Developing a Therapeutic Relationship with Clients with Personality Disorders. The Therapeutic Relationship. The Therapeutic Relationship 7/31/15&

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1 Developing a Therapeutic Relationship with Clients with Personality Disorders Jim Seckman, MAC, CACII, CCS The Therapeutic Relationship The therapeutic relationship, also called the therapeutic alliance, refers to the relationship between a counselor and a client. It is the means by which a counselor and a client hope to engage with each other, and effect beneficial change in the client The Therapeutic Relationship In my early professional years I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship, which this person may use for his own personal growth? Carl Rogers 1&

2 The Therapeutic Relationship Research has shown that the therapeutic relationship is one of the most important aspects of successful recovery. It is more important than the approach or technique that the counselor uses The Therapeutic Relationship Through the therapeutic relationship the counselor provides the three critical elements of therapy: 1). An explanation of the problem 2). A relationship that focuses on emotions and feelings to work out the problem 3). Hope for change Jerome Frank The Therapeutic Relationship A good working relationship between the client and the counselor is the groundwork for implementing change Successful treatment is grounded in the continuous, strong, and genuine therapeutic relationship 2&

3 What Happens in Addiction? The use of drugs/alcohol affect two primary areas of the brain: The Mid-Brain/Limbic System The Prefrontal Cortex The Disease of Addiction What Happens in Addiction? The Mid-Brain/Limbic System Survival Circuitry Eating, nurturing, sexual activity, defense 3&

4 What Happens in Addiction? The Prefrontal Cortex Rational Decision-Making Choice Inhibition of mid-brain impulsiveness Emotional Attachment What Happens to Relationships? Attachment Disorder Addiction creates an attachment to an object or ritual. The addict then avoids appropriate and healthy attachments with another person What Happens to Relationships? Addicts are unable to make consistently healthy decisions They are unable to recognize their own self-deception They do not trust others They believe they have to manipulate others to get what they want The guilt and shame of addiction radically affects the relationships with others 4&

5 What Happens to Relationships? Addicts will try to control others behaviors The using object/ritual becomes a substitute for feelings May take a victim stance and blame others for their problems No gratitude, see only the negative Isolation and loneliness Establishing the Therapeutic Relationship Our clients isolate. They move away from relationships with others towards a primary relationship with the using object/ritual. One of our tasks is to help them move back into healthy and appropriate relationships with others. Establishing the Therapeutic Relationship When clients admit to our programs they are: Angry Mistrustful Needy Confused Scared In Denial 5&

6 Establishing the Therapeutic Relationship When clients admit to our programs we should: Be welcoming Accepting Respectful Explain the structure and expectations Smile Counselor Qualities Attitude Acceptance Unconditional Positive Regard Respect/Warmth Safety Hope Confidence Practical Suggestions Welcome the new client Meet with them regularly Complete the Psychosocial with them Be the first one to speak SMILE when you see them Have an open door policy Allow them to have their emotions 6&

7 Maintaining the Therapeutic Relationship Within the context of this working alliance, there is a human-to-human encounter that is not found in any other relationship The client is free to explore any issue or feeling in safety, and learn new ways of relating Practical Suggestions Provide safety Establish trust Give Hope Communicate confidence Always be honest Maintain boundaries Provide Information/Explanations Practical Suggestions Enforce the structure Explore existential factors Facilitate the expression of feelings Be a role model Advocate for their health Help them with distress tolerance Provide place to share difficult issues 7&

8 Practical Suggestions Help the client examine:! Past patterns that affect relationships in the present! Behaviors/thoughts/attitudes that hinder or help their relationships! Defenses that prevent closeness with others Safety Counselor Qualities Genuineness Strength against the disease Accurate Empathy Can tolerate tension Willingness to be with the client through the really tough stuff Personality Disorders An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual s culture. Manifested in 2 or more areas: Cognition Affectivity Interpersonal functioning Impulse control 8&

9 Personality Disorders The Personality Disorder will typically predate drug use and is independent of the drug use. So, why use? To fit in, poor impulse control, mood regulation, decrease anxiety, calm racing thoughts, stimulation, relieve depression, boost ego strength, ease loneliness General Considerations Clients with a co-occurring Personality Disorder have difficulty forming therapeutic alliances They are limited in their ability to receive, accept or benefit from corrective feedback The have limited abilities to do feelings work The best structure tends to be the therapeutic community model and group therapy, with individual work as a supplement (helps them process group work) Clusters from DSMIV-TR Cluster A Paranoid, Schizoid, Schizotypal Cluster B Histrionic, Narcissistic, Borderline, Antisocial Cluster C Avoidant, Dependent, OCD 9&

10 Histrionic PD Characteristics Difficulty relating on anything but a superficial level Exaggerated emotions Attention seeking Flamboyant Dramatic Seductive Easily influenced by situations and circumstances Histrionic PD General Problems We may misdiagnose as Borderline or Narcissistic PD Emotionally shallow Difficulty responding to insight-oriented therapy Fragile ego-strength Needy and desiring special attention Will respond negatively to interventions that challenge their self-perception Stay calm Histrionic PD Counselor Attributes Maintain program structure and personal boundaries Be respectful/kind without enabling their perceptions Be a welcoming/safe person for them to go to Be willing to tolerate their tension Be the first one to speak to them 10&

11 Histrionic PD Suggestions for Treatment Strong and clear boundaries and treatment structure Behavioral approach Cannot handle intense emotional interventions Stick with the structure of their Treatment Plan Well-developed Relapse Prevention Plan Don t necessarily need to confront distortions Narcissistic PD Characteristics Love to be the center of attention and have power Grandiose Overemphasize their importance and abilities Feel superior to others Narcissistic PD General Problems Lack of empathy for others and their problems Try to force their agenda onto staff Attempts to manage their own course of treatment Can be compliant but never surrender May include you in their plans as a manipulation 11&

12 Stay calm Smile Narcissistic PD Counselor Attributes Don t try to break them or their denial Maintain personal boundaries and program structure Don t be defensive and avoid power struggles Be very aware of your feelings when around them Narcissistic PD Suggestions for Treatment Point out their distortions of reality Get group feedback Boundaries Treat them like everyone else No special favors Confront their denial Strong behavioral Relapse Prevention Plan Detach Narcissistic PD Suggestions for Treatment Set boundaries and limits Don t react Don t act out their stuff Insight may eventually come but our task is to help them to live within the context of a supportive community 12&

13 Borderline PD Characteristics They do not feel safe in the world General background of trauma Black and white thinking Patterns of intensity in relationships that fluctuate between dependent neediness and aggressive detachment Confusion and distress regarding their emotional state Projection as primary defense mechanism Borderline PD General Problems They will test the rules for safety They will try and split the staff They can bring a community into chaos Little tolerance for others problems and issues Like to be the center of attention Peers end up avoiding them or forming alliances Staff tend to either hate them or love them Borderline PD Counselor Attributes Consistent calm, steady emotions Maintain personal boundaries and program structure Ability to tolerate tension Awareness of feelings Be someone safe they can come to Be welcoming, respectful, and accepting 13&

14 Borderline PD Suggestions for Treatment Provide a safe environment Treat them the same as everyone else Confront cognitive distortions Don t use the diagnosis as an excuse Focus on the process Point out the projections of their internal process Don t get upset stay calm and even-tempered Borderline PD Suggestions for Treatment Enforce the rules Give them some early attention Straightforward Treatment Plan Assess any risk of self-harm and intervene quickly Assist client in developing skills to manage negative emotions Set clear boundaries and expectations Borderline PD Suggestions for Treatment For persons with Borderline P.D the therapeutic relationship is critical. It may be the only healthy relationship they have EVER had, so it becomes a role model for how to relate to others. The client s healing will be found through the relationship Without the foundation, safety, and structure of the relationship, no other technique will matter. 14&

15 Antisocial PD Characteristics Cannot empathize with others or form social bonds Other people are objects to be used for their benefit or amusement, or for the release of their anger and anxiety Violate boundaries and rights of others Antisocial PD Characteristics Unable to function as a member of a community They have extreme difficulty understanding why other people won t do what they want them to do and spend a great deal of time/energy manipulating others Unable to be self-reflective regarding their behaviors Antisocial PD General Problems They may make fun of other s work May not feel the need for treatment Other clients may be confused or frightened Can charm or isolate from peers Other clients may become frustrated and harm the client Will break rules without forethought or regard 15&

16 Antisocial PD Counselor Attributes Do not try to form an empathetic bond NO self-disclosure Maintain personal boundaries and program structure Don t engage in debates, state you view clearly Focus on behavior, not insight Antisocial PD Suggestions for Treatment Maintain/enforce program and group rules Watch your boundaries Focus on them and their behavior Do not try to challenge their denial Have a clear and concrete MTP Antisocial PD Suggestions for Treatment Your feelings are the best tool you ve got! No insight-oriented therapeutic interventions Use consequences and the negative effects of using to help them understand There is no cure for APD (don t try) 16&

17 DO NOT: Reenact F.O.O. patterns Identify with projections and act out their anxiety Break structure for them Work harder than they do Be their drug Special Considerations The Container Model Projection/Projective Identification Need to be moved towards responsibility Tolerating Tension Finally: A method for designing interventions: Intervention Ideas Behavior/Attitude Possible Causes Intervention Ideas 17&