Family Therapy and Mental Health

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Family Therapy and Mental Health

• University of Guelph
• Office of Open Learning

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Course Instructor

• Carlton Brown, M.Sc., M.Div., RMFT
• 3-1216 Upper Wentworth Street, Hamilton ON L9A
  4W2
• Tel [phone]
• Email carl_at_mftsolutions.ca
• Slides http//www.mftsolutions.ca/Pages/MentalHea
  lthCourse.html

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Reflections on the Course So Far

• Comments
• Questions
• Assignments

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Today

• Personality Disorders

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Presentations

• Borderline Personality Disorder - Sara

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What is a personality?

• Traits
• Goals
• Narrative

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OCEAN Traits

• Openness to Experience (Thinking)
• Conscientiousness (Conscience)
• Extraversion (Relating)
• Agreeableness (Willfulness)
• Neuroticism (Emotional Stability)

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Goals

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

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Personality as Story

• Narrative
• the story that I tell about myself
• integrity vs. despair (Erickson)

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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)

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Personality Disorder

• Goals that tend to put the person in conflict
  with others

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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

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Object Relations Theory

• MFT Applications

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Object Relations Theory

• The object of object relations
• a human object
• Internal or external
• Fantasied or real

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Object Relations TheoryA Brief History

• Melanie Klein (18821960)
• Contemporary of Freuds
• 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

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Object Relations TheoryA 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)

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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

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Object Relations TheoryA Brief History

• William Fairbairn (1889 1964)
• Continued to shift focus from pleasure to
  relationships
• Developmental scheme
• early infantile dependency
• transitional period
• mature dependence

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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

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Object Relations TheoryA 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

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Object Relations TheoryA 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

The first two states are repressed
psychopathology
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Margaret Mahler

• Normal Developmental Stages of Infants
• Autistic
• Symbiotic
• Separation-individuation
• Differentiation
• Practicing
• Rapprochement
• Libidinal object constancy

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Differentiation

• 6 - 10 months
• mother is separate
• stranger anxiety
• increasing differentiation of self and object

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Practicing

• 10 - 16 months
• quadruped locomotion
• physical distance from mother

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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

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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

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Object Relations TheoryA 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

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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

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Kohut

• self psychology
• parents and significant others are selfobjects
• distinct, objectively separate individuals in
  the childs life who eventually become
  incorporated into the self
• praise from a selfobject is internalized as pride
• shame is internalized as guilt

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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

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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

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Break
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Personality Disorder

• An enduring pattern of inner experience and
  behavior that deviates markedly from the
  expectations of the individuals 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

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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
• Doesnt 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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e.g. this is an Axis II disorder that arises from
an Axis I disorder (see Item C above)
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(No Transcript)
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Cluster A (odd, eccentric)

• Paranoid distrust, interprets others as
  malevolent
• Schizoid detachment, restricted range of affect
• Schizotypal discomfort in relationships,
  cognitive distortions, eccentric behavior

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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

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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

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Cluster A

• Odd, eccentric

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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

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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

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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

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Cluster B

• Dramatic, emotional, erratic

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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

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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

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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

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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

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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

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Cluster C

• Anxious, fearful

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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

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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

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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
• cant delegate
• miserly
• rigid and stubborn

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DSM-IV DSM-V
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DSM-IV DSM-V
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DSM-V Levels of Function
_____ 0 No Impairment  _____ 1 Mild
Impairment  _____ 2 Moderate Impairment  _____
3 Serious Impairment _____ 4 Extreme
Impairment
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DSM-V Types

• Antisocial/Psychopathic Type
• Avoidant Type
• Borderline Type
• Obsessive-Compulsive Type
• Schizotypal Type

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DSM-V Trait Domains

• Negative Emotionality
• Introversion
• Antagonism
• Disinhibition
• Compulsivity
• Schizotypy

  Trait levels are assessed on a four-point
scale0   Very little or not at all     1
Mildly Descriptive       2 Moderately Descriptiv
e      3 Extremely Descriptive      
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OCEAN DSM-V
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DSM-IV DSM-V
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Treatment

• Joining (with limits)
• Understanding
• Educating
• Intervening

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Dialectical Behavior Therapy

• An Overview

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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

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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
• Youre great the way you are and
• You can do better

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DBT Assumptions

• Dont have the ability to engage in behaviour
  needed to solve problems
• Even when they have the skills, they dont 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

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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

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DBT Modes of Therapy

• Group skills training
• Acceptance skills
• Mindfulness
• Distress tolerance
• Change skills
• Interpersonal effectiveness
• Emotion regulation

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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

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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

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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

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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

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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

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Narcissistic Injury

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

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Twinship Failure

• Child lacks experiences of joining with the
  parent in activities
• Defective empathy, creativeness, humor, wisdom,
  acceptance of ones own transience
• Lack of skills and competence

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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

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• 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

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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?

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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

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Lunch
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Application and Discussion

• Movie clip
• Diagnosis
• Treatment based on developmental models

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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

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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

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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

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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

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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

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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

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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

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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

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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
• cant delegate
• miserly
• rigid and stubborn

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The Couple from Hell

• After the break

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Guest Dr. Joseph Ferencz
Assistant Chief, Department of Psychiatry, St.
Joseph's Healthcare HamiltonVice Chair, Clinical
Dept. of Psychiatry and Behavioural
Neurosciences, McMaster University Areas of
Special InterestForensic PsychiatryMedical
EducationEmergency PsychiatryAssessment and
Treatment of Psychotic Disorders
Friend, Vice Chair Psychiatry McMaster, Clinical
Director of Psychiatry St. Josephs Healthcare,
Metaphysician and all around good guy...
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Next Class

• Friday, October 22 (three weeks)
• Panic and Anxiety
• Here again, McLaughlin 120A

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