GENDER DIFFERENCES IN A PERSONALITY TREATMENT PROGRAMME

2. GENDER DIFFERENCES IN A PERSONALITY TREATMENT PROGRAMME Kyle MacDonald Segar House - Rauaroha ADHB, New Zealand

3. HISTORY OF GENDER CONSIDERATIONS IN THE PROGRAMME • Fears about the implications for the group therapy process • Most male client referrals were inclined towards low-level acts of aggression, normally towards intimate partners

4. HISTORY OF GENDER CONSIDERATIONS IN THE PROGRAMME • Added a Mentalization aspect to our DBT based therapeutic approach • Allowed us to understand the process of attachment based aggression in an adult presentation • How did our treatment approach need to be different?

5. ASSESSMENT OF AGGRESSION • Had only occurred in the context of intimate and family relationships • Was followed by shame and contrition • Had not resulted in serious injury • Distinguish this from a more sociopathic or narcissistic pattern: • more random pattern to the offending • absence of remorse and accountability

6. CASE EXAMPLE: “DAVE” • 42 year old New Zealand European man • Hospitalised after relationship breakdown • Threatening and aggressive towards rejecting partner whilst in a dissociated state • Followed by a profound depression • History of failed relationships • “Not an angry man.”

7. CASE EXAMPLE: “DAVE” • Alien self is a term used in Mentalization Based Therapy • Outcome of “chronically insensitive or misattuned caregiving.” • Self representation internalises aspects of the other, “creating a fault in the construction of the psychological self” • If later trauma occurs, it can “force the child to dissociate from the pain by using the alien self to identify with the aggressor.” (Fonagy et.al. 2002)

8. CASE EXAMPLE: “DAVE” Trauma Symptom Inventory at Intake

9. CASE EXAMPLE: “DAVE” • On Trauma Symptom Inventory (T.S.I.)significant result for: • Anxious Arousal • Depression • Intrusive Experiences • Defensive Avoidance • Tension Reduction Behaviours • Summary scales for Trauma and Dysphoria

10. CASE EXAMPLE: “DAVE” • Formulation • When Dave didn’t acknowledge his anger, due to a fear he would be “like his father,” he denied a part of himself and in his denial and dissociation lost control and kept repeating the very thing he sought to dis-own.

11. CASE EXAMPLE: “DAVE” • Dave’s “alien self” can then be understood as an example of identifying with the aggressor • Dave utilises the defensive structure of projection to protect against painful affect, most notably shame • This angry aggressive part felt to Dave like “not me.” • He alternates between: persecutory rage and aggression/ and the persecution of the self via suicidal depression and self harm.

12. CASE EXAMPLE: “DAVE” Trauma Symptom Inventory at Discharge

13. CASE EXAMPLE: “DAVE” Trauma Symptom Inventory at Intake

14. MBT AND DBT: GENDERED MODELS? • Application of MBT seems more helpful to our team when thinking about aggression and interpersonal violence • Primary author of DBT is female, and most of it’s application has been to female borderline clients targeting self harming behaviour • MBT’s lead authors are male; it’s literature talks more freely about interpersonal violence, and the model’s therapeutic application to anti-social personality disorder

15. TEAM RESPONSES • Have we treated our female clients as “fragile”? • In our fear of treating “violent men” were we failing to mentalize our male referrals? • Because we feared, did we make them frightening?

16. To be open to wondering and thinking about their experiences, to see the whole person, in all their complexity and to hold their mind in mind