psychological intervention in the trenches: working effectively with inmates with cluster b...

Psychological Intervention in the Trenches: Working Effectively With Inmates With Cluster B Personality

Disorders S. Doug Lemon, Psy.D., Chief Psychologist, USP McCreary

The views expressed in written conference

materials or by this speaker do not necessarily reflect the official policies of the Federal Bureau of Prisons; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

DISCLAIMER

“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 leads to distress or impairment”(DSM-5)

PERSONALITY DISORDERS

Manifested in 2 or more of the following ways: Cognition Affectivity Interpersonal functioning Impulse control

(DSM-5)

PERSONALITY DISORDERS

Differentiate from traits by functional

impairment or subjective distress Sometimes can dx after only one interview Inmate may not experience distress or

recognize impairment R/O medical cause and other mental disorder Can always put “antisocial traits” if not

enough information available

PERSONALITY DISORDER DIAGNOSIS

Antisocial, narcissistic diagnosed more in men Histrionic, dependent, borderline diagnosed

more in women Don’t overlook diagnoses rarely diagnosed in

the gender you are working with

GENDER ISSUES IN DIAGNOSIS

Tend to be emotional, dramatic, erratic (DSM-

5) Over-represented in a correctional

environment Correctional facilities are less tolerant of such

behavior

CLUSTER B

A pervasive pattern of disregard for and violation of the rights of others as indicated by three (or more) of the following: Failure to conform to social norms with respect

to lawful behaviors, as indicated by repeatedly performing acts that are grounds for arrest.

Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure.

Impulsivity or failure to plan ahead.

ANTISOCIAL PERSONALITY DISORDER

Irritability and aggressiveness, as indicated by

repeated physical fights or assaults. Reckless disregard for safety of self or others. Consistent irresponsibility, as indicated by repeated

failure to sustain consistent work behavior or honor financial obligations.

Lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from others.

(DSM-5)Majority of USP inmates meet criteria

ANTISOCIAL PERSONALITY DISORDER

PREOCCUPATION- Manipulating/being

manipulated CENTRAL AFFECT- Rage, envy BELIEF ABOUT SELF- I can make anything

happen BELIEF ABOUT OTHERS- Everyone is selfish,

manipulative, dishonorable PRIMARY DEFENSE- Reaching for omnipotent

control(PDM)

PERSONALITY DYNAMICS-Antisocial

Antisocial believes prison is the final injustice

in a string of injustices In the past, laws, rules, and rights meant little

to him In prison, he becomes highly legalistic about

asserting his own rights Despite being in prison, the antisocial expects

to do as he pleases and for the prison to accommodate him

(Samenow, 1984)

PERSONALITY DYNAMICS- Antisocial

Convey a powerful presence Understand what motivates patient has to do

with what makes him/her look/feel powerful (PDM)

Educate the criminal regarding errors in thinking

Predict destructive consequences for self and others if he continues in this way (Walters, 1990)

INTERVENTION- Antisocial

One of the drivers of disruptive behavior Often because he feels disrespected or is told

“no” by staff Often engage in threats of suicide or gestures Holding food slot, throwing urine/feces, refusing

to return handcuffs or cuff up Typically understands power Can be reasoned with Operates from an egocentric perspective Altruism doesn’t work

DISRUPTIVE BEHAVIOR- Antisocial

“Learning disabled” (slow learner) Behavior has short-term positive

consequences, with long-term negative consequences

Capable of learning if staff are consistent Concerned with their rep on the range

DISRUPTIVE BEHAVIOR- Antisocial

Your reputation/integrity are crucial Take time to listen and address legit concerns Hold them accountable, and be straightforward Some need to hear “the speech” in R&D Show respect at all times- do not be

unprofessional A good SHU interventionist is a good actor Don’t get caught in a power struggle- you

already won! Do SHU rounds same day/time weekly


Explain your orientation to your exec staff and

lieutenants- try to get buy-in Effective interventionists are tough, principled Don’t be in a hurry to go see gamers Don’t put people on suicide watch who aren’t

suicidal (what are you reinforcing?) Get up and go in to see these folks for SRA’s

at any time of the day or night- it pays off in the long run

Support the use of restraints when called for


A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity, as indicated by five (or more) of the following: Frantic efforts to avoid real or imagined abandonment.

(Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)

A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation.

Identity disturbance: markedly and persistently unstable self-image or sense of self.

BORDERLINE PERSONALITY DISORDER

Impulsivity is at least two areas that are

potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). (Note: Do not include suicidal or self-mutilating behavior covered in Criterion 5.)

Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior.

Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability, or anxiety usually lasting a few hours and only rarely more than a few days.)


Chronic feelings of emptiness. Inappropriate, intense anger or difficulty

controlling anger (e.g., frequent displays of temper, constant anger, recurrent physical fights).

Transient, stress-related paranoid ideation or severe dissociative symptoms.

(DSM-5)


PREOCCUPATION- emotional validation CENTRAL AFFECT- shame BELIEF ABOUT SELF- I must be loved by all the

important people in my life at all times or I am worthless

BELIEF ABOUT OTHERS- Some people are all good, and some are all bad

PRIMARY DEFENSES- splitting, projection, denial

PERSONALITY DYNAMICS- Borderline

Abandonment depression is composed of

rage, suicidal impulses, panic, hopelessness, helplessness, emptiness, and guilt

Underlying threat kept at bay Act out to avoid these feelings

(Masterson, 2004)


Emotional vulnerability- high sensitivity, high

intensity, and slow return to baseline Self-invalidation- feel chronically invalidated Unrelenting crises Inhibited grieving- inhibit and over-control

negative emotional responses Active passivity- passive interpersonal

problem-solving style (may be passive in session)


Apparent competence- appear deceptively more

competent than he/she is

Interpreting communications of intense pain/agony or current crises as manipulative is invalidating to the patient, and contraindicated

SIB is an attempt to re-establish emotional equilibrium

Splitting is due to cognitive rigidity. They vacillate between divergent views they cannot reconcile

(Linehan, 1993)


Short-term goals: containment of acting out,

verbalization of affects, improved ego functioning and adaptation, increase in self-activation

Confrontation is the primary approach

(Masterson, 2004)

INTERVNETION-Borderline

Get Me Out of Here , Stop Walking on

Eggshells– great therapy resources Linehan’s book/workbook- Bible Weekly IT sessions and weekly skills groups

(different therapists if possible) Crisis-initiated contacts ok, but deduct time

from IT session as a result In IT session, do behavioral analysis of

crises/acting out from previous week

INTERVENTION- Borderline

Another driver of disruptive behavior Unlike antisocial, not based on power Can be due to boredom, intense emotions,

being alone, feeling hopeless Often threaten self-injury or engage in

SIB/gestures Lots of SRA’s (templates) Also can assault others, hold food slot, destroy

property

DISRUPTIVE BEHAVIOR- Borderline

Use a DBT-informed approach Be aware of behavioral principles Pull from the cell weekly (be consistent) Use DBT handouts Be very brief with crisis intervention Can use the phone from home Must get the SHU Lt. on board May need out of the cell by Lt. when upset

(holding cell)

INTERVENTION-Borderline

A pervasive pattern of excessive emotionality and attention seeking, as indicated by five (or more) of the following: Is uncomfortable in situations in which he or she is not

the center of attention. Interaction with others is often characterized by

inappropriate sexually seductive or provocative behavior.

Displays rapidly shifting and shallow expression of emotions.

Consistently uses physical appearance to draw attention to self.

HISTRIONIC PERSONALITY DISORDER

Has a style of speech that is excessively

impressionistic and lacking in detail. Shows self-dramatization, theatricality, and

exaggerated expression of emotion. Is suggestible (i.e., easily influenced by others

or circumstances). Considers relationships to be more intimate

than they actually are.(DSM-5)

HISTRIONIC PERSONALITY DISORDER

PREOCCUPATION- Power and sexuality in own

gender/other gender CENTRAL AFFECTS- Fear, shame, guilt BELIEF ABOUT SELF- My gender makes me

weak, vulnerable BELIEF ABOUT OTHERS- People of my gender

are of little value; people of the other gender are powerful, exciting, potentially damaging

PERSONALITY DYNAMICS- Histrionic

PRIMARY DEFENSES- Repression, regression,

conversion, sexualizing, acting out

(PDM)


More likely to encounter in female institutions More prevalent with homosexual men and/or

men with symptoms of GD Differs from borderline PD- not self-

destructive, chronic feelings of emptiness and identity disturbance

Differs from narcissistic PD- willing to appear weak/inferior to gain attention


Relationally-oriented therapy is most helpful Patient needs to increase self-definition May respond well to interpretation

(PDM)

INTERVENTION- Histrionic

Allow patient to vent strong emotions Demonstrate healthy boundaries Identify self-defeating behaviors Assertiveness training, anger management Focus on strengths May be more likely to make PREA allegations-

follow policy

INTERVENTION- Histrionic

A pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy as indicated by five (or more) of the following: Has a grandiose sense of self-importance (e.g.,

exaggerates achievements and talents, expects to be recognized as superior without commensurate achievements).

Is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love.

Believes that he or she is “special” and unique and can only be understood by, or should associate with, other special or high status people (or institutions).

NARCISSISTIC PERSONALITY DISORDER

Requires excessive admiration. Has a sense of entitlement (i.e., unreasonable

expectations of especially favorable treatment or automatic compliance with his or her expectations).

Is interpersonally exploitative (i.e., takes advantage of others to achieve his or her own ends).

Lacks empathy: is unwilling to recognize or identify with the feelings and needs of others.

Is often envious of others or believes that others are envious of him or her.

Shows arrogant, haughty behaviors or attitudes.(DSM-5)

NARCISSISTIC PERSONALITY DISORDER

PREOCCUPATION- Inflation/deflation of self-

esteem CENTRAL AFFECTS- Shame, contempt, envy BELIEF ABOUT SELF- I need to be perfect to feel

okay BELIEF ABOUT OTHERS- Others enjoy riches,

beauty, power, and fame; the more of those I have, the better I will feel

PRIMARY DEFENSES- Idealization, devaluation(PDM)

PERSONALITY DYNAMICS- Narcissistic

Have a sense of inner emptiness and

meaninglessness requiring recurrent infusions of external confirmation of their importance and value

When deprived (PRISON), they feel depressed, shamed, and envious of those who succeed in attaining the supplies they lack

Spend a lot of time evaluating their status relative to others

(PDM)


Different from antisocials- don’t exhibit

impulsivity, aggression, deceit, criminal behavior


Must effect therapeutic change without

precipitating a defensive reaction Confrontation is contraindicated Therapeutic neutrality and keeping the

therapeutic frame are primary interventions

(Masterson, 2004)

INTERVENTION- Narcissistic

May make disparaging, belittling comments-

be professional Praise appropriate behavior and capacity for

same Exhibit healthy boundaries- they expect staff

to do whatever they want/need Likely to have cellmate problems and

problems with staff- address from egocentric perspective (work within the belief system)

INTERVENTION- Narcissistic

Why didn’t my professor tell me about this? Very common among BOP inmates More borderline/antisocials on our radar at

USP’s Lot of antisocial/narcissists in prison

HYBRID PERSONALITY DISORDERS

Antisocial/narcissists- avoid making them

defensive or feel belittled, and avoid appearing to want to control them

Antisocial/borderline- validate their emotional experience while not coming off as telling them what to do

HYBRID PERSONALITY DISORDERS

Consult with peers Own your interventions/style Practice interventions out loud and use

visualization Seek supervision Read, read read! “Don’t cast your pearls before swine” “The teacher appears when the student is

ready”

FINAL THOUGHTS

psychological intervention in the trenches: working effectively with inmates with cluster b...

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