young professionals and personality disorder training

[BlackSkirtTetra]

Hi all.

Do any of you find that once you graduate with your MSW (or equivalent in your field) and are working, you have nothing to fall back on re: treating personality disorders? I am finding myself working with multiple people who have really exceptionally rough histories, most with personality disorders, and to be perfectly blunt it's harder than I ever thought it would be. It's exhausting and sometimes I wonder if I should just resign and go live under a rock. It can get that stressful.

In school both of my clinical internships were nothing compared to this (one with adolescents and one in a halfway house) and my psychopathology classes did not prepare me for this. I had no training at all that was specifically about personality disorders.

What is your advice? I've asked my supervisors (a DSW and a LCSW) but haven't gotten clear answers from the two of them. An LP I know (from elsewhere) told me, "either you have it or you don't," meaning that either you can work with severe personality disorders, or not.

I guess I'm just in an odd state, after getting done with school and trying to make it work for a few months but still finding myself unable to do the work I'm supposed to be trained for. I just don't feel competent, qualified, or effective to treat these severe disorders, but everybody is telling me I am...any feedback will be helpful.

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[sonofva]

what sort of work specifically are you doing?

 

[SuperSoccer19]

Personality disorders can be VERY difficult to "treat," if not impossible in some cases. If the patient is not getting any better or making very slow progress, it might not be you or your approach. Its difficult to give advice in a forum without knowing the specifics or what exactly are the PDs and problems you are experiencing, but I wanted to throw that out as some support. These patients can often lack insight and their pathology is so deep rooted that its hard to break and is often a slow process.

For example, comprehensive DBT--involving groups, individual and even sometimes medication management all as a team approach--can take years according to some providers. Gains are often not present until months into treatment and even at a year out symptoms are often present (trying to find a citation for this, but I do not have a good internet connection).

Just wanted to say hang in there. Even if you PDs are not your forte, you will probably learn quite a bit from this experience.

 

[BlackSkirtTetra]

Thank you both. I'm a program director at a residential facility for women who've just been released from prison. The vast majority of my clients have PDs (ASPD, Narcissistic PD, and Borderline PD are the most common), with issues like rape (perpetrators and victims), one murder, assault, drugs, AIDS, and so on in the mix. The person who was in this position before me quit after a year and before her there were FOUR people in this position within a year (I didn't know this when I accepted the position, I learned it from one of the PRN staff who has been here for years).

The agency itself is good, the benefits and pay are decent, and on paper what's required of me looks totally possible. But the client manipulation, all the police involvement, and so on has me feeling like I am not cut out for this. I don't know if the "this" is the job in particular, the organization, or the client population. I'm leaning towards client population...

 

[InNae]

Can you find adjunct supervision by someone with lots of experience with PDs? My training is a clinical PhD, but I got most of my exposure to PDs during my predoctoral internship and postdoc. A couple of thoughts that might or might not be relevant to your situation:

First, and echoing the poster above, remember that many (most?) people with PDs don't see a problem and are not interested in therapy for the PD. You can negotiate treatment goals with the clients, by which I do NOT mean letting the clients drive therapy, but deciding together what to tackle first, which probably will be something less characterological (e.g., acute trauma-related symptoms, adjustment to an HIV diagnosis). Treating something more acute and less pervasive also is one route to building trust with a person who has personality issues.

Second, maintain your own boundaries religiously. Use the same policies regarding communication, therapy attendance, off-limits topics, or whatever, with EVERY client. In a residential setting, your clients will talk to each other about you, and if someone thinks they're being treated differently, you will have drama. Also, if you let someone push your boundaries even once, a more manipulative person will almost certainly continue to try to take advantage. Although I do not at all want to diminish anyone's autonomy as an adult, it sometimes helped me to think of the behavior as that of an adolescent. Adolescents need firm, consistent, clear boundaries.

Third, confer early and often about each client with that client's other providers. Explicitly let the client know you're doing this, be clear about what type of information you will share, and emphasize that this is the optimal team approach to facilitating the client's transition back into society. People with PDs (and plenty of people without them!) will try to split providers, as you know. Open, frequent communication is the best way to prevent or minimize that.

Fourth, remember that personality issues are on a continuum. If a client comes to you with a certain diagnosis, that doesn't necessarily mean that the person's pathology is so severe that you can't work with her around characterological stuff (although in my experience it helps to frame the behavior as behavior/skills, rather than characterological issues).

Finally, don't neglect self-care. It absolutely is exhausting to work with clients with significant trauma histories and the other issues you list. Do what you need to do to take care of your body and mind.

Hope something in there is helpful, and to repeat, try to find an expert in PDs for supervision, even short-term.