Family Therapy and Mental Health

1. 1 Family Therapy and Mental Health University of Guelph Office of Open Learning

2. Course Instructor Carlton Brown, M.Sc., M.Div., RMFT 3-1216 Upper Wentworth Street, Hamilton ON L9A 4W2 Tel: 905-388-8728 Email: carl@mftsolutions.ca Slides: http://www.mftsolutions.ca/Pages/MentalHealthCourse.html (Who the hell are these guys?)(Who the hell are these guys?)

3. 3 Reflections on the Course So Far Comments Questions Assignments

4. 4 Today Personality Disorders

5. 5 Presentations Borderline Personality Disorder - Sara

6. 6 What is a personality? Traits Goals Narrative

7. 7 OCEAN Traits Openness to Experience (Thinking) Conscientiousness (Conscience) Extraversion (Relating) Agreeableness (Willfulness) Neuroticism (Emotional Stability)

8. 8 Goals Strategies, plans and concerns Behaviour desired goals Personal projects, life tasks, strivings Dynamic, goal-directed The journey we take in life

9. 9 Personality as Story Narrative the story that I tell about myself integrity vs. despair (Erickson)

10. 10 Personality Disorder Traits that tend to put the person in conflict with others Not so open (or too open) to new experiences Not so conscientious (or too conscientious) Not so extraverted (or too extraverted) Not so agreeable (or too agreeable) Not so neurotic � i.e. emotional instability (or too neurotic, i.e. lack of emotional range)

11. 11 Personality Disorder Goals that tend to put the person in conflict with others

12. 12 Personality Disorder Stories that tend to put the person in conflict with others, or that tend to put others in conflict over the person Good vs. evil (splitting) Story about the client One bright, beautiful Sunday morning, everyone in tiny Anytown got up early and went to the local church. Before the service started, the townspeople were sitting in their pews and talking about their lives, their families, and so on. Suddenly, Satan appeared at the front of the church. Everyone started screaming and running for the front entrance, trampling each other in a frantic effort to get away from evil incarnate. Soon everyone had left the church except for an elderly gentleman who sat calmly in his pew, not moving, seemingly oblivious to the fact that God's ultimate enemy was in his presence. Now, this confused Satan a bit, so he walked up to the man and said, "Hey! Don't you know who I am?" The man replied, "Yep, sure do." Satan asked, "Aren't you afraid of me?" "Nope, sure ain't," said the man. Satan was a little perturbed at this and queried, "Why aren't you afraid of me?" The man calmly replied, "I've been married to your sister for 25 years."One bright, beautiful Sunday morning, everyone in tiny Anytown got up early and went to the local church. Before the service started, the townspeople were sitting in their pews and talking about their lives, their families, and so on. Suddenly, Satan appeared at the front of the church. Everyone started screaming and running for the front entrance, trampling each other in a frantic effort to get away from evil incarnate. Soon everyone had left the church except for an elderly gentleman who sat calmly in his pew, not moving, seemingly oblivious to the fact that God's ultimate enemy was in his presence. Now, this confused Satan a bit, so he walked up to the man and said, "Hey! Don't you know who I am?" The man replied, "Yep, sure do." Satan asked, "Aren't you afraid of me?" "Nope, sure ain't," said the man. Satan was a little perturbed at this and queried, "Why aren't you afraid of me?" The man calmly replied, "I've been married to your sister for 25 years."

13. 13 Object Relations Theory MFT Applications

14. 14 Object Relations Theory The �object� of object relations: a �human� object Internal or external Fantasied or real

15. 15 Object Relations Theory:A Brief History Melanie Klein (1882�1960): Contemporary of Freud�s First direct work with children Children devote more energy to interpersonal relationships than to libidinal impulses They create internal and play representations of their important relationships Intensely studied mom & infant

16. 16 Object Relations Theory:A Brief History Klein in continuation with Freud believed in a destructive inner force (death instinct) inner struggle of live v death projected on the outer world external destructive objects (bad objects: giants, monsters, villains) external life objects (good objects: mothers, fathers, heros)

17. 17 Klein, cont Resolving Good and Bad in Relationships Positions Paranoid (0-3 months) birth is stressful, the child feels persecuted and attacked takes it out on the breast splitting good v bad persecutory anxiety Depressive (4 months - 2 years) splitting is reversed and mom is whole object again appreciate good and bad instead of good or bad anxiety about harming the parent with guilt comes empathy

18. 18 Object Relations Theory:A Brief History William Fairbairn (1889 � 1964) Continued to shift focus from pleasure to relationships Developmental scheme early infantile dependency transitional period mature dependence

19. 19 Fairbairn cont Early infantile dependency child merged with caretaker poorly developed sense of self Transitional stage lifelong process away from one-way dependency Mature dependence mutuality and exchange healthy interdependence

20. 20 Object Relations Theory:A Brief History Fairbairn: three types of objects Good becomes �ideal object� Bad becomes �exciting object� (formed from teasing or tempting child) - makes child feel frustrated and empty �rejecting object� (formed by hostile or rejecting caregiver) - makes child feel unloved and unwanted

21. 21 Object Relations Theory:A Brief History Fairbairn Three ego states Exciting object ? libidinal ego Always thirsting, never satisfied, deprived Rejecting object ? anti-libidinal ego Hateful and vengeful, longs for acceptance Ideal object ? central ego Results in conforming behaviour

22. 22 Margaret Mahler Normal Developmental Stages of Infants Autistic Symbiotic Separation-individuation Differentiation Practicing Rapprochement Libidinal object constancy

23. 23 Differentiation 6 - 10 months mother is separate stranger anxiety increasing differentiation of self and object

24. 24 Practicing 10 - 16 months quadruped locomotion physical distance from mother

25. 25 Rapprochement 15 - 30 months language interaction with other adults (father) self-assertion and separateness strong need for help and reassurance crisis: need for parent v need for separation need a balance of support and firmness

26. 26 Libidinal Object Constancy 30 months - 3 years stable internal representation of the mother enables the child to function on its own develops relationships with others integration of positive and negative, good and bad, objects if not completed, in later life tend to see others as either punitive and rejecting or unrealistically gratifying

27. 27 Object Relations Theory:A Brief History Otto Kernberg (1928- ) Bipolar representations self other affective colouring e.g. mother-child-positive and fulfilling or mother-child-frustrating and depriving Various bipolar representations are �metabolized� to form foundation of personality

28. 28 Kernberg, cont Development Introjection primitive experiences, undifferentiated splitting good v bad Identification more mature, beginning of self-object understanding more control over affective colouring Ego Identity synthesized bipolar representations integrated sense of self

29. 29 Kohut self psychology parents and significant others are selfobjects �distinct, objectively separate individuals in the child�s life who eventually become incorporated into the self� praise from a selfobject is internalized as pride shame is internalized as guilt

30. 30 Kohut cont children are naturally narcissistic develop a positive and rewarding structure of self children have two basic needs to show off (If others see me as good, then I must be good) - healthy omnipotence - mirroring selfobject to merge with an ideal selfobject (My mother is good, and I am my mother, so I am good) - healthy connectedness - idealizing selfobject

31. 31 Kohut Mirroring I am perfect and you must admire me Idealizing You are perfect and I am a part of you Normally, these two continue through life in increasingly mature and complex ways, and you become a selfobject for your children, your spouse, and your clients

32. 32 Break

33. 33 Personality Disorder �An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual�s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.� DSM-IV-TR, p. 685

34. 34 Axis II Used for reporting Personality Disorders and Mental Retardation, maladaptive personality features and defense mechanisms Intention is to prevent these less �florid� (less flowery) disorders from being overlooked Doesn�t mean that personality disorders should be viewed or treated differently than Axis I disorders (but they frequently are) DSM-IV-TR p 28

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37. 37 Paranoid � distrust, interprets others as malevolent Schizoid � detachment, restricted range of affect Schizotypal � discomfort in relationships, cognitive distortions, eccentric behavior Cluster A (odd, eccentric)

38. 38 Cluster B (dramatic, emotional, erratic) Antisocial � disregard for, and violation of, the rights of others Borderline � unstable relationships, self image, affects, and impulsive behavior Histrionic � excessive emotion and attention seeking Narcissistic � grandiosity, need for admiration, lack of empathy

39. 39 Cluster C (anxious, fearful) Avoidant � social inhibition, feelings of inadequacy, hypersensitivity to negative evaluation Dependent � submissive, clinging, need to be taken care of Obsessive-Compulsive � preoccupied with orderliness, perfectionism, and control

40. 40 Cluster A Odd, eccentric

41. 41 301.0 Paranoid Personality Disorder Pervasive distrust and suspiciousness (interprets others� motives as malevolent) beginning in early adulthood, 4 or more of: suspects others are exploiting or harming doubts loyalty or trustworthiness of friends reluctant to confide in others reads hidden threats in benign remarks or events bears grudges perceives attacks from others doubts fidelity of sexual partner

42. 42 301.20 Schizoid Personality Disorder Pervasive detachment and restricted affect beginning in early adulthood, four or more of: no joy in close relationships almost always chooses solitary activities little interest in sexual experiences pleasure in few, if any, activities lacks close friends apart from close relatives appears indifferent to praise or criticism emotionally cold, detached, flattened affect

43. 43 301.22 Schizotypal Personality Disorder Pervasive social deficits, acute discomfort and reduced capacity for close relationships, cognitive distortions and eccentric, 5 or more: ideas of reference odd beliefs unusual perceptions odd thinking and speech paranoid ideation constricted or inappropriate affect peculiar behaviour lack of close friends; social anxiety r/t paranoia

44. 44 Cluster B Dramatic, emotional, erratic

45. 45 301.7 Antisocial Personality Disorder Pervasive disregard for and violation of the rights of others since age 15, 3 or more: repeatedly acting s.t. grounds for arrest deceitful, lying, conning for personal profit impulsive or failure to plan ahead irritable, aggressive, fights and assaults reckless disregard for safety of self or others consistent irresponsibility lack of remorse at least 18; history of Conduct Disorder

46. 46 301.83 Borderline Personality Disorder Pervasive pattern of instability in relationships, self-image, affects, and marked impulsivity. Five or more: frantic efforts to avoid abandonment pattern of unstable and intense relationships unstable self image impulsivity in two areas suicidal or self-mutilating behaviour affective instability chronic feelings of emptiness

47. 47 301.83 Borderline Personality Disorder Pervasive pattern of instability in relationships, self-image, affects, and marked impulsivity. Five or more: inappropriate, intense anger transient, stress-related paranoid ideation or severe dissociative symptoms

48. 48 301.50 Histrionic Personality Disorder Pervasive pattern of excessive emotionality and attention-seeking, five or more: likes to be centre of attention sexually provocative rapidly shifting, shallow emotions uses physical appearance to draw attention impressionistic style of speech theatrical suggestible thinks relationships are intimate

49. 49 301.81 Narcissistic Personality Disorder Pervasive grandiosity, need for admiration and lack of empathy, five or more: self-importance fantasies of unlimited success special requires excessive admiration sense of entitlement interpersonally exploitative lacks empathy envies others arrogant and haughty

50. 50 Cluster C Anxious, fearful

51. 51 301.82 Avoidant Personality Disorder Pervasive social inhibition, feelings of inadequacy, hypersensitivity to criticism, 4 +: avoids jobs with people avoids people in general well behaved in intimate relationships preoccupied with rejection inhibited in new situations sees self as inferior to others reluctant to take risks

52. 52 301.6 Dependent Personality Disorder Pervasive and excessive need to be taken care of, submissive, clingy, five or more: difficulty making decisions needs others to be responsible difficulty disagreeing with others difficulty initiating projects goes to great lengths to get support feels helpless when alone serial relationships afraid of being left alone

53. 53 301.4 Obsessive-Compulsive Personality Disorder Pervasive preoccupation with orderliness, perfectionism, control, four or more: details, rules, lists perfectionism that prevents task completion workaholic overconscientious (morals, ethics, values) pack rat can�t delegate miserly rigid and stubborn

54. 54 DSM-IV DSM-V

55. 55 DSM-IV DSM-V

56. 56 DSM-V Levels of Function

57. 57 DSM-V Types Antisocial/Psychopathic Type Avoidant Type Borderline Type Obsessive-Compulsive Type Schizotypal Type

58. 58 DSM-V Trait Domains Negative Emotionality Introversion Antagonism Disinhibition Compulsivity Schizotypy

59. 59 OCEAN DSM-V

60. 60 DSM-IV DSM-V

61. 61 Treatment Joining (with limits) Understanding Educating Intervening

62. 62 Dialectical Behavior Therapy An Overview

63. 63 Dialectical Behavior Therapy (DBT) Dialectics is �the reconciliation of opposites in a continual process of synthesis� In DBT, this reconciliation happens in: Acceptance & change Validation & problem solving Reciprocal & irreverant approach Consultation & intervention

64. 64 DBT Philosophy Individuals with BPD are so sensitive to negative feedback that their ability to change is drastically reduced Balance acceptance strategies with change strategies: �You�re great the way you are� and �You can do better�

65. 65 DBT: Assumptions Don�t have the ability to engage in behaviour needed to solve problems Even when they have the skills, they don�t use them (motivation) Punished for being skillful and rewarded for negative behaviour (eg. suicide attempts) Need help taking what they learn in treatment and applying it to the real world

66. 66 DBT: Modes of Therapy Individual psychotherapy Orient to therapy Agree on treatment goals Target life threatening behaviours Attend to therapy interfering behaviours Address problems that affect quality of life Generalize skills to daily life

67. 67 DBT: Modes of Therapy Group skills training Acceptance skills Mindfulness Distress tolerance Change skills Interpersonal effectiveness Emotion regulation

68. 68 DBT: Modes of Therapy Telephone consultation In between individual sessions Check-in/coaching Difficulty asking for help Relationship enhancement and problem solving Reduces crises and increases skill generalization Equalize power in relationship

69. 69 DBT: Modes of Therapy Consultation for Therapists Patient reinforces therapist for doing ineffective treatment and punishes therapist for doing effective things Need peer consultation Prevent burnout Support use of DBT skills and techniques From 2-6 therapists Apply validation and change strategies to therapist

70. 70 DBT: Core Strategies Validate problems and teach problem solving skills Like reframing � find the grain of truth and validate it Behavioural analysis (how) Solution analysis & commitment Irreverant attitude � blunt, direct, outrageous Reciprocal communication

71. 71 DBT: Outcome Data Controlled clinical trial Levels of self-injury were half that of control group Levels of re-hospitalizations were half that of control group Makes DBT very appealing to medical community and financial supporters

72. 72 Kohut reprise: Twinship The parent partners with the child in significant tasks The child develops empathy, creativeness, humor, wisdom and acceptance of his/her transience Innate skills and talents

73. 73 Narcissistic Injury The parent repeatedly fails the child Mirroring failure � inability to consistently reflect pride in the child�s accomplishments Inadequacy, emptiness, despair, meaninglessness, need for reassurance Idealizing failure � e.g. parent who is a drug addict, �don�t use me as a role model� Defective self-soothing, inability to pursue goals with commitment (what�s the use? Look where I came from)

74. 74 Twinship Failure Child lacks experiences of joining with the parent in activities Defective empathy, creativeness, humor, wisdom, acceptance of one�s own transience Lack of skills and competence

75. 75 Narcissitic Injury and Rage The self develops through selfobject provisions of mirroring, idealizing and twinship The self attempts to protect itself at all costs Selfobject failures lead to narcissitic injury The child feels and is afraid to express rage (for fear of destroying the parent) The therapist gets to deal with the rage

76. 76 In spite of selfobject failure and narcissistic injury, the self protects its integrity through defenses, and where the parents failed, hope springs eternal that the partner will make everything right

77. 77 Relationship Management David Dawson and Harriet MacMillan Look at the process of the personality disorder: what is the client trying to accomplish? How does this make sense developmentally? What is a developmentally appropriate intervention?

78. 78 Be helpful by being different avoid your assigned role position assume a warm but benign, neutral posture be paradoxical discuss the new social contract overtly always assume the client is a responsible, competent adult but overtly set appropriate limits and consequences you are prepared to deliver be carefully honest

79. 79 Lunch

80. 80 Application and Discussion Movie clip Diagnosis Treatment based on developmental models

81. 81 301.0 Paranoid Personality Disorder Pervasive distrust and suspiciousness (interprets others� motives as malevolent) beginning in early adulthood, 4 or more of: suspects others are exploiting or harming doubts loyalty or trustworthiness of friends reluctant to confide in others reads hidden threats in benign remarks or events bears grudges perceives attacks from others doubts fidelity of sexual partner

82. 82 301.22 Schizotypal Personality Disorder Pervasive social deficits, acute discomfort and reduced capacity for close relationships, cognitive distortions and eccentric, 5 or more: ideas of reference odd beliefs unusual perceptions odd thinking and speech paranoid ideation constricted or inappropriate affect peculiar behaviour lack of close friends; social anxiety r/t paranoia

83. 83 301.7 Antisocial Personality Disorder Pervasive disregard for and violation of the rights of others since age 15, 3 or more: repeatedly acting s.t. grounds for arrest deceitful, lying, conning for personal profit impulsive or failure to plan ahead irritable, aggressive, fights and assaults reckless disregard for safety of self or others consistent irresponsibility lack of remorse at least 18; history of Conduct Disorder

84. 84 301.83 Borderline Personality Disorder Pervasive pattern of instability in relationships, self-image, affects, and marked impulsivity. Five or more: frantic efforts to avoid abandonment pattern of unstable and intense relationships unstable self image impulsivity in two areas suicidal or self-mutilating behaviour affective instability chronic feelings of emptiness

85. 85 301.83 Borderline Personality Disorder Pervasive pattern of instability in relationships, self-image, affects, and marked impulsivity. Five or more: inappropriate, intense anger transient, stress-related paranoid ideation or severe dissociative symptoms

86. 86 301.50 Histrionic Personality Disorder Pervasive pattern of excessive emotionality and attention-seeking, five or more: likes to be centre of attention sexually provocative rapidly shifting, shallow emotions uses physical appearance to draw attention impressionistic style of speech theatrical suggestible thinks relationships are intimate

87. 87 301.81 Narcissistic Personality Disorder Pervasive grandiosity, need for admiration and lack of empathy, five or more: self-importance fantasies of unlimited success special requires excessive admiration sense of entitlement interpersonally exploitative lacks empathy envies others arrogant and haughty

88. 88 301.6 Dependent Personality Disorder Pervasive and excessive need to be taken care of, submissive, clingy, five or more: difficulty making decisions needs others to be responsible difficulty disagreeing with others difficulty initiating projects goes to great lengths to get support feels helpless when alone serial relationships afraid of being left alone

89. 89 301.4 Obsessive-Compulsive Personality Disorder Pervasive preoccupation with orderliness, perfectionism, control, four or more: details, rules, lists perfectionism that prevents task completion workaholic overconscientious (morals, ethics, values) pack rat can�t delegate miserly rigid and stubborn

90. 90 The Couple from Hell After the break

91. 91 Guest: Dr. Joseph Ferencz

92. 92 Next Class Friday, October 22 (three weeks) Panic and Anxiety Here again, McLaughlin 120A