Family Therapy and
Mental Health
University of Guelph
Open Learning and Educational
Support
1
Reflections on the Course So
Far



Comments
Questions
Assignments
2
Today


ADHD
Personality Disorders
3
Presentation

ADHD – Stacey and Mark
4
Attention-Deficit/Hyperactivity
Disorder




Inattention and/or hyperactivity-impulsivity
Interferes with functioning or development
Occurs in at least two settings
Starts young (before 12)
5
Attention-Deficit/Hyperactivity
Disorder










Inattention (6 or more):
Careless mistakes in schoolwork
Difficulty sustaining attention
Doesn’t seem to listen
Doesn’t follow instructions
Difficulty organizing tasks
Avoids sustained mental effort
Loses things
Easily distracted
Forgetful
6
Attention-Deficit/Hyperactivity
Disorder










Hyperactivity and impulsivity (6 or more):
Fidgets
Leaves seat
Runs around
Unable to play quietly
On the go, motor-driven
Talks excessively
Blurts out answers
Difficulty waiting in line
Interrupts
7
Attention-Deficit/Hyperactivity
Disorder





Six or more of at least one of the categories
above
Starts before age 12
Two or more settings
Interferes with functioning
Rule out schizophrenia
8
Attention-Deficit/Hyperactivity
Disorder




5% of children and 2.5% of adults
Stress may predispose (low birth weight,
smoking, alcohol, child abuse, neglect)
Genetic
Males:females 2:1
9
ADHD - Impact







Reduced school performance
Reduced academic attainment
Social rejection
Poorer occupational attainment
Reduced attendance
Increased unemployment
Increased interpersonal conflict
10
ADHD - Treatment





Parent training (positive attending, tokens,
response cost, time out, special situations)
COPE
Family education and intervention
School supports (educational aid)
Medication: stimulants, antidepressants,
SNRI, other (including antipsychotics and
blood pressure meds)
11
Adults Have it Too



Therapy
Medication
GTD and other techniques
12
Presentation

Narcissistic Personality Disorder – Grigoriy
and Andrew
13
Presentation

Borderline Personality Disorder – Margarete
and Amy
14
Personality vs. Temperament

Temperament refers to behavioral style, the
how of behavior. Personality describes the
what or why of behavior. Long recognized as
different, researchers have investigated
connections between biological aspects of
behavior and personality structure and
development.

https://www.b-di.com/personality.html, accessed
November 17, 2015
15
Personality Traits

Currently, one of the most popular personality theories is
the Big Five theory of Paul Costa and Robert McCrae.
Based on repeated factor analysis of personality traits,
these authors have concluded that personality is
comprised of five universal dimensions: Extroversion,
Agreeableness, Neuroticism, Openness, and
Conscientiousness. They believe that these five factors
can be found in self-ratings of personality in youngsters
as soon as they are able to rate themselves, and remain
invariant through adulthood.

https://www.b-di.com/personality.html accessed November 17, 2015
16
OCEAN Traits
Open to Experience (Thinking)
Conscientious (Conscience)
Extraverted (Relating)
Agreeable (Willfulness)
Neurotic (Emotional Stability)






E.g. my friend D, male, 56, believes that because
one group of terrorists belongs to a particular
religious group, therefore all members of that
religious group are predisposed toward violence
17
Other views of personality

Myers-Briggs

Personality = temperament + character



Temperament = inclinations = predisposition
Character = habits = disposition
“Foxes are predisposed – born – to raid hen
houses…unless arrested in its maturation by an
unfavorable environment, develops the habit
appropriate to its temperament: stealing chickens”

David Keirsey (1998), Please Understand Me II:
Temperament, Character, Intelligence (Del Mar,
California: Prometheus), p. 20
18
Carl Jung



People have a multitude of instincts or
archetypes, all equally valid
Naturally inclined toward extraversion or
introversion
Prefer one of four basic psychological
functions: thinking, feeling, sensation,
intuition

David Keirsey (1998), Please Understand Me II:
Temperament, Character, Intelligence (Del Mar,
California: Prometheus), p. 3
19
20
David Keirsey (1998), Please Understand Me II: Temperament, Character,
Intelligence (Del Mar, California: Prometheus), pp. 4-5
3 Axes, 16 Combinations








Thinking – Feeling
Sensing – Intuiting
Perceiving – Judging
Extraverted – Introverted
SPs: ESTP, ISTP, ESFP, ISFP
SJs: ESTJ, ISTJ, ESFJ, ISFJ
NFs: ENFJ, INFJ, ENFP, INFP
NTs: ENTJ, INTJ, ENTP, INTP

David Keirsey (1998), Please Understand Me II: Temperament, Character,
21
Intelligence (Del Mar, California: Prometheus), pp. 11-12
Myers-Briggs, 4 personality
types

Artisans (SPs) or Concrete Utilitarians


Ernest Hemingway, Winston Churchill, Dylan
Thomas, Ronald Reagan, foxes
Guardians (SJs) or Concrete Cooperators

George Washington, Hobbits, Harry Truman,
beavers
22
Myers-Briggs, 4 personality
types

Idealists (NFs) or Abstract Cooperators


Mohandas K. Gandhi, Plato, (Socrates?), dolphins
Rationals (NTs) or Abstract Utlitarians

Einstein, Professor Higgins (Pygmalion), owls
23
Maybe personality can be
defined on the basis of life
goals
Strategies,




plans and concerns
Behaviour
desired goals
Personal projects, life tasks, strivings
Dynamic, goal-directed
The journey we take in life
Robert A. Emmons (1999). The Psychology of Ultimate Concerns:
Motivation and Spirituality in Personality. New York: Guilford
24
Personality as Story
Narrative


the story that I tell about myself
integrity vs. despair (Erickson)
25
Personality Disorder

“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, and leads to distress or
impairment.”

DSM-5, p. 645
26
No longer “Axis II”





Personality Disorders, Developmental
Disorders, maladaptive personality features
and defense mechanisms used to have a
separate niche in the DSM
The Axes have been removed and PD’s
return to the mainstream (Section II)
They also have an “Alternative Model” for
PD’s in Section III of the DSM-5 (p. 761)
Section II is very similar to the DSM-IV
Section III is a new model emerging...
27
Cluster A (odd, eccentric)



Paranoid – distrust, interprets others as
malevolent
Schizoid – detachment, restricted
range of affect
Schizotypal – discomfort in
relationships, cognitive distortions,
eccentric behavior
28
Cluster B (dramatic,
emotional, erratic)




Antisocial – disregard for, and violation of,
the rights of others
Borderline – unstable relationships, self
image, affects, and impulsive behavior
Histrionic – excessive emotion and attention
seeking
Narcissistic – grandiosity, need for
admiration, lack of empathy
29
Cluster C (anxious, fearful)



Avoidant – social inhibition, feelings of
inadequacy, hypersensitivity to negative
evaluation
Dependent – submissive, clinging, need to
be taken care of
Obsessive-Compulsive – preoccupied with
orderliness, perfectionism, and control
30
Clusters are not validated
(then again, nothing is)


Individuals may present with co-occurring
personality disorders from different clusters
Prevalence






Cluster A 5.7%
Cluster B 1.5%
Cluster C 6.0%
Any personality disorder, 9.1%
Approximately 15% of U.S. adults have at least
one personality disorder
Approximately 70% of high-conflict post-divorce
couples have at least one partner with a
personality disorder
31
General Personality Disorder

Enduring pattern of inner experience and
behaviour that deviates in two or more ways







Thinking
Feeling
Interpersonal functioning
Impulse control
The enduring pattern is inflexible and
pervasive (i.e. enduring)
Causes distress or impairment
Stable (i.e. enduring)
32
Personality Disorder
1. Traits that tend to put the person in conflict
with others





Not so open (or too open) to new experiences
Not so conscientious (or too conscientious)
Not so extraverted (or too extraverted)
Not so agreeable (or too agreeable)
Not so neurotic – i.e. emotional instability (or
too neurotic, i.e. lack of emotional range)
33
Personality Disorder
2. Goals that tend to put the person in conflict
with others
34
Personality Disorder
3. Stories that tend to put the person in
conflict with others, or that tend to put
others in conflict over the person


Good vs. evil (splitting)
Story about the client
35
Cluster A

Odd, eccentric
36
Paranoid Personality Disorder

Pervasive distrust and suspiciousness
(interprets others’ motives as malevolent)
beginning in early adulthood, 4 or more of:







suspects others are exploiting or harming
doubts loyalty or trustworthiness of friends
reluctant to confide in others
reads hidden threats in benign remarks or events
bears grudges
perceives attacks from others
doubts fidelity of sexual partner
37
Schizoid Personality Disorder

Pervasive detachment and restricted affect
beginning in early adulthood, four or more of:







no joy in close relationships
almost always chooses solitary activities
little interest in sexual experiences
pleasure in few, if any, activities
lacks close friends apart from close relatives
appears indifferent to praise or criticism
emotionally cold, detached, flattened affect
38
Schizotypal Personality
Disorder

Pervasive social deficits, acute discomfort
and reduced capacity for close relationships,
cognitive distortions and eccentric, 5 or more:







ideas of reference
odd beliefs
unusual perceptions
odd thinking and speech
paranoid ideation
constricted or inappropriate affect
peculiar behaviour
lack of close friends; social anxiety r/t paranoia
39

Cluster B

Dramatic, emotional, erratic
40
Antisocial Personality
Disorder

Pervasive disregard for and violation of the
rights of others since age 15, 3 or more:








repeatedly acting s.t. grounds for arrest
deceitful, lying, conning for personal profit
impulsive or failure to plan ahead
irritable, aggressive, fights and assaults
reckless disregard for safety of self or others
consistent irresponsibility
lack of remorse
at least 18; history of Conduct Disorder before
age 15
41
Borderline Personality
Disorder

Pervasive pattern of instability in
relationships, self-image, affects, and marked
impulsivity. Five or more:







frantic efforts to avoid abandonment
pattern of unstable and intense relationships
unstable self image
impulsivity in two areas potentially self-damaging
suicidal or self-mutilating behaviour
affective instability
chronic feelings of emptiness
42
Borderline Personality
Disorder

Pervasive pattern of instability in
relationships, self-image, affects, and marked
impulsivity. Five or more:


inappropriate, intense anger
transient, stress-related paranoid ideation or
severe dissociative symptoms
43
Histrionic Personality Disorder

Pervasive pattern of excessive emotionality
and attention-seeking, five or more:








likes to be centre of attention
sexually provocative
rapidly shifting, shallow emotions
uses physical appearance to draw attention
impressionistic style of speech
theatrical
suggestible
thinks relationships are intimate
44
Narcissistic Personality
Disorder

Pervasive grandiosity, need for admiration
and lack of empathy, five or more:









self-importance
fantasies of unlimited success
special
requires excessive admiration
sense of entitlement
interpersonally exploitative
lacks empathy
envies others
arrogant and haughty
45
Cluster C

Anxious, fearful
46
Avoidant Personality Disorder

Pervasive social inhibition, feelings of
inadequacy, hypersensitivity to criticism, 4 +:







avoids jobs with people
avoids people in general unless they like him/her
well behaved in intimate relationships
preoccupied with rejection
inhibited in new situations
sees self as inferior to others
reluctant to take risks
47
Dependent Personality
Disorder

Pervasive and excessive need to be taken
care of, submissive, clingy, five or more:








difficulty making decisions
needs others to be responsible
difficulty disagreeing with others
difficulty initiating projects
goes to great lengths to get support
feels helpless when alone
serial relationships
afraid of being left alone
48
Obsessive-Compulsive
Personality Disorder

Pervasive preoccupation with orderliness,
perfectionism, control, four or more:








details, rules, lists
perfectionism that prevents task completion
workaholic
overconscientious (morals, ethics, values)
pack rat
can’t delegate
miserly
rigid and stubborn
49
Family Etiology


PDs defined as a pattern of relationship that
doesn’t work in the patient’s current setting
Why would anyone develop a pattern of
relating that doesn’t work?
50
Family Etiology


A: It did work, at one time, in a different
setting
Biopsychosocial pattern





Affect regulation
Cognitive perception
Interpersonal relations
(In)appropriate behaviour
Impulse control
Malcolm M. MacFarlane, ed. (2004), Family Treatment of Personality Disorders (New York: Haworth), p. 5
51
Family Etiology



Object Relations
Self Psychology
Attachment

“Those who endure abusive, extremely inconsistent, and neglectful
attachments fail to develop a sense of object constancy and mastery of
basic ego functions, such as affect regulation, impulse control, and the
ability to develop trusting attachments. Instead, they tend to rely on
primitive defenses, such as splitting good and bad elements of the self
and others, projection, acting out, have a tendency for emotional
dysregulation, and have unstable interpersonal relations.”
Malcolm M. MacFarlane, ed. (2004), Family Treatment of Personality Disorders (New York: Haworth), p. 16
52
Biology



Malcolm M. MacFarlane, ed. (2004),
Family Treatment of Personality Disorders
(New York: Haworth), p. 17
Doubtless genetics plays a role
Some evidence: borderline, anti-social, OCD
Cloninger 1986, 1987




Novelty-seeking = dopamine
Harm-avoidance = serotonin
Reward-dependency = norepinephrine
“In effect, these systems set the constraints for
personality, and combining these tendencies
allows for the individual differences in personality
as well as explaining disorders.”
53
Treatment




Joining (with limits)
Understanding
Educating
Intervening
54
Tailor the Treatment to the
Deficiency




Understand and appreciate client’s limits (e.g.
don’t expect OCPD to express emotion, do
expect BPD to have frequent crises)
Attend to safety
Step a little outside the client’s comfort zone
(e.g. OCPD promote exposure, discourage
compulsive behaviour; BPD be a
disappointing helper)
See more below (DBT)

Feinberg, R., & Greene, J. T. (1997). The Intractable Client: guidelines for working with
personality disorders in family law. Family and Conciliation Courts Review, 35(3), 55
351–365.
Object Relations
Theory
MFT Applications
56
Object Relations Theory

The ‘object’ of object relations:



a “human” object
Internal or external
Fantasied or real
57
Object Relations Theory:
A Brief History

Melanie Klein (1882–1960):





Contemporary of Freud’s
First direct work with children
Children devote more energy to interpersonal
relationships than to libidinal impulses
They create internal and play representations of
their important relationships
Intensely studied mom & infant
58
Object Relations Theory:
A Brief History

Klein




in continuation with Freud believed in a
destructive inner force (death instinct)
inner struggle of live v death projected on the
outer world
external destructive objects (bad objects: giants,
monsters, villains)
external life objects (good objects: mothers,
fathers, heros)
59
Klein, cont


Resolving Good and Bad in Relationships
Positions

Paranoid (0-3 months)





birth is stressful, the child feels persecuted and attacked
takes it out on the breast
splitting good v bad
persecutory anxiety
Depressive (4 months - 2 years)




splitting is reversed and mom is whole object again
appreciate good and bad instead of good or bad
anxiety about harming the parent
with guilt comes empathy
60
Object Relations Theory:
A Brief History

William Fairbairn (1889 – 1964)


Continued to shift focus from pleasure to
relationships
Developmental scheme



early infantile dependency
transitional period
mature dependence
61
Fairbairn cont

Early infantile dependency



Transitional stage



child merged with caretaker
poorly developed sense of self
lifelong process
away from one-way dependency
Mature dependence


mutuality and exchange
healthy interdependence
62
Object Relations Theory:
A Brief History

Fairbairn: three types of objects


Good becomes ‘ideal object’
Bad becomes


‘exciting object’ (formed from teasing or tempting
child) - makes child feel frustrated and empty
‘rejecting object’ (formed by hostile or rejecting
caregiver) - makes child feel unloved and unwanted
63
Object Relations Theory:
A Brief History

Fairbairn


Three ego states
Exciting object → libidinal ego


Rejecting object → anti-libidinal ego


Always thirsting, never satisfied, deprived
Hateful and vengeful, longs for acceptance
Ideal object → central ego

Results in conforming behaviour
The first two states are repressed: psychopathology
64
Margaret Mahler

Normal Developmental Stages of Infants



Autistic
Symbiotic
Separation-individuation




Differentiation
Practicing
Rapprochement
Libidinal object constancy
65
Differentiation




6 - 10 months
mother is separate
stranger anxiety
increasing differentiation of self and object
66
Practicing



10 - 16 months
quadruped locomotion
physical distance from mother
67
Rapprochement







15 - 30 months
language
interaction with other adults (father)
self-assertion and separateness
strong need for help and reassurance
crisis: need for parent v need for separation
need a balance of support and firmness
68
Libidinal Object Constancy





30 months - 3 years
stable internal representation of the mother
enables the child to function on its own
develops relationships with others
integration of positive and negative, good
and bad, objects

if not completed, in later life tend to see others as
either punitive and rejecting or unrealistically
gratifying
69
Object Relations Theory:
A Brief History
Otto Kernberg (1928- )


Bipolar representations



self
other
affective colouring



e.g. mother-child-positive and fulfilling
or mother-child-frustrating and depriving
Various bipolar representations are “metabolized”
to form foundation of personality
70
Kernberg, cont

Development

Introjection



Identification



primitive experiences, undifferentiated
splitting good v bad
more mature, beginning of self-object understanding
more control over affective colouring
Ego Identity


synthesized bipolar representations
integrated sense of self
71
Kohut


self psychology
parents and significant others are selfobjects



“distinct, objectively separate individuals in the
child’s life who eventually become incorporated
into the self”
praise from a selfobject is internalized as
pride
shame is internalized as guilt
72
Kohut cont

children are naturally narcissistic


develop a positive and rewarding structure of self
children have two basic needs


to show off (If others see me as good, then I must
be good) - healthy omnipotence - mirroring
selfobject
to merge with an ideal selfobject (My mother is
good, and I am my mother, so I am good) healthy connectedness - idealizing selfobject
73
Kohut

Mirroring


Idealizing


I am perfect and you must admire me
You are perfect and I am a part of you
Normally, these two continue through life in
increasingly mature and complex ways, and
you become a selfobject for your children,
your spouse, and your clients
74
Dialectical Behaviour
Therapy
Adapted from Anita Federici, Ph.D.
© Homewood Health™ Confidential & Proprietary
75
Dialectics
• Everything is made of opposing forces
• Gradual changes lead to turning points,
where one opposite overcomes the other
• Change is evolutionary
• There is truth on both sides
• Balance of acceptance and change
© Homewood Health™ Confidential & Proprietary
76
The Biosocial Model
emotionally
vulnerable
person
invalidating
environment
BEHAVIOURALLY
DYSREGULATED PERSON
© Homewood Health™ Confidential & Proprietary
77
What is emotion regulation?
• Ability to decrease (or increase) physiological arousal
associated with emotion
• Inhibit mood-dependent action
• Experience emotions without escalating or blunting
• Organize behaviour in the service of external,
non-mood dependent goals
(Gottman & Katz, 1989)
© Homewood Health™ Confidential & Proprietary
78
DBT Assumptions
1. Clients are doing the best they can
2. Clients want to improve
3. Clients need to do better, try harder, be more
motivated
4. Clients may not have caused all of their
problems, but they have to solve them
anyway
5. Clients lives are currently unbearable
6. Clients must learn new behaviours
7. Clients cannot fail in DBT
© Homewood Health™ Confidential & Proprietary
79
Behaviour change strategies
•
•
•
•
Antecedents, Behaviour, Consequences
Diary cards (self-monitoring form)
Behaviour chain analysis
Contingency management
• Reinforcement (“Scratch the good dog, not the bad one” –
Buddha)
• Punishment – immediate, consistent, firm
• Shaping – guiding toward new behaviour
© Homewood Health™ Confidential & Proprietary
80
DBT Skills Training
• Mindfulness
•
Mindfulness is the awareness that emerges through
paying attention on purpose, in the present moment, and
non-judgmentally to things as they are
•
•
Mindfulness is intentional
Mindfulness is experiential, and it focuses
directly on present moment experience
Mindfulness is non-judgmental
The practice of mindfulness teaches us to shift
into being mode so that we can be more at
peace with our emotions
•
•
(Williams et. al., 2007)
© Homewood Health™ Confidential & Proprietary
81
DBT Skills Training: Mindfulness
• Three states of mind:
• Reasonable Mind
• Left hemisphere
• Rational, logical, facts, observable data
• Cause effect, consequences
• Emotion Mind
• Right hemisphere
• Impulsive
• Creative, passionate, empathy
• Wise Mind
• Synthesis of both
• Need both to make decisions
• Less impulsive
© Homewood Health™ Confidential & Proprietary
82
DBT Skills Training
• Practicing mindfulness:
• WHAT Skills
• Observe (being aware, noticing)
• Describe (“just the facts”)
• Participate (completely, in the moment)
• HOW Skills
• Non-judgmentally
• One-mindfully (be present)
• Effectively (do what works!)
© Homewood Health™ Confidential & Proprietary
83
DBT Skills Training
•
Distress tolerance skills
•
For how to survive a crisis without making it
worse
• Crisis survival skills:
1. STOP skill
2. Distract with Wise Mind ACCEPTS
3. Self-soothing with the five senses
4. IMPROVE the moment
5. Pros/Cons of engaging in behaviour
© Homewood Health™ Confidential & Proprietary
84
DBT Skills Training
•
Distress tolerance skills
•
Acceptance skills
1.
2.
3.
4.
Observe the breath
Awareness of the body
Half-smile
Radical Acceptance
•
•
Turn the mind
Willingness vs. wilfulness
© Homewood Health™ Confidential & Proprietary
85
DBT Skills Training: Distress Tolerance
• Distract with Wise Mind ACCEPTS
•
•
•
•
•
•
•
Activities
Contributing
Comparisons
opposite Emotions
Pushing away (leave it for a while)
with other Thoughts
use other intense Sensations (e.g. holding ice)
© Homewood Health™ Confidential & Proprietary
86
DBT Skills Training: Distress Tolerance
• Self-soothing
•
•
•
•
•
•
•
Using the five senses
Comfort, nurture, be gentle w/self
Developing compassion for the Self
5-4-3-2-1 technique (Yvonne Dolan)
Incorporate mindfulness skills
Not making it worse
Being creative (e.g. using playlists or slide shows
on iPod)
• Exercise: create a self-soothing collage/scrapbook
© Homewood Health™ Confidential & Proprietary
87
DBT Skills Training: Distress Tolerance
• IMPROVE the moment
•
•
•
•
•
•
•
Imagery (safe place, relaxing scene)
Meaning
Prayer/spiritual beliefs
Relaxation
One thing in the moment
Vacation
Encouragement
© Homewood Health™ Confidential & Proprietary
88
DBT Skills Training: Distress Tolerance
• Radical Acceptance
• Accepting completely and fully situations,
circumstances, and/or people
• “Pain is inevitable, suffering is optional”
- Buddha
• Accepting completely and fully one’s genetic
predisposition to body shape, size, metabolism
• Accepting that they are in treatment
• Includes “turn the mind” and “willingness vs.
willfulness”
© Homewood Health™ Confidential & Proprietary
89
DBT Skills Training: Interpersonal Effectiveness Skills
•
•
•
•
•
•
•
Asking for things & making requests
Saying “No”’ to requests, staying firm
Focus on being effective
Reviews myths to IPE and helps to challenge them
Objectives effectiveness: DEAR MAN
Relationship effectiveness: DEAR GIVE
Self-respect effectiveness: DEAR FAST
© Homewood Health™ Confidential & Proprietary
90
DBT Skills Training: IPE Skills
•
DEAR MAN
•
•
•
•
•
Describe the current situation
Express feelings and opinions
Assert by asking or saying no
Reinforce the person ahead of time
Mindful of objectives without distraction
• Broken record
• Ignoring attacks
• Appear effective and competent
• Negotiate alternative solutions
• Turn the tables
© Homewood Health™ Confidential & Proprietary
91
DBT Skills Training: Emotion Regulation
• Goals of emotion regulation skills
• Understand emotions
• Identify, observe & describe (mindful),
understand function
• Reduce emotional vulnerability
• Decrease negative vulnerability (emotion mind)
• Decrease emotional suffering
• Being mindful of painful emotions and letting go
• Acting in a manner opposite to painful emotion
© Homewood Health™ Confidential & Proprietary
92
DBT Skills Training: Emotion Regulation
• Understanding emotions
• Emotions communicate to (and influence) others
• Emotions organize and motivate action
• Don’t have to think everything through
• Emotions communicate to ourselves
• can be self-validating
• Provides us with information about a situation
• Can be a signal or an alarm that something is happening
© Homewood Health™ Confidential & Proprietary
93
DBT Skills Training: Emotion Regulation
• Reduce emotional vulnerability (staying out of
emotion mind)
•
•
•
•
•
•
treat PhysicaL illness
balance Eating
avoid mood-Altering drugs
balance Sleep
get Exercise
build MASTERy
© Homewood Health™ Confidential & Proprietary
94
DBT Skills Training: Emotion Regulation
• Decreasing emotional suffering
• Observe your emotion
• Be aware of it, step back, get unstuck
• Experience your emotion
• As a wave, don’t block or suppress it
• Don’t hold on to or amplify it
• Remember: You are not your emotion
• Practice loving your emotion
• Don’t judge it, radically accept it
© Homewood Health™ Confidential & Proprietary
95
DBT Skills Training: Emotion Regulation
• Acting opposite to the current emotion
• Not trying to mask or hide emotions
• Throw your entire self into acting opposite to the
emotion, go all the way!
• Works best when your emotions are not realistic
for the situation
• e.g. fear – doing what you are afraid of, over and over
again
anger – “be kind, and if you can, be a little bit nice”
or gently avoid (vs. attack)
© Homewood Health™ Confidential & Proprietary
96
Kohut reprise: Twinship



The parent partners with the child in
significant tasks
The child develops empathy, creativeness,
humor, wisdom and acceptance of his/her
transience
Innate skills and talents
97
Narcissistic Injury

The parent repeatedly fails the child

Mirroring failure – inability to consistently reflect
pride in the child’s accomplishments


Inadequacy, emptiness, despair, meaninglessness,
need for reassurance
Idealizing failure – e.g. parent who is a drug
addict, “don’t use me as a role model”

Defective self-soothing, inability to pursue goals with
commitment (what’s the use? Look where I came
from)
98
Twinship Failure

Child lacks experiences of joining with the
parent in activities


Defective empathy, creativeness, humor, wisdom,
acceptance of one’s own transience
Lack of skills and competence
99
Narcissitic Injury and Rage





The self develops through selfobject
provisions of mirroring, idealizing and
twinship
The self attempts to protect itself at all costs
Selfobject failures lead to narcissitic injury
The child feels and is afraid to express rage
(for fear of destroying the parent)
The therapist gets to deal with the rage
100

In spite of selfobject failure and narcissistic
injury, the self protects its integrity through
defenses, and where the parents failed, hope
springs eternal that the partner will make
everything right
101
Relationship Management




David Dawson and Harriet MacMillan
Look at the process of the personality
disorder: what is the client trying to
accomplish?
How does this make sense developmentally?
What is a developmentally appropriate
intervention?
102
Be helpful by being different







avoid your assigned role position
assume a warm but benign, neutral posture
be paradoxical
discuss the new social contract overtly
always assume the client is a responsible,
competent adult
but overtly set appropriate limits and
consequences you are prepared to deliver
be carefully honest
103