1. Working With Challenging Clients: Mental Health Perspective Identifying and understanding challenging clients Effective & practical strategies and skills for working with challenging clients Alexander S. Brown, MBA, PhD, LCSW Clinical Director Metropolitan Family Services One North Dearborn #10 Chicago, IL 60602 312.986.4031 brownal@metrofamily.org

2. Personality Disorders Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) Personality disorders –Enduring patterns of behaviors and feelings –Very different from cultural norms or expectations –Pervasive, inflexible, stable over time –Begin by adolescence or early adulthood –Lead to emotional distress or impairment in functioning

3. Main Personality Disorders 1.Dependent 2.Antisocial 3.Narcissistic 4.Histrionic 5.Obsessive-Compulsive 6.Avoidant 7.Borderline 8.Paranoid

4. Dependent Excessive need to be taken care of that leads to submissive and clinging behavior and fears of separation and at least FIVE of the following: 1.difficulty making everyday decisions without an excessive amount of advice and reassurance from others 2.needs others to assume responsibility for most major areas of life 3.has difficulty expressing disagreement with others because of unrealistic fear of loss of support or approval 4.difficulty initiating projects or doing things on own because of lack of self-confidence or confidence in own judgment

5. Dependent (continued) 5.goes to excessive lengths to obtain nurturance and support from others, to the point of doing things that are unpleasant 6.feels uncomfortable or helpless when alone because of exaggerated fears of being unable to care for self 7.urgently seeks another relationship as a source of care and support when a close relationship ends 8.is unrealistically preoccupied with fears of being left to take care of self

6. Antisocial Personality Disregard for and violation of the rights of others and at least three of the following: 1.performing acts that are grounds for arrest 2.deceitfulness, lying, use of aliases, or conning others for pleasure or gain 3.impulsivity or failure to plan ahead

7. Antisocial Personality (continued) 4. fights or assaults 5.reckless disregard for safety of others 6.failure to sustain consistent work or honor financial obligations 7.lack of remorse, indifference to or rationalizing having hurt, mistreated, or stolen from another

8. Narcissistic Grandiose fantasy or behavior, need for admiration, and lack of empathy and at least FIVE of the following: grandiose sense of self-importance preoccupied with fantasies of unlimited success & power believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high status people requires excessive admiration

9. Narcissistic 5.has a sense of entitlement 6.is interpersonally exploitative, i.e., takes advantage of others to achieve his or her own ends 7.lacks empathy 8.is often envious of others or believes are

10. Histrionic Excessive emotionality and attention seeking, and at least FIVE of the and following: 1.uncomfortable when not the center of attention 2.inappropriate sexually seductive or provocative behavior 3.rapidly shifting and shallow expression of emotions 4.uses physical appearance to draw attention to self

11. Histrionic (continued) 5.speech that is excessively impressionistic and lacking in details 6.shows self-dramatization, theatricality, and exaggerated expression of emotion 7.suggestible & easily influenced 8.considers relationships to be more intimate than they actually are

12. Obsessive-Compulsive Preoccupation with orderliness and interpersonal control, at the expense of flexibility, openness, and efficiency and at least FOUR of the following: 1.preoccupied with details, rules, lists, order, organization, or schedules to the extent that the major point of the activity is lost 2.perfectionism that interferes with task completion, like unable to complete a project because overly strict standards are not met 3.excessively devoted to work and productivity to the exclusion of leisure activities and friendship without obvious economic need 4.overly conscientious, scrupulous, and inflexible about matters of morality, ethics, or values without cultural or religious identification

13. Obsessive-Compulsive (continued) 5.unable to discard worn-out or worthless objects even when they have no sentimental value 6.reluctant to delegate tasks or to work with others unless they submit to exactly his or her way of doing things 7.adopts a miserly spending style towards both self and others; money is viewed as something to be hoarded for future catastrophes 8.shows rigidity and stubbornness

14. Avoidant Pattern of social inhibition, feelings of inadequacy, and hypersensitivity to negative evaluation and at least FOUR of the following: 1.avoids occupational activities that involve significant interpersonal contact, because of fears of criticism, disapproval, or rejection 2.unwilling to get involved with people unless certain of being liked 3.shows restraint within intimate relationships because of fear of being shamed or ridiculed

15. Avoidant 1.preoccupied with being criticized or rejected in social situations 2.inhibited in new interpersonal situations because of feelings of inadequacy 3.views self as socially inept, personally unappealing, or inferior to others to others 4.unusually reluctant to take personal risks or to engage in any new activities because they may prove to be embarrassing

16. Borderline Instability of interpersonal relationships, self image, and affects, and marked impulsivity and at least FIVE of the following: 1.frantic efforts to avoid real or imagined abandonment 2.Pattern of unstable and intense interpersonal relationships characterized by alternating between idealization and devaluation 3.Marked and persistent self-image or sense of self 4.Impulsivity in at least two areas that are potentially self- damaging like spending, sex, substance abuse, binge eating, etc.

17. Borderline (continued) 5. recurrent suicidal behaviors, gestures, or threats, or self-mutilating behavior (e.g., making multiple small cuts on arms or legs with a razor blade) 6. affective instability due to a marked reactivity to mood (e.g., intense anxiety or irritability usually lasting a few hours or a few days) 7. chronic feelings of emptiness 8. inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights) 10. transient, stress-related paranoid thoughts or dissociative symptoms (i.e. feelings of losing touch with reality)

18. Paranoid Pervasive distrust and suspiciousness of others such that their motives are interpreted as malevolent and at least FOUR of the following: 1.suspects, without sufficient basis, that others are exploiting, harming, or deceiving him or her 2.preoccupied with unjustified doubts about the loyalty or trustworthiness of friends or associates 3.reluctant to confide in others because of unwarranted fear that the information will be used maliciously against him/her

19. Paranoid (continued) 4.reads hidden demeaning or threatening meanings into benign remarks or events 5.persistently bears grudges (i.e., is unforgiving of insults, injuries, or slights 6.perceives attacks on his or her character or reputation that are not apparent to others and is quick to react angrily or to counterattack 7.has recurrent suspicions, without justification, regarding fidelity of spouse or sexual partner –

20. Discussion