tfptherapy_biotalk

"The recognition and management of AXIS II pathology in practice" was given by Pamela A. Foelsch, PhD at the Northeastern Regional Biofeedback Society meeting on June 10, 2001. Essential information from the presentation is excerpted below. This information is divided into two sections: Identification and Treatment Frame. For further information or questions please contact Dr. Foelsch at paf@tfptherapy.com.

Identification: Patient and Therapist Observations
The following are the characteristics that may indicate that character pathology is present. It is the pattern that is significant, not the isolated presence of a characteristic. The red items warrent possible referral for diagnostic evaluation and/or adjunctive treatment in addition to the need to create a structured treatment frame.

"Abnormal" patient presentation
Presence of anxiety, depression, &/or anger
Interpersonal concerns
Lack of treatment progress
Suspected secondary gain
Medication seeking/manipulation
Frequent calls/canceled appointments
Unusual responses to treatment
Disruptive behaviors
ER utilization (excessive/inappropriate).

The awareness of the following feelings and thoughts in the treater are indications that the patient may have a personality disorder. At a minimum, it indicates the need to frame and structure the treatment to preserve the therapist's ability to be optimally effective.

"Non-normal" therapist reactions
Frustration with the lack of treatment progress
Belief that nothing will help
Belief that the presenting condition is in the head
Becoming overly involved-working too hard
(in relation to the patient's level of involvement)
Pressure to prescribe interventions &/or
medication (the need to do something)
Difficulty in coordinating adjunctive treatments

In addition to the above indicators, if the history of the patient contains the following characteristics, this is evidence that the treatment will be potentially more difficult and that the prognosis is worse.

Personality Disorder Assessment Flags for
                          Poor Prognosis
Negative therapeutic reaction
Interpersonal difficulties
   - Antisocial features
   - Pervasive aggression
   - Secondary gain
   - Low intelligence
   - No love life --- attractiveness
   - No work or shifting

The following graphic is from the chapter "A Psychoanalytic Theory of Personality Disorders" by Otto F. Kernberg in the book titled Major Theories of Personality Disorder edited by John F. Clarkin and Mark F. Lenzenweger, published by The Guilford Press, 1996. This chapter is an excellent introduction to Kernberg's theory of personality disorders. This slide was presented in this talk as an illustration of the interrelationship of the DSM AXIS II personality disorders with a broader conceptualization of personality pathology. It also indicated how there are two different lines seperated along the dimension of introversion/extroversion. This is important in helping clincians to recognize not only the overtly difficult patients, but those whose presentations don't "ring bells" immediately. It also highlights the relationship of presenting symptoms.

Treatment Frame: Concepts, Components, Process
The following highlight the key aspects of managing the personality pathologied patient in clinical practice, when the focus of treatment is not the personality disorder.

Creating a Treatment Frame
Contract setting and eliminating secondary gain of illness
Maintaining the boundaries of the treatment and controlling
acting out
Attending to the general priorities of treatment
Maintaining common perceptions of treatment goals (reality)

Concepts Behind the Contract
I. Defining the responsibilities of patient and therapist
II. Protecting therapist's ability to think clearly
III. Allowing the patient's entire symptom picture to
     unfold in a safe place (balancing...make referral)
IV. Setting the stage for confronting and reevaluating
    treatment when/if deviations from the contract occur
    later in therapy
V. Providing an organizing therapeutic frame that
    permits therapy to be effective in the patient's life

Treatment Contract Components
Universal Patient Responsibilities
     *attendance
     *fees
     *method of treatment
Therapist Responsibilities
     *attending schedule
     *limits of involvment
     *confidentiality policy
Threats to Treatment (Individualized to Patient)
     *attendance quality
     *threats to self/other
     *external problems impinging on treatment