|Variation in personality is a normal and
natural aspect of humanity. More extreme variations are sometimes labelled as
eccentric, adaptive and even brilliant. However, when these variations negatively
effect the client or others, there is utility in grouping various personality types and
subsequently providing tailored approaches based on experience and
As with other groupings, personality
disorders often do not neatly fit in one category or another. In addition, a
diagnostic label should only be used if the cluster of symptoms deviates significantly
from others in cultural groupings and is causing problems.
Those with personality disorders can often trigger strong reactions from staff.
Understanding and managing these reactions may improve client outcomes,
as well as increase staff morale, and reduce conflict within and between staff.
Understanding the meaning behind a diagnosis of personality disorder may improve common
language and understanding required in multi-disciplinary approaches.
Some personality disorders are more likely to coexist with substance
use (eg anti-social, borderline and dependent personality
disorders). While facilitating significant change in personality may be beyond the scope of most health and welfare workers,
successful drug interventions are more likely when personality factors are incorporated
into treatment plans.
Caution in uncovering negative emotional
Identify and manage your
Table of Personality Disorders
|The DSM-lV describes ten disorders which fall
into three categories:
Eccentric or odd behaviour:
Paranoid, schizoid and schizotypal personality disorders
Dramatic, erratic and emotional behaviour:
Borderline, antisocial, narcissistic and histrionic personality disorders
Anxious, fearful, and/or constricted behaviour:
Obsessive-compulsive, avoidant and dependent personality disorders
|Most theories about the development of
personality disorders stress the use of maladaptive coping strategies to cope with life
problems. These problems may be severe, prolonged and experienced early in life (eg
ongoing child sexual abuse). As the coping strategies tend to avoid rather than deal
with issues, chronic underlying stress states develop which call for even more of the same
As unresolved issues mount, so does general life chaos.
In this context, substance use may provide yet another maladaptive coping strategy which
also increases the range and depth of overall problems.
As these coping strategies become in-grained, certain developmental tasks are poorly
achieved. This results in personalities which often evoke strong reactions in others thus
reinforcing and maintaining the personality disorder and associated chaos.
In addition some theorists suggest a bio-social predisposition
to certain personality disorders (eg borderline personality
disorder). This theory hypothesise an autonomic nervous
system which over-reacts to low levels of stress and takes longer
than normal to return to normal baseline states. This mechanism is
likely to also predispose to increased substance use.
uncovering underlying negative emotional states
As most personality disorders are the manifestation of long-term protection
against stress and anxiety states, be cautious of uncovering deep emotional states,
particularly if unsupported or when undergoing detoxification.
Doing so may increase
anxiety and exacerbate negative symptoms associated with personality
disorder and possibly increase the likelihood of relapse into
maladaptive defence mechanisms such as excessive drug use.
Identify and manage your reaction
Personality disorders often trigger a range of issues within self. These reactions
can threaten professional conduct with the client and other staff. Use good
communication skills between staff as well as with the client. Set clear boundaries
and limits and stick to them.
Supervision will help to see own reactions and maintain professional conduct. Where
treatment is not progressing, supervision may help ensure all that can be done is being
done (which is the criteria for staff success).
Specialist therapy may be indicated for some personality disorders, particularly
when there are concurrent symptoms such as self-harm or very aggressive behaviour.
These treatments should generally only be carried out under close supervision of someone
experienced in these treatments such as a clinical psychologist or
Family members may require support as clients in their own right. Where children are
involved, a careful assessment of child safety may be required, generally by someone
specifically trained in this area such as a child protection worker.
Family and significant others may have extensive experience in
dealing with maladaptive behaviours and can be a key resource in
both assessment and ongoing treatment if appropriately engaged and
involved in case management.
Table of Personality Disorders
The table below provides a brief sketch of personality disorders. While the staff
reaction column is based on the author's previous experience rather than
hard research, it is provided to stimulate consideration of
possible reactions and management of these reactions.
||OVERLY: suspicious, mistrustful,
conspiracy theories. hold grudges, sensitive to criticism
||Defensive, anger, sarcasm
||Do not argue the point.
Use empathy rather than hunt for detail
Keep professional distance
Be open and straightforward
||Detached, solitary, emotionally cold,
eccentric (eg superstitious, telepathic) vague speech
||Emotional distance, frustration at not
||Respect withdrawal and distance but
'hang in there'. Continue to be there after the client expects you to give up
||Poor interpersonal relationships -
people seen as either wonderful or terrible.
Hates being alone, impulsive and moody.
May have self-harm, eating disorders, depression
Often previously abused with post traumatic stress
|Staff splitting: may feel like the
only one who 'really understands' (if being flattered) while others feel resentful (if
they are being devalued).
Danger of crossing client/counsellor boundaries
|Work with here & now problems
using structured problem solving approach, rather than issues in the past.
High level communication with other staff. Maintain client/counsellor
boundaries & limits.
Specialist therapy such as
Behaviour Therapy & Cognitive Behavioural Therapy helpful
||Self absorbed, need to be constantly
admired, lack of empathy with others, arrogant, May over flatter counsellor or criticise
if total attention not given
|Staff splitting as with Borderline PD.
Feeling hurt and angry or flattered & charmed.
|Similar to Borderline PD
Set time limits with client
Recognise own narcissistic issues
||History of conduct disorder in
Disregard for the rights of others
Unlawful, lying, impulsive, aggressive, irresponsible, lack of remorse, reckless
with self and others. May be charismatic and corrupting
|Vicarious excitement & admiration
Loathing at lack of conscience
Attempts to control may result in aggression
|Resist temptation to collude or
reinforce anti-social behaviour.
Reframe hurtful exploits in a matter-of-fact manner as hurtful and not glamorous.
Focus on resolving immediate problems.
||Attention seeking and over-emotional,
dramatic. Over-use of metaphor & flowery language
Easily falls in love (with counsellor)
|Impatient or frustrated when
difficulty in getting to the point or
Engrossed with poetic style
|Maintain boundaries and use clarifying
||Perfectionist, rigid, in control, no
Irritable or angry when their order is threatened
Depressed if they can't meet their own expectations
|Irritated by lack of flexibility
Frustrated counselling when client is over-inclusive and pedantic about detail.
Battle to over-come their obsession with control
|Work with underlying feelings,
particularly feelings of hostility and anger (care with worker and client safety)
||Distant social relationships (although
unlike Schizoid PD, these would like intimate relationships but fear rejection). May be
anxious and depressed
||Withdrawal as client is quiet and
||Respect distance, but continue to be
Cognitive therapy helpful in challenging negative beliefs about social situations
||Rely on others to make decisions, care
for and control them
Submissive and require constant reassurance
Rarely disagree for fear of loss of relationship
Ask the counsellor for all the answers
Severe depression may accompany relationship disharmony
|Counsellor does all the talking and
Cut off from client for fear of being consumed by their dependence
|Resist giving advice or
cutting-off. Rather use a problem solving or solution focused brief therapy approach
and congratulate client success.
Dependence is a key feature of addiction. Motivational therapy, 12 step programs
and cognitive behavioural therapy may all be useful.