motives of others • Little curiosity about mental states • Lots of words spoken with poor content • External factors emphasised at the expense of mental states • Little acknowledgement of accompanying feelings

30. Mentalisation Based Treatment 1 • Focuses on the here and now: understanding what is going on in current interactions and relationships • This is of course informed by the past and examples from the past come up, but the emphasis is not on trawling through the past or making interpretations about it • Interpretations most likely lead to the client feeling not heard and misunderstood experiencing not being validated

31. Mentalisation Based Treatment 2 Aims of treatment: • To support client to reflect on their own mental and feeling states • To check out assumptions with others • To recognise failures in mentalising • To link acting out behaviour such as cutting with the context of relationships, interactions and feeling and mental states • To work towards reflecting on this rather than getting rid of feelings by harming self or others • To acknowledge and tolerate difference • To improve quality of relationships and interactions

32. Form of Treatment 1 Group or individual? • Group is highly recommended as the dynamics people frequently encounter will come up in the group and can be thought about by the whole group in the here and now • Groups offer the possibility to return after a difficult exchange and work through it with support • Opportunity to have feedback from peers, not only therapists, and notice similarities and differences • Groups give a different experience of being together with other people

33. Form of Treatment 2 PD Pathway: • Introduction to Mentalisation 12 week group, 1 ½ hours per week • 3 day a week 12-18 month Therapeutic Community • 1 day a week 12-18 month TC informed programme • One group plus one individual session with a different therapist, per week, for one year: MBT programme • CAT, CBT, psychodynamic individual and group therapies • Outreach work: holding sessions for clients, consultation to other services, co-working with other services, offering training, new group for Family and Friends

34. Mentalising as Workers 1 • Is it possible to recognise the distress a misunderstanding has caused the client while remaining clear about your own intention and being able to clarify it? • If a client has a pattern of difficult exchanges with professionals then this is likely to happen with you and you can help the client think about this • Acknowledging own errors

35. Mentalising as Workers 2 • Do you ever find yourself desperately trying to justify your own point of view? • Is there a space to go back over a difficult encounter with a client so you can both try to understand what happened? • Do you have a space away from the client to talk about the difficult feelings that come up for you?

36. Issues with Assessment • What difficulties do you encounter with the assessment process??

37. PD Pathway: Referral Process • Initial phone call to TCOS to discuss potential referral. Also consult with CMHT and/or GP if these are client’s main point of contact • Putting referral in writing stating why the referral is being made at this point in time and including as much supporting material, e.g. previous reports, as possible • Email to Specialist Psychotherapy Service Referrals from inside the Trust. • Discussed at weekly referrals meeting and then fed back to referrer • Write to CHAMPRAS (mental health single point of entry), City and Hackney Centre for Mental Health, Homerton Row, E9 6SR, from outside the Trust • They will allocate referral

38. Assessment Process at TCOS and SPS • In depth extended assessment at either TCOS or SPS, communication between the two. • Over several appointments • Active attempts to engage client, working with difficulties in engagement • SCID questionnaire • Discussion in team to think through client’s presentation. Especially important where there is a split amongst professionals • Discussion with client re diagnosis • Treatment plan

39. Screening Questions • Are you scared of rejection and abandonment? • Are relationships with family and friends unstable? • Do you see things in absolute terms? All right or all wrong? • Do you have trouble who you are and what is important to you? • Do you act impulsively in ways that might damage you? • Do you self-harm, overdose or behave in a suicidal manner? • Do you have mood swings? • Do you feel empty and need others to make you feel whole? • Do you get very angry in a manner that is to your own detriment? • Do you numb out, dissociate, or sometimes feel overly suspicious or paranoid when stressed?

40. References • American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders (DSM-iv-TR). APA, 2000 • Bateman, A and Fonagy, P: MBT-Introduction Manual. Anna Freud Centre/UCL, 2012 • Bateman, A and Fonagy, P: Psychotherapy for Borderline Personality Disorder: Mentalisation Based Treatment. OUP, 2004 • Bateman, A and Kravitz, R: Borderline Personality Disorder: An Evidence Based Guide for Generalist Mental Health Workers. OUP, 2013 • Gerhardt, S: Why Love Matters – How Affection Shapes A Baby’s Brain. Routledge 2004 • World Health Organisation: International Statistical Classification of Diseases and Related Health Problems. WHO, 1992