Personality: Traits, Types & Disorders

Effective Psychotherapy for

characterological issues

D r M a r k Wi d d o w s o n , T S TA , E C P
University of Salford
 Workshop Content
2

 What is personality?
 Personality Traits
 Psychoanalytic Personality Types; issues, diagnosis,
interventions, treatment planning
 Personality Traits; identifying, modifying/
interventions and treatment planning
 Personality Disorders
 DSM-5 alternative dimensional system for
personality disorders
 General treatment recommendations for PD
 All supported by research evidence
 Evidence-Based Teaching and Learning
Methods
3

 Didactic input
 Scaffolding- linking to prior knowledge
 Retrieval Practice
 Generative Learning
 Problem-Based Learning
 Group Contract
4

 Confidentiality
 Take personal responsibility
 Take charge of your comfort needs
 Take care of yourself and each other
 Be willing to stretch yourself, challenge and be
challenged
 Provide honest, but sensitive feedback and take on
board the feedback of others
 Mutual respect / I+ U+
 Transparency: My stance on this issue
5

 I aim to take a non-stigmatising, non-pathologising

stance wherever possible
 This workshop will incorporate a trauma-informed
stance and will challenge dominant oppressive
discourse
 We must remember the people we are talking about
are people and NOT diagnostic labels
 Also, remember your compassion and empathy and
continue to reflect on why any given individual might
develop in a specific way.
 6

 ‘Nobody is a borderline. Nobody is a narcissist.

Nobody is a schizoid…. when we diagnose, we are
describing a pattern… never a person. All people are
unique. Labels, however well intended, cannot do
justice to human complexity’ (Greenberg, 2016: 3)
 The starting point
7

 Our focus when considering these issues should

always be:
 What happened to you?’
 NOT
 ‘What is wrong with you?’
 What is personality?

 What do you think the word ‘personality’ means?

 What constitutes someone’s personality?

 We all ‘know’ what personality is and it can be hard to

pin down .
 Let’s make is personal- what about your
personality
9

 Make a list of adjectives to describe who you are as a

person. Notice which aspects are more important to
you than others.
 Getting feedback on your personality
10

 Next, ask three people who know you well to

‘truthfully’ list the words they think best characterise
who you are.

 I suggest you send a text to three different people

who you know will give you honest feedback. ask
them for five positive and three negative adjectives/
traits
 Go a step further
11

 I invite you to spend time on some practical

homework from today’s session as continuing to elicit
some feedback on your personality as experienced by
others
 Also, ask yourself frequently; ‘is this an aspect of my
personality?’
 Start to notice aspects of other’s personalities and
also consider what might have happened that led
them to develop in that way.
 12

 What does personality actually mean?How do you

determine which aspects of the client’s personality
are problematic and which are not? Can you think of
any specific personality types? How might therapy
proceed from here.
 Defining Personality

 Personality includes ‘relatively stable ways of

thinking, feeling, behaving, and relating to others. In
this context, “thinking” encompasses not only one’s
belief systems and ways of making sense of self and
others, but also one’s moral values and ideals. Each of
us has a set of individual assumptions by which we
try to understand our experience, a set of values and
characteristic ways of pursuing what we see as
valuable, a personal repertoire of familiar emotions
and typical ways of handling them, especially in our
personal relationships’ (PDM task force, 2006: 17)
Additional (non official) Aspects of Personality
14

 Thought processes; concentration, focus, coherence, logical

functions
 Capacity for self-reflection and objectivity
 Level of intelligence, verbal intelligence, mathematical
intelligence etc
 Resilience, grit, willpower
 Capacity to tolerate and contain emotions, conflicts,
impulses
 Response to social pressures and authority
 Initiative, independence/ self-sufficiency
 Social conscience
 Tastes, values, aesthetics
 Personality-Related Concepts in TA
15

 When we think about the definition and components

of personality, which TA concepts are relevant and
how?
 Discuss this in small groups
 Anything else?
16

 Are there other aspects of personality that you can

think of that have not already been discussed?
 How well do I really know myself?
17

 We have a cognitive bias in that people generally tend

to evaluate themselves in a more positive light than
others might.
 This isn’t necessarily a problem but it can mean our
own self-image isn’t well-rounded to include other’s
views.
 The Johari Window is a useful way to think about
increasing your self-awareness
 Are you brave enough to get open, honest accurate
feedback from people who know you about your
personality strengths and difficulties?
 Unpalatable truths
18

 Are there certain words that have been used to

describe you more than once?
19
 Brief Assessment of Personality in Intake
20

 Routinely ask all clients the following 8 questions are

part of your intake procedure:
 In general do you have difficulty making and keeping
friends?
 Would you normally describe yourself as a loner?
 In general, do you trust other people? (R)
 Do you normally lose your temper easily?
 Are you normally an impulsive sort of person?
 Are you normally a worrier?
 In general, do you depend on others a lot?
 In general, are you a perfectionist?
 Scoring Brief Assessment
21

 The brief assessment is known as the

 Standardised Assessment of Personality- Abbreviated
Scale [SAPAS] (Moran)
 A score of 3/8 or above indicates that the client may
have personality disorder.
 The measure has a sensitivity of 0.94 and a specificity
of 0.85 (overall, identifies around 90% of people with
a personality disorder)
 Routine assessment of all clients will improve
treatment engagement and also help you to focus
your diagnosis and treatment plan quickly
 Stability of Personality
22

 Personality is generally thought of as being stable

offer time and relatively permanent and
unchanging….

 To some extent, this is true, however a recent large-

scale longitudinal study found that over a 63 year
period, personality does indeed change. The extent of
this change may be quite large.
 see: Harris, M.A., et. al., (2016). Personality stability
from age 14 to age 77 years. Psychology of Aging,
31(8):862-874.
 Psychotherapy accelerates the personality
change process
23

 A recent meta-analysis of 207 studies (n=20k+)

found that significant changes occurred due to the
effects of psychotherapy.
 The rate of change was double that which would
happen through maturation.
 All therapies had equal effect.
 Biggest changes were seen in Neuroticism and
Extraversion.
 Also amongst clients with depression, anxiety and PD
 Smallest change seen amongst Substance Abuse
Disorders (Roberts, et.al. 2017)
 Does the personality change?

 Although our personality is relatively stable, there is

considerable evidence that our personality can and
does change over time

 The process of personality change is accelerated by

psychotherapy. Typically, a person can experience as
much change in their personality (certainly in specific
traits) in 3 months of therapy as they might
experience in 10 years of life
 Managing Expectations
25

 It can be useful to explain to clients early in therapy:

 Although aspects of an individual’s personality can and

will change, a complete change in personality is not
possible
 They are not going to change into some horrible,
narcissistic person (many fear this). They had a
different developmental pathway and it is impossible to
go back and completely re-do one’s childhood at this
stage.
 Instead, therapy will help to become the best version of
themselves
 Factors influencing personality formation
26

 There are two main categories of development

 factors;
 1) Genetic
 2) Social/ Environmental
 Each contributes approximately 50% (Livesley et al.,
1993)
 Our personality development process is from birth
and continued throughout the lifespan (some would
argue it begins in utero and even before…)
Specific Factors 1: Genetic & Organic Cluster
27

 Genetics. Whether we like it or not, research

repeatedly highlights genetic links which predisposes
people to a proneness to certain problems/traits
 In utero.Our experiences in the womb are likely to
have an impact. E.g. maternal stress, nutrition etc.
 Physique and appearance. Let us be clear, ones
appearance plays a significant part in this. Although
it is considered very poor manners to mock a person’s
appearance- it happens an awful lot. How physically
strong you are influences your development and it
can ‘open doors’ for you
Specific factors 2: Social and Environmental
28

 Family. Obviously our family of origin will have had

a significant part to play in the development of our
personality. Our parents model and tell us what
behaviour is acceptable and what is not, what they
value, what they do not. We learn our parent’s view of
the world- will it serve us well? Some authors believe
that personality disorders are largely the result of
repeated invalidation from others. Were siblings
around and what was the relationship with them like.
 Economic Factors. People growing up in a very
poor council estate are more likely to have very
different life experiences, which in turn helps shape
 Specific Factors 3
29

 School/ Education. Our experiences at school very

clearly affect many people for a long time. Whether the
words are of encouragement or anger, school shapes
who we are as people (and university does too)
 Normal maturation. As people grow, they become
clearer about their own identify and sense of purpose.
Also there is evidence that people with a PD will show
positive improvement on all their scales over time.
maturation has a lot to be said for it.
 Early experience. Our very earliest experiences may
be of a sense of safety and being loved. For others
conflict in their parents relationship, neglect, how
 Other factors
30

 Temperament. We will discuss this shortly

 Nurturing. A significant factor contributing towards
an individual’s personality growth is the availability
of responsive, consistent, nurturing caregivers. Was
their home life characterised by love, warmth,
affection and encouragement, or hostility and
criticism?
 Additional factors to consider
31

 Endocrine functioning. The entire endocrine

system helps regulate our body, and has a huge
impact on our emotional reactivity, our adaptability,
our energy levels, our sense of drive and so on.
 Brain and nervous system. How our nervous
system and brain developed pre-birth and continues
to develop. What one’s brain can and cannot handle
is likely to become part of one’s personality.
 Intelligence level. People who are very intelligent
are often very resourceful and also good at adjusting
to their environment quickly.
 Additional factors
32

 Successes and failures. Both success and failures

are a part of life. How we celebrate and show our joy
influences our personality. How we deal with failure
and what we do about it can set the scene for later
unfolding of personality
 Culture. We all live within cultures. We may or may
not have strong family cultures,however we live in a
society that gives us a sense of identity and how
things are done. Our culture may or may not be
supportive of ‘people like me’ and may or may not
inspire and encourage. We may have a strong
regional , national or ethnic culture
 Additional factors
33

 The physical environment. Did the person live in

a clean, tidy house or a more chaotic one? Did they
live in a large house in a rural area, or in a deprived
inner-city area?
 Exposure to diversity. Did the person grow up in a
well-integrated and culturally diverse area, or did
they grow up in a mono-ethnic environment with
little diversity?
 34

 Taking the factors previously discussed into account,

working in small groups or pairs, spend some time
talking about how these different factors have
influenced your personality development
 Temperament
35

 Any parent will tell you their child was born with
their own personality
 Any parent of more than one child will tell you each
child was different from birth (some easier than
others!)
 What accounts for this difference?
 On what dimensions do new born babies differ?
Temperament (Chess & Thomas, 1996)
36

High Low
Activity Level

Distractibility

Intensity (affect)

Regularity

Sensitivity

Approachability

Adaptability

Persistence

Mood
 Temperament ‘fit’
37

 There is an interaction between the infant’s

temperament and their parents personalities (and
circumstances)
 Each person will find different temperament aspects
easier to manage than others
 Sometimes there is a ‘good fit’ between the child’s
temperament and the parents personalities,
sometimes there is not
 This interaction between temperament and the
parents personalities is a major factor in personality
formation
 Identifying Strengths
38

 Accounting for client’s strengths promotes positive

growth and is a less pathologising stance
 Routinely ask all clients during intake what their
strengths are
 Whenever you see a strength, comment on it
 Look for examples / situations where something
which might potentially be problematic might
actually be a strength
 Flexibility-Rigidity
39

 Aspects of personality do not necessarily cause

problems when they are flexible
 The greater rigidity an individual has, the more likely
they are to experience distress and/ or get into
problems due to their personality
 As therapists, a significant part of our role is to help
clients develop greater flexibility in their personality
 This mostly relates to increasing flexibility in how
they think, feel, behave and relate to others
 Aspects of personality

 Traits
 Facets (these are smaller aspects of traits)

 Personality Types / Personality Structure

 Personality Disorder
 Personality Structures/ types
41

 The following material was based on Nancy

McWilliams book Psychoanalytic diagnosis and also
the Psychodynamic Diagnostic Manual
 You will probably recognise yourself in several of
these descriptions
 You will certainly recognise others in these
descriptions, but do be cautious- you only know your
perceptions, and not necessarily how the person is in
their entirety or of exceptions to the rule and so on
 There is almost always more to a person than these
descriptions- ‘hold them lightly’
 Psychopathic/ Antisocial

 Essentially a problem in attachment, empathy and

poor capacity to regulate feelings without acting
destructively and/or manipulatively. There is often a
grandiosity and sense of delight in ‘getting one over’
on other people or other cold and calculating
behaviour towards others. May see ‘ordinary’
emotions as signs of weakness and be extremely cut
off from feelings.
 Antisocial
43

 Preoccupation: manipulating/ being manipulated

 Pathogenic beliefs
 Self: I can make anything happen
 Others: are selfish, dishonest, pathetic
 Defence; seeking omnipotent control
 Transference/ Countertransference: Projects
internal predator, manipulative/ charming. Ct- lack
of empathy, afraid of client, moralistic outrage

 Remember- power is the only thing that people with

antisocial structure respect!
 Narcissistic

 This structure is organised around the need to

maintain self-esteem by gaining external affirmation
and admiration and preoccupation with how one
appears to others. Often what is underneath a self-
assured, proud, arrogant, vain and grandiose exterior
is an inner sense of shame, envy, inferiority,
weakness and emptiness. Tend to be relentlessly
perfectionistic and intolerant of imperfections in both
self and others. There often seems to be a continuous
process whereby people, possessions and events are
graded according to their social desirability.
 Narcissistic
45

 Preoccupation: Inflation. deflation of self esteem

 Pathogenic beliefs
 Self: I need to be perfect to feel OK
 Others: Others enjoy riches, power, fame- the more of
those I have the better I will feel
 Defence: idealisation/ devaluation
 Transference/ Countertransference: devalue/
idealise, client uninterested in interventions, ct-
feeling used, irrelevant, bored, irritated, unempathic.
Alternatively, sense of grandiosity (best therapist in
the world)
 Masterson’s Narcissistic Triad
46

Grandiose Defence Attack on Self

Sensitivity to Shame
 Schizoid

 People with schizoid characters are often

hypersensitive to being over-stimulated and are
prone to fantasy and withdrawal. They are often very
creative people with deeply caring and gentle natures
and frequently enjoy literature and the arts and are
often unconventional and despite their sensitivity can
be brutally realistic in outlook. They tend to be prone
to anxiety, depression and withdrawal and are usually
ambivalent about relationships- craving closeness but
fearful of engulfment or being controlled and may
present with feelings of alienation, loneliness and
social awkwardness.
 Schizoid
48

 Preoccupation: fear of closeness/ longing for

closeness
 Pathogenic beliefs
 Self: dependency and love are dangerous
 Others: others are engulfing, the world is impinging
 Defence: withdrawal
 Transference/ Countertransference: detached, client
afraid of engulfment, ct- weakness, helplessness,
seeing client as special and unique, exceptionally wise
(which they probably are)
 Masterson’s Schizoid Dilemma
49

Longing for Closeness/ Fear of Engulfment/

Intimacy Enslavement
 Paranoid

 A key feature of the paranoid structure is the tendency

to project hostile, persecutory or threatening intention
on others and a deep suspiciousness and lack of trust in
others. They are often hostile, envious, jealous and
angry and as such actively create the very
circumstances which they suspect will occur by leading
people to be distrusting and hostile in return and will
use their hypervigilance to find confirmation of their
suspicions. There is often a grandiosity about their self-
referential thoughts. Their emotions tend to be
characterised by anger, resentment, vindictiveness and
fear and they may also experience a deep sense of guilt.
They are often afraid of being shamed, humiliated,
dominated criticised or attacked by others
 Paranoid
51

 Preoccupation: attacking/ being attacked by

humiliating others
 Pathogenic beliefs
 Self: hatred, aggression and dependency are
dangerous
 Others: The world is full of potential attackers and
users
Defence: projection, PI, denial, reaction formation
 Transference/ Countertransference: Usually
negative, th. seen as humiliating/ source of attack. Ct-
anxious, hostile
 Aetiology/ Developmental Factors
52

 What do you imagine might have happened in the

development or early life/ relationships for someone
who developed one of these four personality types?
 Depressive

 In contrast to grief, where the external world is seen as

missing something important, in depressive character it is
the self that is seen as deficient. A key dynamic is anger
turned against the self, which usually manifests as
unrelenting and often sadistic self-criticism and feelings of
guilt. Because they aim their hostility inwards, they are
often kind, caring and compassionate people and their
understanding of sadness makes them empathic to others
who are suffering. Their self-effacement means that they
are prone to pleasing others which makes them good
friends and clients although often these tendencies mean
they put others needs before their own in a way that is
unhealthy. They tend to attribute anything bad that
happens to their shortcomings and anything good to either
luck or others and often have a deep seated belief that they
are bad inside
 Depressive
54

 Preoccupation: goodness/ badness, aloneness/

relatedness
 Pathogenic beliefs
 Self:there is something bad or incomplete about me
 Others: if they really get to know me they will reject me
 Defence: introjection, idealisation of others,
devaluation of self
 Transference/ Countertransference: Afraid th will
abandon/ reject them, negativity, projecting criticism
ct- easy to like, affection, depression, helplessness/
hopelessness/ incompetence
 Manic

 People with manic or manic-depressive characters

have essentially the same internal conflicts as
depressive characters. They are often energetic,
cheerful and highly sociable. Despite this, people
often feel that they don't really know the manic
person and the person with this character may be
prone to excess, impulsivity or acting out in ways
which can be destructive. Repetitive, severe and
traumatic losses are common features of the histories
of people with a manic character. They are often very
afraid of attachment due to an unconscious fear of
expected abandonment/ loss.
 Manic
56

 Preoccupation: (see depressive)

 Pathogenic beliefs
 Self: (see depressive)
 Others: (see depressive)
 Defences: Denial, impulsive acting out
 Transference/ Countertransference: trs- same as
depressive ct- fascinating but exhausting, you never
really feel like you know them, underestimating the
extent of their pain
 Masochistic

 People with a masochistic structure are often self-

sabotaging and complaining and present as long-
suffering martyrs- often with strong moralistic
tendencies. Their emotional worlds are characterised
by sadness, guilt, resentment and suppressed anger.
They will often feel unfairly treated, victimised and
helpless or will use moral arguments to justify the
'rightness' of their suffering, and may seek to elicit
the sympathy of others or make others feel guilty
 Masochistic
58

 Preoccupation: suffering/ losing relationships or self-

esteem
 Pathogenic beliefs
 Self: By blatantly suffering I can show moral
superiority and maintain my attachments
 Others: Only notice you when you are in trouble
 Defence: introjection, turning against the self,
moralising
 Transference/ Countertransference: ‘I’ll show you
how much I suffer’, seeks rescuing, fear of th.
criticism. Ct- sadism/ masochism, trying harder,
 Obsessive-Compulsive

 People with this structure tend to be perfectionistic,

orderly, stubborn, meticulous, punctual, overly
conscientious, and usually lacking in flexibility. They are
also often plagued with indecisiveness and
procrastination. There is often a strong need to feel in
control, a fear and intolerance of uncertainty and
ambiguity, a strong sense of responsibility and a fear of
strong or 'messy' emotions. People with obsessive-
compulsive structure tend to intellectualise and avoid
certain feelings or certain variations on feelings although
they tend to be aware of feelings of anxiety, guilt, shame,
self-righteous anger and fear and usually are the world's
biggest worriers
 Obsessive-Compulsive
60

 Preoccupation: submission or rebellion to authority.

Orderliness
 Pathogenic beliefs
 Self: my aggression is dangerous and must be
controlled
 Others: try to control and I must resist
 Defences: isolation of affect, intellectualisation,
moralising
 Transference/ Countertransference: ‘good client’ but
see th. as judgmental and demanding parent.
(comply/oppose). ct- irritation, impatience, restriction,
emotional disconnection
 Histrionic

 People with Histrionic personalities are energetic and

sociable and usually very loving and caring, but are
extremely emotional (often in ways which alienate
others) and prone to dramas, exaggeration and high
anxiety. They can be highly creative and have a powerful
imagination. They often feel insecure and afraid of
rejection and may act helpless- inviting others to rescue
them. They often have strong conflicts around love and
sex, and may often appear sexually provocative, yet feel
afraid that others will sexually objectify them. Similarly,
they often fear being the centre of attention and yet will
repeatedly create situations where they end up being the
centre of attention
 Histrionic
62

 Preoccupation: power and sexuality

 Pathogenic beliefs
 Self: my gender makes me weak/ vulnerable
 Others: people of own gender are of little value/ other
gender are powerful, exciting but potentially damaging
 Defences: repression, regression, conversion,
sexualising, acting out
 Transference/ Countertransference: prototypical
therapy! client in Child, intimidated, co-operative,
seductive, anxious. Th. hostile/ competitive, seductive,
parental, infantilising, distancing, grandiosity,
Rescuing
 Aetiology/ Developmental Factors
63

 What do you imagine might have happened in the

development or early life/ relationships for someone
who developed one of these five personality types?
 Personality Types References:

 McWilliams, N. (2011). Psychoanalytic Diagnosis:

Understanding personality Structure in Clinical
Process (2nd edn). New York: Guilford Press.
 PDM Task Force (2006) Psychodynamic Diagnostic
Manual. Silver Spring MD: Alliance of Psychoanalytic
Organisations.
 Borderline
65

 To start with, in small groups, spend a few minutes

discussing what you think borderline personality is,
the internal experience of someone with borderline
personality and how this manifests in terms of their
behaviour and in their relationships
 Borderline Prevalence
66

 1%-5.9% of general population (NICE, 2009;

Bateman & Krawitz, 2013)
 10% psychiatric outpatients
 20% psychiatric inpatients
 70% are female

 75% have recovered at 15 year follow up

 92% have recovered at 27 year follow up

 See: Paris et al., (1987); Paris et al. (2001); Zanarini

et al., (2010)
 Borderline Personality (DSM criteria)
67

 1) Fear of rejection/ abandonment (real or imaginary)

 2) Unstable intense relationships (idealise/ devalue)
 3) Unstable sense of self/ identity
 4) Self-destructive impulsivity
 5) Recurring self-harm / suicidal behaviour
 6) Intense, unstable mood
 7) Chronic feeling of emptiness
 8) Inappropriate, intense anger and irritability and
difficulty containing anger
 9) Stress related paranoid ideation/ dissociation
 68

 Pathogenic beliefs
 Transference/ Countertransference
 Love, Admiration and Safety
69

 Elinor Greenberg (2016) notes that clients with a

borderline process tend to be preoccupies with their
need for love, nurturing and also the possibility of
abandonment or engulfment
 Those with narcissistic process are preoccupies with
self-esteem enhancement and the possibility of
public humiliation and exposure
 Those with schizoid process are highly sensitive to
issues relating to trust and interpersonal safety
Be cautious when using category type models!
70

 Remember- very few people entirely fit into one

category.
 Don’t try and view everything about your client
through a narrow lens.
 Take account of the ways they do fit any given
category type, but also acknowledge the aspects of
them that don’t fit or the ways that they are different
to the type.
 Pay Attention to what is Here-and-Now!
71

 You can learn a lot by noticing what themes seem

most important to your client
 Instead of speculating about their childhood, or
unobservable theoretical concepts, it is more useful to
notice how an individual creates their reality on a
moment-by-moment basis.
 How do they attend to information? What
information do they filter out? What seems most
important to them? How do they interpret
information? How do they relate to others and what
do they elicit from others? (Greenberg, 2016)
 Treatment Planning: Developing Therapeutic
Objectives
72

 Working in small groups, identify two potential

therapeutic objectives for each personality type (not
including redeciding/ changing the pathogenic script
belief!)

 Once you know the objectives, you can combine these

with your client’s goals to form the basis of the
treatment plan. The remainder of the treatment plan
is concerned with working out what strategies/
techniques/ stance you need to take to help the client
achieve their goals and reach the therapy objective
 Therapeutic Objectives
73

 Once you know the objectives, you can combine these

with your client’s goals to form the basis of the
treatment plan. The remainder of the treatment plan
is concerned with working out what strategies/
techniques/ stance you need to take to help the client
achieve their goals and reach the therapy objective
Contracting for Change
74
 Some TA thoughts
75

 What you stroke is what you get

 Help your client’s Child feel free to experiment, and use
their Adult to reprogram their Parent to allow new
thoughts, feelings, behaviours
 Keep checking in; ‘How is this working for you?’ ‘Does
this feel OK?’ ‘How are you feeling about how I am
working with you?’
 Help your client learn about how others experience
them (transactions)
 Challenge the Frame of Reference
 Challenge the underlying Script beliefs through
experiential disconfirmation
 Personality Traits
76

 If you were to describe someone’s personality, the

chances are you would mostly pick out their
personality traits.
 The five-factor model: OCEAN
77

 The most widely validated model of personality traits

is the five-factor model (Goldberg, 1990; McCrae &
John, 1992; McCrae & Costa, 1987). The five traits in
the model are:
 Openness (to experience)
 Conscientiousness
 Extraversion
 Agreeableness
 Neuroticism
 Each person can be scored high or low on each trait,
giving a combination of traits which comprise their
 Openness to Experience
78

 Definition: Open to new ideas, new art, experiences,

values, ideas

 High Score: Enjoys diversity, curious,

unconventional, imaginative

 Low Score: prefers not to be exposed to alternative

views, narrow interests, conventional, not artistic or
analytical
 Conscientiousness
79

 Definition: Tendency to be punctual, follow rules,

hard-working, neat, organised.

 High Score: Never late, hardworking, neat, organised,

tidy, persevering, self-disciplined

 Low Score: Prefers to be spontaneous, doesn’t plan,

unreliable, hedonistic, lax
 Extraversion
80

 Definition: Tendency to be sociable, talkative and

enjoy the company of others

 High Score: Life and soul of the party, fun-loving,

affectionate, active, optimistic

 Low Score: Prefers quieter time at home, sober, quiet,

aloof, unenthusiastic
 Agreeableness
81

 Definition: Tendency to agree with and go along with

others instead of asserting ones own views and
choices

 High Scores: Agrees with others, good-natured,

forgiving, helpful, forgiving, can be gullible

 Low Scores: quickly asserts own rights, irritable,

rude, uncooperative, can be manipulative
 Neuroticism
82

 Definition: Tendency to experience negative

emotions as well as being interpersonally sensitive

 High Score: Constantly worrying, depressed,

irritable, feels inadequate, tendency to
hypochondriasis

 Low Score: Not easily irritated, calm, secure,

unemotional or emotionally stable
 Self-Evaluation
83

 Using the scaling form, where you would place

yourself on each of these five personality factors?

 Notice- do any of these factors change depending on

circumstances and situation?
 Facets
84

 Each of the five personality factors can be sub-

divided into facets
 Extraversion-Intraversion
85

 Facets:
 Gregariousness (sociable)
 Assertiveness (forceful)
 Activity (energetic)
 Excitement-seeking (adventurous)
 Positive emotions (enthusiastic)
 Warmth (outgoing)
 Agreeableness- Antagonism
86

 Facets:
 Trust (forgiving)
 Straightforwardness (not demanding)
 Altruism (warm)
 Compliance (not stubborn)
 Modesty (not show-off)
 Tender mindedness (sympathetic)
 Conscientiousness- Lack of Direction
87

 Facets:
 Competence (efficient)
 Order (organised)
 Dutifulness (not careless)
 Achievement striving (thorough)
 Self-discipline (not lazy)
 Deliberation (not impulsive)
 Neuroticism- Emotional Stability
88

 Facets:
 Anxiety (tense)
 Angry hostility (irritable)
 Depression (not contented)
 Self-consciousness (shy)
 Impulsiveness (moody)
 Vulnerability (not self-confident)
 Openness- Closedness to Experience
89

 Facets:
 Ideas (curious)
 Fantasy (imaginative)
 Aesthetics (artistic/ creative)
 Actions (wide interests)
 Feelings (excitable)
 Values (unconventional)
 Changing Traits
90

 Recent research has shown that it is possible to

change personality traits
 The study shows that by undertaking at least two
pieces of ‘homework’ per week, for a period of fifteen
weeks, that personality traits can and do change.
Pre-requisites for change
91

A willingness to take an honest look at yourself and acknowledge there is a problem

Believe that it is possible to change and especially that it is possible for you to change. Ask
yourself on a scale of 1-10, how likely are you have done something about this by next week
(if less than 7, they probably won’t do it)

Identify a specific problem personally trait, Then think very carefully about how you want to
feel, think, behave and relate after this issue is resolved.

Change doesn’t come about without working hard

Allow yourself to experience and express any ambivalent feelings you have, and come up
with a plan to deal with those. Pay attention to your own self-sabotage mechanisms.

Seriously consider whether the trait might become more useful with the passage of time,

Keep visualising your future self

If there skills you need to learn, learn them. identify them, find out what educational
opportunities are available

watch for opportunities to keep moving forward

This type of therapy is intense- you have to continually find events and opportunities to try to
be a little different. Also accept that changes like this are hard to experience, but you will
pick yourself up and shake yourself down
Trait-change interventions
92
 Increasing Extraversion
93

 Gratitude journal
 Say hello to the cashier in a shop
 Smile and say hello to someone in the street
 Make a positive comment on someone’s Facebook
post
 Post something about a positive or funny experience
on Facebook
 Go to a familiar cafe, restaurant or bar and chat with
your server
 Invite a friend to go for coffee or for a meal
 Ask a question in class
 Increasing Agreeableness
94

 Make a point of saying ‘please’ and ‘thank you’ when

asking for something or to someone you normally
wouldn’t
 Hold a door open for someone and smile
 Make a list of 5 things you’re grateful for in one of your
relationships
 Take 5 minutes to think about the positive qualities of
people you know
 Buy a friend a drink/ Pay for someone in line’s coffee
or give the money to a charity/ random act of kindness
 Send a thank you card or get well soon card to
someone
 Increasing Openness to Experience
95

 Watch a new TV show

 Read a news story about science or technology
developments
 Try a new food
 Visit a gallery or museum
 Spend ten minutes writing about places you'd like to
visit and why
 Increasing Conscientiousness
96

 Keep your phone in your pocket when you are in

company
 Spend 5 minutes writing about the benefits of being
organised, hardworking and thorough
 When you notice something you need or need to do,
make a note of it on your phone
 Clean up the kitchen as soon as you finish eating
 Start that studying you have been putting off
 Organise and tidy up a drawer or your desk
 Make an arrangement and arrive five minutes early
 Increasing Emotional Stability
97

 Before you get overwhelmed, take ten slow breaths

 Write down 5 positive things from each day before
bed and 1 thing to look forward to tomorrow
 Schedule in 30 minutes for an activity you enjoy
 Exercise for 20 minutes
 When you start worrying, spend two minutes
thinking about the best case scenario
 Talk to a friend about both the good and bad things in
life
 Whenever you notice something positive or enjoyable
spend at least two minutes savouring it
 98

 Working in small groups, brainstorm additional ideas

for interventions to help a client change personality
traits
 Levels of Personality Problems
99

 ‘Normal’ Personality- 35%

 Personality Difficulty- 48%
 Mild Personality Disorder- 12%
 Moderate Personality Disorder- 4.5%
 Severe Personality disorder- 0.5%
 (Yang, et al., 2010)
Personality Disorders
100
 Aetiology of Personality Disorders
101

 Recognised as being approximately 50% genetic/

biological/ 50% environmental/ social
 Mixture of genetics, biology, social factors and
environmental factors
 ACE’s and Trauma
 Disrupted Attachment/ Attachment trauma
 Routinely Screen for Personality Problems and
Disorders
102

 Routinely screen all clients in intake using SAPAS

 Follow this early in therapy by use of the Big Five
Personality Inventory
 Use PID-5 (brief or longer version) to get more
information on pathological traits where there is
evidence of personality problems or indications that
the client may have personality disorders
 Opening up personality disorder
103

 What words come to mind when you think of

‘personality disorder’?
 Personality disorder word associations
104

 Manipulative?
 Attention seeking?
 Difficult?
 Hostile?
 Resistant?
 Self harming/ suicidal?
 Untreatable?
 Attitudes influence behaviours: Self-fulfilling
prophecy
105

 What are the behavioural and relational implications

of your perceptions of personality disorders?
 E.g. if you go into a session expecting someone to be
difficult or hostile, this shapes your expectations,
which shapes how you relate to them
 You may be despairing, impatient, un-empathic etc
 Prone to interpreting client frustrations as evidence
of them being difficult/ hostile
 This can then be a self-fulfilling prophecy
 If you have negative perceptions of the client they
will pick up on it and you will be unable to be
authentic in your relationship with them
 Advantages and Disadvantages of Diagnosis
106

 In order to develop a critical stance, we need to

understand the advantages and disadvantages of
diagnosis and work out our own position
 Get into two teams
 One team will brainstorm the advantages of
diagnosis, the other will brainstorm the
disadvantages for ten minutes
 Come back and present your argument to the group
 Then go back to your base group and come up with
rebuttals for five minutes
 Then present these to the group
DSM-5 Personality Disorder Diagnostic
Categories
107
 ICD-11 Personality Disorder Diagnostic
Categories
108

 All PD subtypes have been removed from ICD-11

 Replaced with four levels of PD with domain traits
 (personality difficulty, mild PD, moderate PD, severe
PD)
 Domains:
 Negative affective features
 Dissocial features
 Disinhibition features
 Anankastic features
 Detachment features
 May have ‘borderline specifier’
DSM-5 General Criteria for Personality Disorder
109

 An enduring patterns of inner experience and

behaviour. This pattern manifests in two or more of
the following areas:
 a) Thinking
 b) Feeling
 c) Interpersonal relationships
 d) Impulse control
 The pattern deviates markedly from cultural norms
and expectations
 It is pervasive and inflexible, is stable over time and
leads to distress or impairment
 Critique
110

 Take a few minutes to develop a critique of these

general criteria
DSM5 General Criteria for Personality Disorders
111

 Impairments in self and interpersonal functioning

 Self Functioning:
 1) Identity
 2) Self-Direction

 Interpersonal Functioning:
 3) Empathy
 4) Intimacy
 One or more pathological personality trait domain or
trait facets
Dimensional Approach to Personality Disorders
112

 The DSM-5 has proposed a radically different

approach to diagnosis of personality disorders
 The ‘missing’ personality disorders
113

 In the DSM-5 alternative model, only six personality

disorders have been retained;
 Antisocial, Avoidant, Borderline, Narcissistic,
Obsessive-compulsive and Schizotypal).

 The authors argued there was insufficient research

evidence to support the four omitted disorders
(paranoid, schizoid, histrionic, dependent).
 114

 criteria
 severity indicator
 trait-specified
Pathological Personality Traits
115
The Big Five and Maladaptive Traits
116

Neuroticism (emotional Emotional stability

instability)

Extraversion Introversion (detachment)

Openness Closedness
(unconventiality) (conventionality)

Agreeableness Antagonism

Conscientiousness Disinhibition
 Negative Affect
117

 Negative Affect (polar opposite- emotional

stability)
 Emotional lability
 Anxiousness
 Separation anxiety
 Submissiveness
 Hostility
 Perseveration
 Detachment
118

 Detachment (polar opposite is extroversion)

 Withdrawal
 Intimacy avoidance
 Anhedonia
 Depressivity
 Restricted Affect (limited emotional range)
 Suspiciousness
 Antagonism
119

 Antagonism (polar opposite is agreeableness)

 Manipulativeness
 Deceitfulness
 Grandiosity
 Attention seeking
 Callousness
 Hostility
 Disinhibition
120

 Disinhibition (polar opposite is conscientiousness)

 Irresponsibility
 Impulsivity
 Distractibility
 Risk-taking
 Rigid perfectionism
 Psychoticism
121

 Psychoticism (polar opposite is lucidity)

 Unusual beliefs and experienced
 Eccentricity
 Cognitive and perceptual dysregulation
Changing pathological traits: interventions
122
 Personalities vary
123

 Clearly, everyone has their own unique way of ‘being

them’ .
 However there are similarities and differences about
the whole field of personality Also information needs
to ‘cascade up’
 The significance of attachment
124

 You will never encounter anyone with a personality

disorder who has a secure attachment style!
 Insecure, problematic attachment is always at the
heart of personality disorders
 A history of attachment trauma is common
 The therapist needs to be a secure base for the client,
often over a considerable period of time for the client
to begin to develop greater attachment security
 So why is this relevant?
125

 The most important therapeutic factor in any

psychotherapy is the therapeutic relationship
 The therapeutic relationship requires empathy, a non-
judgemental and accepting stance, and authenticity
 When a therapist forgets that their client with PD is a
traumatised individual who feels insecure in the world
and distrusting of others due to attachment trauma, the
therapist may lack the necessary warmth, empathy,
acceptance and authenticity for the therapy to be
effective
 Beware of Iatrogenic Harm!
 Critical Perspectives
126

 85% of people with PD do not want treatment (Tyrer,

2013)
 A large proportion of those who do want treatment
have a diagnosis of BPD (Tyrer, 2018)
A trauma-informed approach
127
 The general personality disorder factor
128

 Interviews with 966 inpatients (Sharp, et al., 2015)

 Bi-factor model for understanding personality
disorder- general (g) and specific (s) factors
 BPD not found to be distinct from general factors
 Epistemic vigilance / mistrust is proposed as the ‘P
factor’ (Fonagy et al., 2014)
 Epistemic Trust
129

 Part of a developmental triad of understanding

personality disorder: attachment, mentalization and
epistemic trust
 Epistemic trust is ‘an individual’s willingness to
consider new knowledge from another person as
trustworthy, generalisable, and relevant to the self’
(Fonagy & Allison, 2014)
 ‘In proposing that epistemic mistrust might underpin
the p factor that underlies long-term impairment, we
thus also consider that (the relearning of) epistemic
trust may be at the heart of all effective
psychotherapeutic interventions (Fonagy et al., 2014)
 The problem of BPD
130

 Borderline PD does not fit with other personality

disorders and is more accurately described as a
problem of affect regulation
 Around 75% of those diagnosed with BPD are
survivors of childhood sexual abuse
 I propose:
 There is no such thing as borderline personality
disorder:
 It is a disorder (or syndrome) of affect dysregulation
 It is commonly a manifestation of complex PTSD.
 More on the problem of BPD
131

 Between 40% and 71% of people diagnosed with BPD

report having been sexually abused in childhood
(Zanarini, 2000*)
 Adults with BPD are more likely to be the victim of
violence, sexual assault and rape and other crimes
 There is some evidence of potential neurological factors
associated with poor impulse control, affect
dysregulation, irritability/ anger amongst people with
BPD.
 There are 256 combinations of symptoms that could lead
to a diagnosis of BPD.


 Self-harm in borderline presentations
132

 Self-harm is not attention seeking, it is a problem of

emotional regulation
 Emotional regulation requires the person to be able
to:
 1) Notice that they gave an emotional experience
 2) Name and understand the emotion
 3) Express the emotion appropriately
 4) Manage the emotion so it is less overwhelming or
intense
 Remember- BPD is a disorder of emotional
regulation
 Self-harm in borderline presentations 2
133

 When a person with Borderline presentation self-

harms, it calms intense emotions and also enlivens
them when they feel deadened internally
 This emotion regulation function also means that
self-harm serves and attachment function
 The self-harm can become the individual’s secure
base
 Seeing self-harm as attachment seeking and an
attempt to regulate intense emotions is a more
compassionate, and accurate way to understand self-
harm with these clients
A new finding: Poor interoceptive perception
and self-harm
134
 Masterson’s Borderline Triad
135

Defence/ Acting out Abandonment Depression

Self Activation
 Key Therapeutic Interventions for ‘Borderline
Personality’
136

 Use confrontation
 Help them to understand the connection between
self-destructive behaviours and the feelings they are
trying to avoid
 Do not ‘reward’ helpless, crazy or regressive
behaviour but challenge it instead
 Do not allow between session contact (use affect
regulation instead)
 Affect Regulation
137

 Enjoyable activities to lift mood (get the client to list

them and keep the list somewhere handy)
 Exercise
 Breathing exercise
 Compassionate self-talk
 Meditation/ yoga/ tai chi etc
 Visualisation
 Interpersonal contact
Working with Trauma
138
 Additional Focus
139

 In the treatment plan for someone with PD, always

ensure that there is sufficient emphasis on;
 Symptom improvement/ change
 Interpersonal functioning
 Psychosocial functioning
 General Suggestions for Therapy with PD
140

 Encourage clients to feel all their feelings, without

feeling flooded
 Support the client’s unfolding true self
 Teach clients how to ask their inner self for guidance
 Encourage clients to tell you what is working, what
isn’t and how they feel about their therapy
 Teach them how to tolerate distress and regulate
their emotions and self-soothe
 Do it and do it again
 Treat your clients with respect, compassion and
encourage them to do the same to their self
 Useful Therapy Guidebooks
141

 Greenberg, E. (2016) Borderline, Narcissistic and

Schizoid Adaptations. New York: Greenbrooke Press
 Masterson, J.
 Linehan, M. (1993) DBT Skills manual
 McWilliams, N. (XXXX) Psychoanalytic Diagnosis
(2nd Ed). New York, Guilford Press.
 References
142

 Fonagy,P. & Allison, L. (2014). The role of

mentalizing and epistemic trust in the therapeutic
relationship. Psychotherapy, 51(3): 372-80.
 Fonagy, P., Luyten, P., Campbell, C. & Allison, L.
(2014) Epistemic trust, psychopathology and the
great psychotherapy debate. retrieved from
http://www.societyforpsychotherapy.org/epistemic-t
rust-psychopathology-and-the-great-psychotherapy-
debate
 References
143

 Roberts, B.W. et al., (2017) A systematic review of

personality trait change through intervention.
Psychological Bulletin, 143(2): 117-141.
 Sharp, C. et. al., (2015) The structure of personality
pathology: both general (‘g’) and specific (’s’) factors?
Journal of Abnormal Psychology, 124(2).
 References
144

 Tyrer, P. (2013)
 Yang, M. et al. (2010) A national survey of personality
pathology recorded by severity. British Journal of
Psychiatry, 197(3): 193-9
 Zanarini, M.C. (2000). Childhood experiences
associated with the development of borderline
personality disorder. Psychiatric Clinics of North
America 23(1): 89-101.

 Acknowledgements to Dan Warrender