Managing symptoms of personality disorders

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These symptoms are often present to varying degrees in many clients and do not necessarily indicate a personality disorder; however, they can make the therapeutic process more difficult. Strategies for managing the symptoms of personality disorders are outlined in Table 45. Some of these personality characteristics, impulsivity in particular, place clients at extremely high risk for suicide. It is therefore particularly important to monitor the risk of suicide and self-harm. Assisting clients to develop skills (e.g., breathing retraining, meditation, cognitive restructuring) to manage negative emotions is also fundamental [94]. 

Clients with personality disorders tend to have difficulty forming a genuinely positive therapeutic alliance. They tend to frame reality in terms of their own needs and perceptions and not to understand those of others. They are also limited in their ability to receive, accept or benefit from corrective feedback; therefore, progress is likely to be slow and uneven [94].

Engagement and rapport building form an intensely important part of therapy and, as a result, these areas may require more time and attention than they do in other clients. Clients with personality disorders may have trouble engaging in treatment due to a history of poor relationships with AOD and other health professionals, a bias towards suspiciousness or paranoid interpretation of relationships, or a chaotic lifestyle, making appointment scheduling and engaging in structured work more difficult [103]. Structure and firm boundaries are very important components of the therapeutic process when managing clients with symptoms of personality disorders.

Table 45: Dos and don’ts of managing a client with symptoms of personality disorders

DO:

  • Place strong emphasis on engagement to develop a good client–worker relationship and build strong rapport.
  • Set clear boundaries and expectations regarding the client’s role and behaviour. Some clients may seek to test these boundaries.
  • Establish and maintain a consistent approach to clients and reinforce boundaries.
  • Anticipate compliance problems and remain patient and persistent.
  • Plan clear and mutual goals and stick to them; give clear and specific instructions.
  • Help with the current problems the client presents with rather than trying to establish causes or exploring past problems.
  • Assist the client to develop skills to manage negative emotions (e.g., breathing retraining, progressive muscle relaxation, cognitive restructuring).
  • Take careful notes and monitor the risk of suicide and self-harm.
  • Avoid judgement and seek assistance for personal reactions (including frustration, anger, dislike) and poor attitudes towards the client.
  • Listen to and evaluate the client’s concerns.
  • Accept but do not confirm the client’s beliefs.

DON'T:

  • Reward inappropriate behaviour (such as demanding, aggressive, suicidal, chaotic or seductive behaviour).
  • Get frustrated and angry with the client. Remain firm, calm and in control.
  • Assume a difficult client has a personality disorder; many do not, and many clients with these disorders are not difficult.

Adapted from NSW Department of Health [277] and Davison [963].