GENDER DIFFERENCES IN A
PERSONALITY TREATMENT
PROGRAMME
Kyle
MacDonald
Segar House Rauaroha
ADHB, New
Zealand
HISTORY OF GENDER CONSIDERATIONS
IN THE PROGRAMME
Fears about the implications for the group
therapy process
Most male client referrals were inclined
towards low-level acts of aggression, normally
towards intimate partners
HISTORY OF GENDER CONSIDERATIONS
IN THE PROGRAMME
Added a Mentalization aspect to our DBT
based therapeutic approach
Allowed us to understand the process of
attachment based aggression in an adult
presentation
How did our treatment approach need to be
different?
ASSESSMENT OF AGGRESSION
Had only occurred in the context of intimate
and family relationships
Was followed by shame and contrition
Had not resulted in serious injury
Distinguish this from a more sociopathic or
narcissistic pattern:
 more random pattern to the offending
 absence of remorse and accountability
CASE EXAMPLE: “DAVE”
42 year old New Zealand European man
Hospitalised after relationship breakdown
Threatening and aggressive towards rejecting
partner whilst in a dissociated state
Followed by a profound depression
History of failed relationships
“Not an angry man.”
CASE EXAMPLE: “DAVE”
 Alien self is a term used in Mentalization Based
Therapy
 Outcome of “chronically insensitive or misattuned
caregiving.”
 Self representation internalises aspects of the
other, “creating a fault in the construction of the
psychological self”
 If later trauma occurs, it can “force the child to
dissociate from the pain by using the alien self to
identify with the aggressor.”
(Fonagy et.al. 2002)
CASE EXAMPLE: “DAVE”
Trauma Symptom Inventory at Intake
CASE EXAMPLE: “DAVE”
• On Trauma Symptom Inventory
(T.S.I.)significant result for:
• Anxious Arousal
• Depression
• Intrusive Experiences
• Defensive Avoidance
• Tension Reduction Behaviours
• Summary scales for Trauma and Dysphoria
CASE EXAMPLE: “DAVE”
Formulation
When Dave didn’t acknowledge his anger, due
to a fear he would be “like his father,” he
denied a part of himself and in his denial and
dissociation lost control and kept repeating
the very thing he sought to dis-own.
CASE EXAMPLE: “DAVE”
Dave’s “alien self” can then be understood as
an example of identifying with the aggressor
Dave utilises the defensive structure of
projection to protect against painful affect,
most notably shame
This angry aggressive part felt to Dave like
“not me.”
He alternates between: persecutory rage and
aggression/ and the persecution of the self
via suicidal depression and self harm.
CASE EXAMPLE: “DAVE”
Trauma Symptom Inventory at Discharge
CASE EXAMPLE: “DAVE”
Trauma Symptom Inventory at Intake
MBT AND DBT:
GENDERED MODELS?
Application of MBT seems more helpful to our
team when thinking about aggression and
interpersonal violence
Primary author of DBT is female, and most of
it’s application has been to female borderline
clients targeting self harming behaviour
MBT’s lead authors are male; it’s literature
talks more freely about interpersonal
violence, and the model’s therapeutic
application to anti-social personality disorder
TEAM RESPONSES
Have we treated our female clients as
“fragile”?
In our fear of treating “violent men” were we
failing to mentalize our male referrals?
Because we feared, did we make them
frightening?
To be open to wondering and thinking
about their experiences, to see the
whole person, in all their complexity
and to hold their mind in mind