5 Tips for Effective Work With Personality Disorders

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Personality disorders (PDO’s) have been of increasing interest in mental health care. To effectively encounter PDOs, one must be at the top of their game; any mental health condition can present some challenges, but PDOs take it to the next level.

Recently, I was fortunate to interview PDO expert Dr. Joseph Shannon, Ph.D., of Columbus, Ohio, who has had a significant influence on my clinical work. Shannon has over four decades’ experience of treating the full range of personality disorders and teaching professionals about the conditions. He reflected on what has made him so successful in working with PDOs and offered five essential things clinicians should keep in mind about personality disorders.

1. “You must have a strong grounding in psychopathology with a particular focus on personality disorders.”

Shannon continued that PDOs are very common in clinical settings. About 20% of the general population is personality-disordered, he said, so the concentration of them in treatment arenas is even higher. Unfortunately, PDOs are generally only taught about within a standard psychopathology or abnormal psychology course, so self-education is essential. There are numerous continuing education opportunities to be found in CEU catalogs, and a plethora of indispensable reads. In particular, Shannon suggested:

• Disorders of Personality by Theodore Millon, Ph.D. Millon provides historical context, modern conceptualizations, etiological considerations, treatment approaches, and case studies for the DSM-5 personality disorders, along with several others.
• Fatal Flaws by Stuart Yudofsky, M.D. Reading like a novel written for professionals and general interest readers, Yudofsky brings several of the most difficult-to-work-with personality disorders to light by recollecting his most challenging but successful cases over the years. He provides a play-by-play understanding of the therapeutic exchanges, and tips for working with/interacting with these disorders.

2. “You must work on physical and emotional boundaries and limit-setting.”

Shannon went on that people with personality disorders are notorious for pushing limits. Whether this is the borderline personality seeking your presence after hours to satisfy a rescue fantasy, a histrionic patient becoming flirtatious, or a narcissistic individual trying to intimidate you, therapists must hold their ground and not make exceptions. Instead, successful treatment involves examining the maladaptive nature of these tendencies and arriving at more constructive ways of getting needs met.

3. "Ask yourself how presenting problems connect with overall pathology."

In other words, be on the lookout for if a personality condition is driving presenting complaints. Someone may initially present, for example, with depression because they feel stuck in life. It's discovered that the patient has a profound unassertive nature and can't make decisions on their own, and meets criteria for dependent personality, hence they're stuck. To only provide mood coping strategies and not recognize that the personality must be worked with for a long-term solution to the depression, is, as Shannon put it, "the equivalent of putting a Band-Aid on a gunshot wound."

4. "Prepare to be fooled."

"High-functioning personality-disordered people can present as extremely normal," explained Shannon. "The personality issue can become apparent much later, surprising even the most seasoned therapists. Don't beat yourself up."

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A therapist may, for a few months, believe they're working with a patient on garden-variety generalized anxiety, for example, a common comorbidity and presenting problem with PDOs. Then, a personal matter requires the therapist to rearrange their schedule, pushing the patient's appointment out a week. This spurs a tirade on how much they depended on the appointments, how you've now disappointed them, and that they shouldn't have put faith in you.

This is not an uncommon scenario for a borderline personality who over-idealized the therapist, and when the therapist's world did not revolve around the patient, they took it as a sign of pending abandonment, sinking the therapist to undervalued status.

5. "Understand the potential litigious hazards."

Shannon recommended, especially if this population is a clinical focus, to get educated about litigious protection. "People with certain personality disorders can be very vindictive," he commented. "If feeling sufficiently crossed somehow by the therapist, they may turn to the legal arena to feel in control of the situation, and vindicated."

A good example is someone with paranoid personality disorder who, highly suspicious by nature, misinterprets a therapist's occasional kind remarks about the patient's outfit and offerings of coffee or tea during the session as flirtatious. They discontinue sessions and report the therapist to the licensing board for sexual harassment, then file a medical malpractice suit.

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Shannon noted that the majority of therapists who find themselves in such an unfortunate scenario are found innocent. However, there is still the headache of having to deal with the situation, including legal fees, potential license suspension during the board investigation, and increased malpractice insurance costs, not to mention a potentially-tarnished reputation.

Clinicians who wish to protect themselves must practice healthy boundaries, keep careful documentation, and receive supervision. Shannon finished that clinicians who interact with PDOs will find High Conflict People in Legal Disputes, a book by attorney and therapist William Eddy.

Disclaimer: Material provided in this post is for informational purposes only and not intended to diagnose, treat, or prevent any illness in readers. The information should not replace personalized care from your provider or formal supervision if you're a practitioner or student.