Working with

Individuals

Diagnosed with

Personality Disorders

Presented by:

Malcolm Horn, LCSW, MAC, SAP

January 10, 2018

Thomas Durham, PhD

Director of Training

NAADAC, the Association for Addiction Professionals

www.naadac.org

tdurham@naadac.org

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F. Malcolm Horn

1231 N 29th

Billings, MT

mhorn@Rimrock.org

Webinar Presenter

Your

Webinar Learning Objectives

LO #1 Know the

diagnostic criteria for

personality disorders

LO #2 Gain understanding

of the theory behind the

etiology of personality

disorders

LO #3 Gain awareness of basic

counseling strategies to work

with individuals diagnosed with

personality disorders

1 32

• Brief review diagnostic criteria

• Key PD that we will focus on:

Borderline

Antisocial

Narcissist

Psychopaths

Sociopaths

• Treatment Goals & Techniques

Agenda

The DSM-5 (APA, 2013) identifies and describes ten specific personality disorders. These ten

diagnoses represent ten specific enduring patterns of thoughts, feelings, and behavior. However,

each of these ten patterns can be distilled down to four core features of personality disorders:

1. Rigid, extreme and distorted thinking patterns (thoughts)

2. Problematic emotional response patterns (feelings)

3. Impulse control problems (behavior)

4. Significant interpersonal problems (behavior)To diagnose a personality disorder a person must exhibit at least two of these four core features.

The Four Core Features of Personality Disorders

1. A personality disorder is enduring pattern of inner experience and behavior. This pattern

manifests in two or more of the following areas:

a. Thinking

b. Feeling

c. Interpersonal relationships

d. Impulse control2. This pattern deviates markedly from cultural norms and expectations.

3. This pattern is pervasive and inflexible.

4. It is stable over time.

5. It leads to distress or impairment

DSM-5 Criteria:

Borderline personality disorder

• Pervasive fear of abandonment

• Unstable perception of self

• Difficulty with stable relationships

• Mood swings

• “Black and white"

• Constantly seek a higher level of

caretaking from others as adults

• Manipulation of others, leaving them

often feeling empty, angry, and

abandoned, which may lead to

desperate and impulsive behavior

Antisocial personality disorder

• Characteristically disregard the feelings,

property, authority, and respect of others

for their own personal gain

• May be violent or aggressive acts

involving or targeting other individuals,

without a sense of regret or guilt for any

of their destructive actions.

Narcissistic personality

disorder

• Severely overly-inflated feelings

of self-worth, grandness, and

superiority over others.

• May exploit others who fail to

admire them

• Overly sensitive to criticism,

judgment, and defeat.

Histrionic personality

disorder

• Overly conscious of their

appearance and are constantly

seeking attention

• Behave dramatically in situations

that do not warrant this type of

reaction

• Emotional expressions are often

seen as superficial and

exaggerated

All of the APD traits but not limited to

criminal bx; manipulative, insincere.

Lack of guilt; think the white collar criminals

(Madoff, Enron)

Many psychopaths never get to prison

More likely to be violent

Values relationships only as they benefit

them

Criminal: likely to take calculated risks to

minimize exposure-premeditated

Psychopaths

• A disregard for laws and social mores

• A disregard for the rights of others

• A failure to feel remorse or guilt

• A tendency to display violent behavior

How insightful are these people to want to change??

Both Sociopaths and Psychopaths have:

Causes of Pathology

“Since we cannot change reality, let us change the eye

that see reality” –Mikos Kazantizakis

Only 3 ways to view these disorders:

1. Born that way

2. Not born that way—the environment did it

3. Born that way and the environment made it

worse.

Causes of Pathology

• Uncompleted developmental tasks lead to

complex defense mechanisms: irresponsibility,

impulsivity, thrill-seeking, poor decision-making,

undeveloped value and moral structure

• They are “stuck” in an underdeveloped age &

emotional deficits…..acting like a child

• The absence of needs being met leads to

emotional deficits which leads to disorders

The “Ultimate Attachment Disorder”

• Chameleon bx (can behave well when it

suits them; usually not sustainable)

• Blaming

• Creative splitting

• They are calm and compliant until

confronted…..

• When you speak logic, it destroys their

reality and they may become explosive

• Charming

What We See in Clients

• Excuse making (lying)

• Justifying/Rationalizing

• Intellectualizing

• Victim stance

• Self-serving acts of kindness

• Asserting power over others/manipulation

• Getting away with anything/Above the law

• Views self as superior/harmless

• Lazy thinking

Complex Defenses

If you didn’t have to hold

yourself accountable,

empathize with others,

feel guilt or remorse,

would you change?

“People don’t react emotionally, or behaviorally to the

events they encounter, rather people cause their own

reactions to the way they interpret or evaluate the

events they experience.”

Albert Ellis

This implies that the thought pattern is dysfunctional

or bad…..but where do we get our thought patterns

from?

Thinking Errors

• Create safety & structure: without this nothing will

happen

• Help gain insight

• Help client understand their behavior

• “Harm” reduction

• Help them navigate their world

• This only works if there is insight and desire to change

Goals of Therapy & Interactions

• It is not about you

• MI is helpful for helping them gain insight—which is

necessary for change

• You goal is to provide safety and trust (with some

exceptions)

• Personality Disorders are classified on the same axis

as mental retardation in DSM-IV

Would you ask a developmentally disabled

person to be “fixed” or would you help them to

better navigate their world?

When working with PDs…..

• Find their strength

• Don’t worry about getting them to like you; don’t focus on

building rapport

• Do not worry about getting the truth; do not focus on fact-

finding

• Ask yourself what the goal is; stick to it

• DBT

• MET

• SFBT

Techniques

• Specifically for

BPD

Reactive attachment

Suicidal behaviors

Eating Disorders/Substance Use

• Clients change behavioral patterns

• Clients increase emotional regulation and

subsequent reactive behaviors by identifying

triggers and emotional states

• Assumes that clients are doing the best they

can with the poor skills that they have

Dialectical Behavioral Therapy

• Mindfulness Observation without judgment

Grounding

• Emotional Regulation Use Distress Tolerance skills

Awareness and acceptance of uncomfortable feelings

• Interpersonal Effectiveness Assertive Communication

• Distress Tolerance Radical Acceptance

Weigh the pros & cons

1. Activating Event

Immediate Environment

2. Belief System

Filters our perception of the Activating event

Memory

3. Consequences

Fight, Flight, or Freeze

Positive

Negative

The ABC process…..

• Sense of necessity for change—which means insight

• Willingness or readiness to change (which means

being uncomfortable & vulnerable)

• Awareness of the problem

• Confrontation of the problem

• Effort towards change

• Hope for change

• Support for change

Change Requires Safety

….what if you don’t know what safe feels like?

• Active Listening

• Be aware of non-verbal

communication (esp tone and

volume)

• Clarify, repeat, and validate

• Non-threatening

• Non judgmental

• Respect

• Low emotion

Listening Skills are Key

“People can change only if they feel

that they are basically liked and

accepted as they are. When

people feel criticized, disliked, and

unappreciated they are not able to

change. Instead, they feel under

siege and dig in to protect

themselves.”

~~John Gottman

• Admire negative traits and behaviors…. reframe

it into a strength and skill

• Redirect/reframe the skill in a positive manner

• Find out the values of the client and help them

align their behaviors with them

• Praise: “it takes courage to confront these

issues” “You are very resilient to have survived

that”

Techniques for Change

• Leave your ego at the door

• Empathize even when it hurts to do so….

• Establish empathy prior to confronting

• Courtesy and permission; ask permission to confront or

give feedback

• Roll with resistance

• Set boundaries

Techniques for Change

• Use scaling to help them identify & see change (or

lack thereof).

• Reframing can help them feel more in control

• Ask hypothetical questions; ask open-ended

questions; use the Miracle Question

• Help them to see their strengths and what they are

doing right

• Role play; gets them out of the client role

Techniques for Change

Don’t get into power-struggles; when we “win” we

undermine the idea that they can make choices

AND…who wants to admit that they are wrong?

These patients have to have a hard shell to

survive……remember that when you are taking that

away, you are leaving them vulnerable.

Porcupines

• Avoid black/white thinking: open up the possibility of

exceptions to the problem

• Put the problem in the past: “recently I’ve seen….so

far….lately…..”

• Reframe: encourage a different perspective of the

problem

• Help them to make good decisions for themselves

• Find and capitalize on their resilience and strengths

How do we Instill Hope?

• Give choices

• State facts

• Parenting…….

• Meditation

• Anger management

• Grief/Anger work

• Trauma work

• DBT Skills:

Emotional Regulation

Interpersonal Communication

Core Mindfulness

Distress Tolerance

Other Techniques

Personality Disorders are classified on the same axis as mental retardation…..both are mental

disorders. PDs impact the affected personality. DD impacts the cognition.

Would you ask a developmentally disabled person to be “fixed”?

People that have problems can have hope that they can solve them. People

who ARE problems see themselves as fundamentally flawed and

unchangeable.

To keep in mind….

You want them to have several people that they can go to

(especially if they are BPD)

• Probation officer

• Case manager

• Additional counselor

• Family

• Psychiatrist

But make sure that you have a release of information so

that you can communicate with your other team-mates

Don’t Go it Alone

Brown, Sandra. Women who love psychopaths.

Harlow, H. (1959). Monkey Love

Hanna, Fred. Dissolving Resistance in Difficult Clients: Techniques for motivation and change.

(PESI)

NAR Associates. Solutions for the “treatment resistant” client;

Samenow, Stanton. Inside the Criminal Mind: Understanding the resistant, Antisocial Client.

References:

F. Malcolm Horn

1231 N 29th

Billings, MT

mhorn@Rimrock.org

Thank You!

Your

www.naadac.org/personality-disorders-webinar

Cost to Watch:

Free

CE Hours Available:

1.5 CEs

CE Certificate for

NAADAC Members:

Free

CE Certificate for

Non-members:

$20

To obtain a CE Certificate for the time you spent watching this

webinar:

1. Watch and listen to this entire webinar.

2. Pass the online CE quiz, which is posted at

www.naadac.org/personality-disorders-webinar

3. If applicable, submit payment for CE certificate or join

NAADAC.

4. A CE certificate will be emailed to you within 21 days of

submitting the quiz.

CE Certificate

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