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

HANDOUT: PERSONALITY TRAITS SEEN IN THE HARD-TO-SERVE CLIENT: CHALLENGES FOR THE TREATMENT TEAM. Stella L. Blackshaw M.D. FRCPC Professor of Psychiatry University of Saskatchewan. Outline. 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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  1. 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

  2. Outline • Case History #1, “Kevin” • Defense mechanisms used by clients with severe personality disorders • Recognizing Splitting and Projective Identification • Managing Splitting and Projective Identification

  3. Outline • Case History #2, “Margaret” • Help-seeking / help-rejecting • Chronic suicidal ideation and it’s management

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

  5. “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.

  6. Borderline Personality “Organization” (Kernberg) Characterized by : • “Poor ego function” (impulsivity, poor reality testing) • Predominant use of immature or primitive defenses: - Denial - Splitting - Projective Identification

  7. 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

  8. 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)

  9. 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”.

  10. 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.

  11. 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.

  12. 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!).

  13. 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.

  14. 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”.

  15. Work as a Team • Resist the urge to be overly critical of others’ management of these challenging patients and difficult situations!

  16. 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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