Psychological Intervention in the
Trenches: Working Effectively With
Inmates With Cluster B Personality
Disorders
S. Doug Lemon, Psy.D., Chief Psychologist, USP McCreary
DISCLAIMER

 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.
PERSONALITY DISORDERS

“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 DISORDER DIAGNOSIS

 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
GENDER ISSUES IN 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
CLUSTER B

 Tend to be emotional, dramatic, erratic (DSM-5)
 Over-represented in a correctional environment
 Correctional facilities are less tolerant of such
behavior
ANTISOCIAL PERSONALITY DISORDER

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
PERSONALITY DYNAMICS-Antisocial

 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)
INTERVENTION- 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)
DISRUPTIVE BEHAVIOR- Antisocial

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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
INTERVENTION- 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
INTERVENTION- Antisocial

 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
BORDERLINE PERSONALITY DISORDER

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.)
BORDERLINE PERSONALITY DISORDER

 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)
PERSONALITY DYNAMICS- Borderline

 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)
PERSONALITY DYNAMICS- Borderline

 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 problemsolving style (may be passive in session)
PERSONALITY DYNAMICS- Borderline

 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)
INTERVNETION-Borderline

 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)
INTERVENTION- 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
DISRUPTIVE BEHAVIOR- 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
INTERVENTION-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)
HISTRIONIC PERSONALITY DISORDER

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)
PERSONALITY DYNAMICS- Histrionic

 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)
PERSONALITY DYNAMICS- Histrionic

 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
INTERVENTION- Histrionic

 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 allegationsfollow policy
NARCISSISTIC PERSONALITY DISORDER

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)
PERSONALITY DYNAMICS- Narcissistic

 PREOCCUPATION- Inflation/deflation of selfesteem
 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)
PERSONALITY DYNAMICS- Narcissistic

 Different from antisocials- don’t exhibit impulsivity,
aggression, deceit, criminal behavior
INTERVENTION- Narcissistic

 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)
HYBRID PERSONALITY DISORDERS

 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
FINAL THOUGHTS

 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”