Understanding Personality Disorders Relationally

Lindsay Jones & Jane Bradley

Outline

• Aims of Workshop:-

• Increase awareness & understanding of Personality Disorder

• Outline causes including attachment difficulties

• Help make GP appointments therapeutic

• Help build therapeutic relationships with clients with personality disorder/difficulties

• Help to manage chaotic interactions

• Links with mental health services

Personality Disorder – three main areas of difficulty

Affect Regulation Modulation / Tolerance

Identity fragile self esteem

Relationships How they relate to

themselves and others

ACEs Clip

Overview of Reciprocal Roles (RR)

• Infants have inborn tendencies to form relationships. For example:-

• Internalised (RR) LOVING

LOVED

• Acts as model for all future relationships

Overview of Reciprocal Roles (RR)

• Internalised relationships rather than individuals involved in this exchange

• We learn 2 Reciprocal Roles, can’t learn one without the other

• We learn rules governing relationships

• So that we can form a sense of & predict how our actions elicit the action of others

• Forms the basis of personality development

RR usually associated with a secure attachment

• Parent Accepting Available • Trusting Attuned • Caring

• Child Lively • Able to grow Heard • Autonomous Understood • Spontaneous • Safe •

Reciprocal Roles

• People with PD have limited repertoire of damaging RRs

• Result of harsh, inconsistent, incoherent, neglectful, chaotic upbringing

• Produces ‘Insecure Attachments’

• Impacts on how they relate to themselves/others (including clinician/services)

COMMON RECIPROCAL ROLES FOR CLIENTS WITH BORDERLINE PERSONALITY DISORDER

• Perfectly Caring • • constantly • seeking • Perfectly cared for • •

• Abusing Controlling Rejecting Critical • Attacking Demanding Abandoning Blaming never feels enough • Neglecting • • •

Abused Controlled Rejected Inadequate • Terrified Powerless Vulnerable Worthless

• ANGER………RAGE……….ANXIETY………..FRUSTRATION………ANGER • • UNMANAGEABLE FEELINGS

•

• Represents Insecure Attachment Jane Bradley (CAT Practitioner)

In Short…

• Others did it to me

• I do it to me

• I do it to others or

• draw others in

• so others do it to me again or

• it feels like others do it to me

Steve Potter

Therapeutic Alliance

• Self Awareness

Clinician “What do I bring? What’s my stuff? What’s theirs?”

Client “This is what I bring?”

Exercise

• Think about a time when you were angry, anxious, or upset. Reflecting on the responses you got from others, what did you experience as helpful and unhelpful?

Compassion

THREAT

DRIVE SOOTHE

The 4Ps model (Annesley and Jones, 2016)

• Developed based on CAT as a framework for reflecting upon and understanding people’s interactions and responses within therapeutic environments

• Offers staff a way of reflecting on their own contributions to interactions with service users

• Simplified approach using accessible language that can be used by all members of a team with minimal training

• Supports the maintenance of empathy and therapeutic boundaries

The 4ps Model: A CAT Derived Reflective Tool

PULL(S) Personal and patient

PATTERN(S)

PAUSE

PROFESSIONAL RESPONSE

(Annesley and Jones, 2016)

Pause

What might signal I need to pause?

Examples:

• A strong or unusual emotion

• Wanting to respond in a way that is not usual for you or is against accepted good practice

• Wanting to respond in a way you wouldn’t want to tell colleagues about

• Knowing that the way you respond is likely to provoke a strong reaction in the patient

• Desire to punish or reject

4 P’s (Annesley & Jones, 2016)

PULL(S) Personal and patient

PATTERN(S)

PAUSE

PROFESSIONAL

RESPONSE

Pulls

• What pulls am I feeling from the patient? • What pulls am I feeling within me?

Examples: Being flippant Stepping in and rescuing Avoiding Rejecting Abusing Punishing

4 P’s (Annesley & Jones, 2016)

PULL(S) Personal and patient

PATTERN(S)

PAUSE

PROFESSIONAL

RESPONSE

Is this a pattern?

• How does this pattern link to past experiences?

• Is this a pattern I often get into with different patients?

• Is this a pattern the patient often gets into?

• Is this a pattern other staff members get into?

• Could this pattern be replaying damaging childhood experiences?

• What are the consequences of this pattern?

4 P’s (Annesley & Jones, 2016)

PULL(S) Personal and patient

PATTERN(S)

PAUSE

PROFESSIONAL

RESPONSE

Professional response

• Reflected on responding rather than reacting

• Respectful

• Sensitive

• Maintains boundaries

• Maintains relationship

• Acknowledges when you are wrong

• Good enough

• Positive role model in interactions with patients and other staff

Exercise

• Using the 4Ps as a reflective tool, think through a recent interaction you had with a challenging patient. Is there anything you would do differently?

In pairs:

• One person helping the other to reflect

• Swap over

Group discussion

• How can you incorporate what you have learned today in your 10 minute appointments?

Useful qualities for staff working with

personality disorder

Personal resilience

Ability to set and maintain boundaries

Ability to cope with hostility and conflict

Engage in supervision and reflection

Able to skilfully reflect on own experience and actions – “self-observation”

Detached management of crisis and conflict Non-judgemental attitude (e.g. Personality Disorder: No Longer A Diagnosis of Exclusion, 2003; Bateman and Krawitz, 2013)

Developing Reflective Practice:

• “People with personality disorders can behave in ways that might appear to invite rejection. They may feel that no help is ever good enough, they may be hostile or demanding. They can, at times, sabotage all attempts at help. This can be frustrating and difficult for practitioners. Skills and knowledge are required to enable staff to understand the reasons for this behaviour; to “rise above” rejecting, judgmental or compulsive responses and to reflect calmly about what may be happening. Practitioners who have these capabilities can maintain a focus on the underlying needs of individuals and can sustain the effort to assist the individual in developing less destructive ways of dealing with relationships….”

• The Personality Disorder Capabilities Framework. NIMHE, Nov 03.

Final Reflections

Thanks

Lindsay.jones1@nhs.net – phone 07917557501

jane.bradley5@nhs.net – phone 01642

368711

TEWV Personality & Relational Services