Strategies for managing the symptoms of personality disorders are outlined in Table 55. The development of coping skills (e.g., breathing retraining, meditation, cognitive restructuring described in Appendix BB and Appendix CC) to regulate emotions is considered fundamental in the treatment of co-occurring personality and AOD use disorders [102]. Coping strategies have been found to mediate the relationship between personality disorder and AOD use [1509] and deficits in emotion regulation are considered core to maintaining symptoms of BPD [1510].
AOD workers may find it difficult to manage symptoms of personality disorders which are some of the most challenging conditions to treat [1511, 1512]. Establishing a positive therapeutic relationship is essential, but often difficult due to the inherent relational difficulties that are experienced by people with these conditions. These difficulties often arise from insecure attachment during childhood and frequently surface in the context of a therapeutic relationship [121]. Other challenges include strong countertransference reactions including anger, frustration or indifference; as well as often needing to manage the heightened risk that is presented with chronic suicidal thinking and AOD use [121, 162]. Some personality characteristics, impulsivity in particular, place clients at extremely high risk for suicide, and require increased levels of monitoring the risk of suicide and self-harm.
Engagement and rapport building form an intensely important part of treatment and clients with personality disorders may require more time and attention than other clients [121]. Clients with personality disorders may have trouble developing positive therapeutic relationships 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 [948]. Structure and firm boundaries are very important components of the therapeutic process when managing clients with symptoms of personality disorders.
Progress may also be slow and uneven as many people with personality disorders have trouble integrating change-oriented feedback [102]. Donald and colleagues [121] note the importance of striking the right balance between validation (i.e., empathetic acceptance of the client and their difficulties), which has typically been lacking from this client group’s experiences and is often responded to well, and change-oriented interventions focused on changing current behaviours (such as developing alternative coping strategies to replace self-harm or AOD use). It may also be helpful to highlight aspects of the client’s personality that may be viewed as strengths, and enhance their prospects of achieving the outcomes they are working towards [162].
Table 55: Dos and don’ts of managing a client with symptoms of personality disorders
| Do: |
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Place strong emphasis on engagement to develop a good client–worker relationship and build strong rapport.
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Set clear boundaries and expectations regarding the client’s role and behaviour. Some clients may seek to test these boundaries.
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Establish and maintain a consistent and reliable approach to clients and reinforce boundaries.
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Anticipate difficulties with adhering to treatment plans and remain patient and persistent.
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Plan clear and mutual goals and stick to them; give clear and specific instructions.
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Help with the current problems the client presents with rather than trying to establish causes or exploring past problems.
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Assist the client to develop skills to manage negative emotions (e.g., breathing retraining, progressive muscle relaxation, cognitive restructuring).
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Maintain a calm environment, as significant stress may exacerbate symptoms.
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Take careful notes and monitor the risk of suicide and self-harm.
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Avoid judgement and seek assistance for personal reactions (including frustration, anger, dislike) and poor attitudes towards the client. Remember that challenging aspects of behaviour often have survival value in the context of past experiences.
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Listen to and evaluate the client’s concerns.
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Accept but do not confirm the client’s beliefs.
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| Don't: |
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Reward inappropriate behaviour (such as demanding, aggressive, suicidal, chaotic, or seductive behaviour).
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Display frustration or anger with the client. Remain firm, calm and in control.
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Assume a difficult client has a personality disorder; many do not, and many clients with these disorders are not difficult.
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Adapted from NSW Department of Health [431], Project Air [1513], Davison [1514], and Fraser et al. [162].