Family Therapy and Mental Health

Family Therapy and Mental Health
University of Guelph Open Learning and Educational Support

Reflections on the Course So Far
Comments Questions Assignments 2

Today ADHD Personality Disorders

Presentation ADHD – Stacey and Mark 4

Attention-Deficit/Hyperactivity Disorder
Inattention and/or hyperactivity-impulsivity Interferes with functioning or development Occurs in at least two settings Starts young (before 12) 5

Inattention (6 or more): Careless mistakes in schoolwork Difficulty sustaining attention Doesn’t seem to listen Doesn’t follow instructions Difficulty organizing tasks Avoids sustained mental effort Loses things Easily distracted Forgetful 6

Hyperactivity and impulsivity (6 or more): Fidgets Leaves seat Runs around Unable to play quietly On the go, motor-driven Talks excessively Blurts out answers Difficulty waiting in line Interrupts 7

Six or more of at least one of the categories above Starts before age 12 Two or more settings Interferes with functioning Rule out schizophrenia 8

5% of children and 2.5% of adults Stress may predispose (low birth weight, smoking, alcohol, child abuse, neglect) Genetic Males:females 2:1 9

ADHD - Impact Reduced school performance Reduced academic attainment
Social rejection Poorer occupational attainment Reduced attendance Increased unemployment Increased interpersonal conflict

ADHD - Treatment Parent training (positive attending, tokens, response cost, time out, special situations) COPE Family education and intervention School supports (educational aid) Medication: stimulants, antidepressants, SNRI, other (including antipsychotics and blood pressure meds)

Adults Have it Too Therapy Medication GTD and other techniques

Presentation Narcissistic Personality Disorder – Grigoriy and Andrew

Presentation Borderline Personality Disorder – Margarete and Amy

Personality vs. Temperament
Temperament refers to behavioral style, the how of behavior. Personality describes the what or why of behavior. Long recognized as different, researchers have investigated connections between biological aspects of behavior and personality structure and development. accessed November 17, 2015

Personality Traits Currently, one of the most popular personality theories is the Big Five theory of Paul Costa and Robert McCrae. Based on repeated factor analysis of personality traits, these authors have concluded that personality is comprised of five universal dimensions: Extroversion, Agreeableness, Neuroticism, Openness, and Conscientiousness. They believe that these five factors can be found in self-ratings of personality in youngsters as soon as they are able to rate themselves, and remain invariant through adulthood. accessed November 17, 2015

OCEAN Traits Open to Experience (Thinking) Conscientious (Conscience)
Extraverted (Relating) Agreeable (Willfulness) Neurotic (Emotional Stability) E.g. my friend D, male, 56, believes that because one group of terrorists belongs to a particular religious group, therefore all members of that religious group are predisposed toward violence

Other views of personality
Myers-Briggs Personality = temperament + character Temperament = inclinations = predisposition Character = habits = disposition “Foxes are predisposed – born – to raid hen houses…unless arrested in its maturation by an unfavorable environment, develops the habit appropriate to its temperament: stealing chickens” David Keirsey (1998), Please Understand Me II: Temperament, Character, Intelligence (Del Mar, California: Prometheus), p. 20

Carl Jung People have a multitude of instincts or archetypes, all equally valid Naturally inclined toward extraversion or introversion Prefer one of four basic psychological functions: thinking, feeling, sensation, intuition David Keirsey (1998), Please Understand Me II: Temperament, Character, Intelligence (Del Mar, California: Prometheus), p. 3

David Keirsey (1998), Please Understand Me II: Temperament, Character, Intelligence (Del Mar, California: Prometheus), pp. 4-5

3 Axes, 16 Combinations Thinking – Feeling Sensing – Intuiting
Perceiving – Judging Extraverted – Introverted SPs: ESTP, ISTP, ESFP, ISFP SJs: ESTJ, ISTJ, ESFJ, ISFJ NFs: ENFJ, INFJ, ENFP, INFP NTs: ENTJ, INTJ, ENTP, INTP David Keirsey (1998), Please Understand Me II: Temperament, Character, Intelligence (Del Mar, California: Prometheus), pp

Myers-Briggs, 4 personality types
Artisans (SPs) or Concrete Utilitarians Ernest Hemingway, Winston Churchill, Dylan Thomas, Ronald Reagan, foxes Guardians (SJs) or Concrete Cooperators George Washington, Hobbits, Harry Truman, beavers

Myers-Briggs, 4 personality types
Idealists (NFs) or Abstract Cooperators Mohandas K. Gandhi, Plato, (Socrates?), dolphins Rationals (NTs) or Abstract Utlitarians Einstein, Professor Higgins (Pygmalion), owls

Maybe personality can be defined on the basis of life goals
Strategies, plans and concerns Behaviour desired goals Personal projects, life tasks, strivings Dynamic, goal-directed The journey we take in life Robert A. Emmons (1999). The Psychology of Ultimate Concerns: Motivation and Spirituality in Personality. New York: Guilford

Personality as Story Narrative the story that I tell about myself
integrity vs. despair (Erickson)

Personality Disorder “An enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” DSM-5, p. 645

No longer “Axis II” Personality Disorders, Developmental Disorders, maladaptive personality features and defense mechanisms used to have a separate niche in the DSM The Axes have been removed and PD’s return to the mainstream (Section II) They also have an “Alternative Model” for PD’s in Section III of the DSM-5 (p. 761) Section II is very similar to the DSM-IV Section III is a new model emerging...

Cluster A (odd, eccentric)
Paranoid – distrust, interprets others as malevolent Schizoid – detachment, restricted range of affect Schizotypal – discomfort in relationships, cognitive distortions, eccentric behavior

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

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

Clusters are not validated (then again, nothing is)
Individuals may present with co-occurring personality disorders from different clusters Prevalence Cluster A 5.7% Cluster B 1.5% Cluster C 6.0% Any personality disorder, 9.1% Approximately 15% of U.S. adults have at least one personality disorder Approximately 70% of high-conflict post-divorce couples have at least one partner with a personality disorder 31

General Personality Disorder
Enduring pattern of inner experience and behaviour that deviates in two or more ways Thinking Feeling Interpersonal functioning Impulse control The enduring pattern is inflexible and pervasive (i.e. enduring) Causes distress or impairment Stable (i.e. enduring) 32

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)

Personality Disorder Goals that tend to put the person in conflict with others

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 One bright, beautiful Sunday morning, everyone in tiny Anytown got up early and went to the local church. Before the service started, the townspeople were sitting in their pews and talking about their lives, their families, and so on. Suddenly, Satan appeared at the front of the church. Everyone started screaming and running for the front entrance, trampling each other in a frantic effort to get away from evil incarnate. Soon everyone had left the church except for an elderly gentleman who sat calmly in his pew, not moving, seemingly oblivious to the fact that God's ultimate enemy was in his presence. Now, this confused Satan a bit, so he walked up to the man and said, "Hey! Don't you know who I am?" The man replied, "Yep, sure do." Satan asked, "Aren't you afraid of me?" "Nope, sure ain't," said the man. Satan was a little perturbed at this and queried, "Why aren't you afraid of me?" The man calmly replied, "I've been married to your sister for 25 years."

Cluster A Odd, eccentric 36

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 37

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 38

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 39

Cluster B Dramatic, emotional, erratic 40

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 before age 15 41

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 potentially self-damaging suicidal or self-mutilating behaviour affective instability chronic feelings of emptiness 42

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 43

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 44

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 45

Cluster C Anxious, fearful 46

Avoidant Personality Disorder
Pervasive social inhibition, feelings of inadequacy, hypersensitivity to criticism, 4 +: avoids jobs with people avoids people in general unless they like him/her well behaved in intimate relationships preoccupied with rejection inhibited in new situations sees self as inferior to others reluctant to take risks 47

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 48

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 can’t delegate miserly rigid and stubborn 49

Family Etiology PDs defined as a pattern of relationship that doesn’t work in the patient’s current setting Why would anyone develop a pattern of relating that doesn’t work?

Family Etiology A: It did work, at one time, in a different setting
Biopsychosocial pattern Affect regulation Cognitive perception Interpersonal relations (In)appropriate behaviour Impulse control Malcolm M. MacFarlane, ed. (2004), Family Treatment of Personality Disorders (New York: Haworth), p. 5

Family Etiology Object Relations Self Psychology Attachment
“Those who endure abusive, extremely inconsistent, and neglectful attachments fail to develop a sense of object constancy and mastery of basic ego functions, such as affect regulation, impulse control, and the ability to develop trusting attachments. Instead, they tend to rely on primitive defenses, such as splitting good and bad elements of the self and others, projection, acting out, have a tendency for emotional dysregulation, and have unstable interpersonal relations.” Malcolm M. MacFarlane, ed. (2004), Family Treatment of Personality Disorders (New York: Haworth), p. 16

Biology Doubtless genetics plays a role
Malcolm M. MacFarlane, ed. (2004), Family Treatment of Personality Disorders (New York: Haworth), p. 17 Doubtless genetics plays a role Some evidence: borderline, anti-social, OCD Cloninger 1986, 1987 Novelty-seeking = dopamine Harm-avoidance = serotonin Reward-dependency = norepinephrine “In effect, these systems set the constraints for personality, and combining these tendencies allows for the individual differences in personality as well as explaining disorders.”

Treatment Joining (with limits) Understanding Educating Intervening 54

Tailor the Treatment to the Deficiency
Understand and appreciate client’s limits (e.g. don’t expect OCPD to express emotion, do expect BPD to have frequent crises) Attend to safety Step a little outside the client’s comfort zone (e.g. OCPD promote exposure, discourage compulsive behaviour; BPD be a disappointing helper) See more below (DBT) Feinberg, R., & Greene, J. T. (1997). The Intractable Client: guidelines for working with personality disorders in family law. Family and Conciliation Courts Review, 35(3), 351–365.

Object Relations Theory
MFT Applications

Object Relations Theory
The ‘object’ of object relations: a “human” object Internal or external Fantasied or real

Object Relations Theory: A Brief History
Melanie Klein (1882–1960): Contemporary of Freud’s 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

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)

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 60

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

Fairbairn cont Early infantile dependency Transitional stage
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 62

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

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

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

Differentiation 6 - 10 months mother is separate stranger anxiety
increasing differentiation of self and object 66

Practicing 10 - 16 months quadruped locomotion
physical distance from mother 67

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 68

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 69

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

Kernberg, cont Development Introjection Identification Ego Identity
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 71

Kohut self psychology parents and significant others are selfobjects
“distinct, objectively separate individuals in the child’s life who eventually become incorporated into the self” praise from a selfobject is internalized as pride shame is internalized as guilt 72

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 73

Kohut Mirroring Idealizing
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 74

Dialectical Behaviour Therapy
Adapted from Anita Federici, Ph.D.

Dialectics Everything is made of opposing forces
Gradual changes lead to turning points, where one opposite overcomes the other Change is evolutionary There is truth on both sides Balance of acceptance and change

The Biosocial Model emotionally vulnerable person invalidating environment BEHAVIOURALLY DYSREGULATED PERSON

What is emotion regulation?
Ability to decrease (or increase) physiological arousal associated with emotion Inhibit mood-dependent action Experience emotions without escalating or blunting Organize behaviour in the service of external, non-mood dependent goals (Gottman & Katz, 1989)

DBT Assumptions Clients are doing the best they can
Clients want to improve Clients need to do better, try harder, be more motivated Clients may not have caused all of their problems, but they have to solve them anyway Clients lives are currently unbearable Clients must learn new behaviours Clients cannot fail in DBT

Behaviour change strategies
Antecedents, Behaviour, Consequences Diary cards (self-monitoring form) Behaviour chain analysis Contingency management Reinforcement (“Scratch the good dog, not the bad one” – Buddha) Punishment – immediate, consistent, firm Shaping – guiding toward new behaviour

DBT Skills Training Mindfulness Mindfulness is intentional
Mindfulness is the awareness that emerges through paying attention on purpose, in the present moment, and non-judgmentally to things as they are Mindfulness is intentional Mindfulness is experiential, and it focuses directly on present moment experience Mindfulness is non-judgmental The practice of mindfulness teaches us to shift into being mode so that we can be more at peace with our emotions (Williams et. al., 2007)

DBT Skills Training: Mindfulness
Three states of mind: Reasonable Mind Left hemisphere Rational, logical, facts, observable data Cause effect, consequences Emotion Mind Right hemisphere Impulsive Creative, passionate, empathy Wise Mind Synthesis of both Need both to make decisions Less impulsive

DBT Skills Training Practicing mindfulness: WHAT Skills HOW Skills
Observe (being aware, noticing) Describe (“just the facts”) Participate (completely, in the moment) HOW Skills Non-judgmentally One-mindfully (be present) Effectively (do what works!)

DBT Skills Training Distress tolerance skills
For how to survive a crisis without making it worse Crisis survival skills: STOP skill Distract with Wise Mind ACCEPTS Self-soothing with the five senses IMPROVE the moment Pros/Cons of engaging in behaviour

Distress tolerance skills
DBT Skills Training Distress tolerance skills Acceptance skills Observe the breath Awareness of the body Half-smile Radical Acceptance Turn the mind Willingness vs. wilfulness

DBT Skills Training: Distress Tolerance
Distract with Wise Mind ACCEPTS Activities Contributing Comparisons opposite Emotions Pushing away (leave it for a while) with other Thoughts use other intense Sensations (e.g. holding ice)

Self-soothing Using the five senses Comfort, nurture, be gentle w/self Developing compassion for the Self technique (Yvonne Dolan) Incorporate mindfulness skills Not making it worse Being creative (e.g. using playlists or slide shows on iPod) Exercise: create a self-soothing collage/scrapbook

IMPROVE the moment Imagery (safe place, relaxing scene) Meaning Prayer/spiritual beliefs Relaxation One thing in the moment Vacation Encouragement

Radical Acceptance Accepting completely and fully situations, circumstances, and/or people “Pain is inevitable, suffering is optional” Buddha Accepting completely and fully one’s genetic predisposition to body shape, size, metabolism Accepting that they are in treatment Includes “turn the mind” and “willingness vs. willfulness”

DBT Skills Training: Interpersonal Effectiveness Skills
Asking for things & making requests Saying “No”’ to requests, staying firm Focus on being effective Reviews myths to IPE and helps to challenge them Objectives effectiveness: DEAR MAN Relationship effectiveness: DEAR GIVE Self-respect effectiveness: DEAR FAST

DBT Skills Training: IPE Skills
DEAR MAN Describe the current situation Express feelings and opinions Assert by asking or saying no Reinforce the person ahead of time Mindful of objectives without distraction Broken record Ignoring attacks Appear effective and competent Negotiate alternative solutions Turn the tables

DBT Skills Training: Emotion Regulation
Goals of emotion regulation skills Understand emotions Identify, observe & describe (mindful), understand function Reduce emotional vulnerability Decrease negative vulnerability (emotion mind) Decrease emotional suffering Being mindful of painful emotions and letting go Acting in a manner opposite to painful emotion

Understanding emotions Emotions communicate to (and influence) others Emotions organize and motivate action Don’t have to think everything through Emotions communicate to ourselves can be self-validating Provides us with information about a situation Can be a signal or an alarm that something is happening

Reduce emotional vulnerability (staying out of emotion mind) treat PhysicaL illness balance Eating avoid mood-Altering drugs balance Sleep get Exercise build MASTERy

Decreasing emotional suffering Observe your emotion Be aware of it, step back, get unstuck Experience your emotion As a wave, don’t block or suppress it Don’t hold on to or amplify it Remember: You are not your emotion Practice loving your emotion Don’t judge it, radically accept it

Acting opposite to the current emotion Not trying to mask or hide emotions Throw your entire self into acting opposite to the emotion, go all the way! Works best when your emotions are not realistic for the situation e.g. fear – doing what you are afraid of, over and over again anger – “be kind, and if you can, be a little bit nice” or gently avoid (vs. attack)

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

Narcissistic Injury The parent repeatedly fails the child
Mirroring failure – inability to consistently reflect pride in the child’s accomplishments Inadequacy, emptiness, despair, meaninglessness, need for reassurance Idealizing failure – e.g. parent who is a drug addict, “don’t use me as a role model” Defective self-soothing, inability to pursue goals with commitment (what’s the use? Look where I came from)

Twinship Failure Child lacks experiences of joining with the parent in activities Defective empathy, creativeness, humor, wisdom, acceptance of one’s own transience Lack of skills and competence

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

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

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? 102

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 103

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