From damage to disorder; working with personality difficulties in a forensic setting Julia Harrison Occupational Therapist - Adult Forensic Services

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1 From damage to disorder; working with personality difficulties in a forensic setting Julia Harrison Occupational Therapist - Adult Forensic Services Northumberland, Tyne and Wear NHS Foundation Trust

2 From Damage to Disorder (and on to Discovery) Working with Personality Disorder Julia Harrison Personality Disorder Hub Service

3 The patients that no-one likes They always want special treatment A right set of b**tards you be careful Untreatable They ll draw you in and exhaust you Just an excuse for bad behaviour Manipulative My heart sink cases

4 What is Personality?

5

6 Relaxed Unreliable Procrastinate Lose interest CONSCIENTIOUSNESS Organised Punctual Dutiful Disciplined Quiet Passive Reserved Reflective EXTROVERSION Joiner Affectionate Talkative Active

7 What is Personality Disorder? An enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual s culture. This pattern is manifested in two (or more) of the following areas : Thoughts and Beliefs Emotions and Mood Interpersonal functioning Impulse control (DSM-V)

8 Presentation is inflexible and pervasive across a broad range of personal or social situations Presentation leads to distress or impairment in social, occupational, or other important areas of functioning Presentation is of long duration It is not better accounted for by another disorder or substance misuse

9 The 3 Ps Problematic. Causes distress for the person or others Persistent. Long standing Pervasive. Across a range of situations

10 Paranoid Schizoid Schizotypal Antisocial Borderline, Narcissistic Histrionic Avoidant Dependent Obsessive-Compulsive DSM-V Categories

11 Borderline Personality Disorder Impulsivity Instability Emotional dysregulation Interpersonal difficulties Transient psychosis Self harm and suicide

12 Those with BPD are like people with third degree burns over 90% of their bodies. Lacking emotional skin, they feel agony at the slightest touch or movement. Marsha Linehan

13 Antisocial Personality Disorder Impulsivity Anger and irritability Lack of remorse Childhood conduct disorder Deceitfulness Disregard for rules/social norms Irresponsibility

14 Personality Disorder - How does it develop?

15 Genetics

16 Biological

17 Environmental They f**k you up, your mum and dad. They may not mean to, but they do. They fill you with the faults they had And add some extra, just for you. (This Be The Verse: Philip Larkin)

18 All I remember feeling until I was 7 was fear no, call that terror terrified every time I heard his key in the door, terrified for me, terrified for me mam. So scared I d wet myself, which just made him worse. By the time I got to 7 though, the fear was gone and there was only rage. I dreamed about battering his head in while he was asleep. I hated him and I hated everyone else

19 Combination

20 When working with the adult it is always helpful to think about the types of experiences they have had and how this will be influencing their behaviour

21 Billy Its his first day at big school. He s excited but a bit scared as he doesn t know many people there At lunch time the school bully teases him, hits him and nicks his lunch money Thinking about development of self, and ability to cope with emotions, what may result if

22 Billy s mam asked him about his day, listened to how he was feeling and they talked together about the best way to handle it? Billy s dad called him an idiot and belted him across his face for losing his money? Billy s mam was stoned when he got home and didn t even notice his cut lip? Billy s dad took him round to the other boy s house to fight him? Billy s mum cried for hours and kept him off school the rest of the week

23 Personality Disorder - What Helps

24 Is Personality Disorder Treatable?

25 What helps? Solid understanding of the diagnosis Rapport and relationship Hope and validation Assessment and Formulation Interventions that develop skills (discovery) Robust sense of self for the therapist Robust shared team approach

26 Formulation

27 Critical Incidents Temperament Beliefs about Self and Others Overdeveloped Strategies Strengths Underdeveloped Strategies

28 Skills building Livesley model Psychoeducation Problem Solving SCM/DBT/MBT Role Identity Life worth living Social Participation Productivity Planning Endings

29 What helps staff?

30 Action and Reaction Cycle People with personality difficulties can trigger strong reactions in professionals which can lead to the professionals acting in a way that is less helpful for the client and ultimately draining for them. There are 3 main ways of reacting that are typical of a professional working with someone with a Personality Disorder:

31 RESCUE ANGER VICTIM

32 Protecting from burn out Supervision of all types Mentoring and seeking advice Training Case formulation Team Approach Creating reflective space Peer Support Work/life balance Insight into own baggage

33 Thank you for all you ve done for me; you helped me find a turning point

34 Practical Management of Personality Disorder John Livesley Cognitive Behavioral Treatment of Borderline Personality Disorder - Marsha Linehan Constructing a new self Christine Padesky The development of an effective occupational therapy assessment and treatment pathway for women with a diagnosis of borderline personality disorder in an inpatient setting (BJOT Nov 2010) Borderline Personality Disorder - an evidence based guide for generalist mental health professionals Anthony Bateman, Roy Krawitz. Understanding the impact of maltreatment on brain development The Big 5 personality traits McRae and Costa [email protected]