Chapter 7Personality Disorders

The word personality describes deeply ingrained patterns of behavior and the manner in which individuals perceive, relate to, and think about themselves and their world. Personality traits are conspicuous features of personality and are not necessarily pathological, although certain styles of personality traits may cause interpersonal problems. Personality disorders are rigid, inflexible, and maladaptive behavior patterns of sufficient severity to cause significant impairment in functioning or internal distress. Personality disorders are enduring and persistent styles of behavior and thought, not atypical episodes.

Several alcohol and other drug (AOD)-induced states can mimic personality disorders. If a personality disorder coexists with AOD use, only the personality disorder will remain during abstinence. AOD use may trigger or worsen personality disorders. The course and severity of personality disorders can be worsened by the presence of other psychiatric problems such as mood, anxiety, and psychotic disorders.

The personality disorders include paranoid, schizoid, schizotypal, histrionic, narcissistic, antisocial, borderline, avoidant, dependent, obsessive-compulsive, passive-aggressive, and self-defeating personality disorder. Many features of the personality disorders may occur during an episode of another mental disorder. Individuals may meet criteria for more than one personality disorder.

Four personality disorders have been selected for detailed discussion: borderline, antisocial, narcissistic, and passive-aggressive. These are among the greatest challenges to treatment providers. This TIP provides information about engagement, assessment, crisis stabilization, and longer-term care, and describes a continuum of care for patients with personality disorders.

Antisocial personality disorder involves a history of chronic antisocial behavior that begins before the age of 15 and continues into adulthood. The disorder is manifested by a pattern of irresponsible and antisocial behavior as indicated by academic failure, poor job performance, illegal activities, recklessness, and impulsive behavior. Symptoms may include dysphoria, an inability to tolerate boredom, feeling victimized, and a diminished capacity for intimacy. Borderline personality disorder is characterized by unstable mood and self-image, and unstable, intense, interpersonal relationships. These people often display extremes of overidealization and devaluation, marked shifts from baseline to an extreme mood or anxiety state, and impulsiveness.

Narcissistic personality disorder describes a pervasive pattern of grandiosity, lack of empathy, and hypersensitivity to evaluation by others. Passive-aggressive personality disorder involves covertly hostile but dependent relationships. People with this disorder commonly lack adaptive or assertive social skills, especially with regard to authority figures. They often display a passive resistance to demands for adequate social and occupational performance. They generally fail to connect their passive-resistant behavior with their feelings of resentfulness and hostility toward others. Exhibit 7-1 describes the characteristics of passive-aggressive, antisocial, and borderline personality disorders.

Avoidant personality disorder includes social discomfort, hypersensitivity to both criticism and rejection, and timidity, with accompanying depression, anxiety, and anger for failing to develop social relations. Obsessive-compulsive personality disorder describes a disorder of perfectionism and inflexibility. Symptoms may include distress associated with indecisiveness and difficulty in expressing tender feelings, feelings of depression, and anger about being controlled by others. Hypersensitive to criticism, these people may be excessively conscientious, moralistic, scrupulous, and judgmental.

Histrionic personality disorder is characterized by a pervasive pattern of excessive emotionality and attention seeking. Behavior may include constant seeking of approval or attention, striking self-centeredness, or sexual seductiveness in inappropriate situations. Paranoid personality disorder is characterized by a pervasive and unjustified proclivity to interpret the actions of others as intentionally threatening, demeaning, and untrustworthy. Dependent personality disorder is characterized by a pervasive pattern of dependent and submissive behavior and an intense preoccupation with possible abandonment. Persons with this disorder often feel anxious and depressed, and may experience intense discomfort when alone for more than a brief time.

Schizoid personality disorder involves a pervasive pattern of indifference to social relationships and a restricted range of emotional experience and expression. Schizotypal personality disorder entails deficits in interpersonal relatedness and peculiarities of ideation, appearance, and behavior and dysphoric states such as anxiety and depression. Self-defeating personality disorder is characterized by a pattern of self-defeating behavior in work and personal relationships, often with complaints of exploitation by others; these persons are often unaware of their contributions to the outcomes of their behavior.

Personality disorders not otherwise specified (NOS) include disorders of personality functioning that are not classifiable as specific personality disorders. Instead, individuals do not meet the full criteria for any one personality disorder; yet their symptoms cause significant impairment in social or occupational functioning, or cause subjective distress. Personality disorders NOS include impulsive, immature, and sadistic personality disorders.

Diagnoses should be clinically based, and not influenced by professional, personal, cultural, or ethnic biases. For example, in the past some African Americans were stereotyped as having paranoid personality disorders; women have been diagnosed too frequently as being histrionic, but they are seldom diagnosed as antisocial or psychopathic; Native Americans with spiritual visions have been misdiagnosed as delusional or having borderline or schizotypal personality disorders.

People with a personality disorder often use AODs for purposes that relate to the personality disorder: to diminish symptoms of the disorder, to enhance low self-esteem, to decrease feelings of guilt, and to amplify feelings of diminished individuality.

People with borderline personality disorder often use AODs in chaotic and unpredictable patterns and in polydrug patterns involving alcohol and other sedative-hypnotics taken for self-medication. People with personality disorders often develop problems with benzodiazepines that have been prescribed for complaints such as anxiety, which may lead to relapse to the primary drug of choice.

Many people with antisocial personality disorder use AODs in a polydrug pattern involving alcohol, marijuana, heroin, cocaine, and methamphetamine. The illegal drug culture corresponds with their view of the world as fast-paced and dramatic, which supports their need for a heightened self-image. Consequently, they may be involved in crime and other sensation-seeking, high-risk behavior. Some may have extreme antisocial symptoms. They tend to prefer stimulants such as cocaine and the amphetamines. Rapists with severe antisocial personality disorder may use alcohol to justify conquests. People with less severe antisocial personality disorder may use heroin and alcohol to diminish feelings of depression and rage.

People with narcissistic personality disorder are often polydrug users with a preference for stimulants. Alcohol has disinhibiting effects, and may help to diminish symptoms of anxiety and depression. Socially awkward or withdrawn people with narcissistic personality disorder may be heavy marijuana users. One group of people with narcissistic personality disorder uses steroids to build up a sense of physical perfection. When not using AODs, people with narcissistic personality disorder may feel that others are hypercritical of them or do not sufficiently appreciate their work, talents, and generosity. During a crisis, these people may be severely depressed and upset.

Drug preference among people with passive-aggressive and self-defeating personality disorders often varies according to gender. Women may prefer alcohol and other sedative-hypnotics to sedate negative feelings such as anxiety and depression. Although men may use these AODs, they may also use stimulants to disinhibit aggressive or risk-taking behaviors. People with passive-aggressive personality disorder often complain of somatic problems, such as migraines, muscle aches, and ulcers. They may seek over-the-counter medications as well as cocaine and amphetamines to relieve somatic symptoms.

Progress with patients who have personality disorders can be slow. Therapists should be realistic in their expectations and should know that patients will try to test them. To respond to such tests, therapists should maintain a matter-of-fact, businesslike attitude, and remember that people with personality disorders often display maladaptive behaviors that have helped them to survive in difficult situations. These behaviors may be called "survivor behaviors."

It is important to educate patients about their AOD use and psychiatric disorders. Patients should learn that recovery from AOD use is not synonymous with treatment for personality disorders. Written and oral contracts can be a useful part of the treatment plan. They should be simple, clear, direct, and time-limited. Contracts can help patients create safe environments for themselves, prevent relapse, or promote appropriate behavior in therapy sessions and in self-help meetings.

Treatment of people with personality disorders requires attention to several particular issues, such as violence to self or others, transference and countertransference, boundaries, treatment resistance, symptom substitution, and somatic complaints.

All suicidal behavior, from threats to attempts, must be taken seriously and assessed immediately to determine the type of immediate intervention needed. Special attention must be given to previous attempts and their seriousness, previous intervention strategies, whether the failure of the attempt was intended or accidental, the relation of previous suicidal behavior to psychiatric symptoms, and current psychiatric symptoms. All suicidal behavior should provoke the following questions:

• How specific is the plan?
• What method will be used?
• When will it happen?
• How available are materials (drugs, weapons)?

Management of self-harm can be accomplished by creating written or oral contracts with patients. In these contracts, a patient may promise to avoid certain self-harm or high-risk behavior (such as suicide or relapse), or may promise to engage in a specific healthy behavior (such as calling his or her 12-step sponsor or a suicide prevention hotline) when self-harm or a high-risk behavior appears imminent.

Therapists should attend to the patient's need for safety. Safety may range from the need for safe shelter to escape domestic violence to the need to reside in a controlled environment in order to remain abstinent.

Transference and countertransference can present problems in group and individual therapy. Therapists should be prepared to manage these issues. Transference refers to positive and negative feelings and perceptions that the patient projects onto the therapist. Countertransference refers to distortions in the therapeutic process due to the therapist's unresolved conflicts. Both transference and countertransference rely on the mechanism of projection.

Projection is a combination of personal past experiences along with feelings experienced during the course of therapy. Being aware of transference issues and commenting on them when appropriate is extremely important when working with these patients.

Boundaries are clear expectations regarding limitations or requirements in roles or behavior. Boundaries are ethical and practical ground rules that help therapists to be therapeutically helpful to patients. The clinician and patient must establish and maintain clear boundaries. Boundaries must also be set in group therapy sessions. For example, therapists should not lend money to patients or involve them in financial deals. Patients should not establish intimate relationships with others in group therapy.

People with personality disorders often assume certain roles or ways of social interaction. They may shift from one role to the next, depending upon the situation. Some of these roles include: the victim, the persecutor, and the rescuer.

As these patients assume a specific role (such as the victim), other people may be prompted to assume a complementary role (such as the rescuer). Therapists should be aware of the roles that people with personality disorders may assume. They should resist assuming dysfunctional complementary roles themselves and become aware when they do assume such roles.

Patients with personality disorders often exhibit acting-out behaviors that were developed as psychological defenses and survival techniques. The patient may be reenacting a response learned during experiences of abuse or trauma. Resistances are defenses and coping mechanisms that help patients survive in situations confronted in therapy which are perceived as threatening.

Confronting a patient's resistance without helping the patient develop other strategies for safety will probably escalate the patient's tension. Therapists should view and use resistance as a therapeutic issue, not as a challenge to treatment.

It is becoming increasingly clear that alcohol and most other drugs of abuse produce acute and subacute withdrawal syndromes. Depending on the specific drug, subacute withdrawal may include mood swings, irritability, impairment in cognitive functioning, short-and long-term memory problems, and intense craving for AODs. Subacute withdrawal syndromes often trigger relapse and exacerbate existing psychiatric symptoms

During periods of abstinence from AODs, some people will engage in other types of compulsive behaviors. Some of these behaviors include eating disorders, and compulsive spending, gambling, and sex. Relationship problems may also increase.

Patients with addictions to prescription drugs often seek treatment because of somatic complaints. Therapists should watch for use of prescription and over-the-counter drugs and for drug-seeking behaviors.

Therapists should be mindful of their own well-being, which can be compromised when working with patients with personality disorders. Clinicians can be drawn into playing certain roles in the lives of patients with personality disorders. To prevent this, therapists should care for themselves by seeking outside supervision. Therapists should join or develop support systems with others in the field through 12-step program participation, regular meetings with other therapists, grand rounds, and the like.

The following sections describe specific strategies and techniques that therapists can use when working with patients who have an AOD use disorder and a borderline, antisocial, narcissistic, or passive-aggressive personality disorder.

Each section describes techniques for assessing patients and engaging them in treatment, stabilizing crises, providing long-term care, and creating a continuum of care. Each section concludes with a case example in which the reader is asked to make a treatment decision. Where appropriate, clinical tools are provided.

Key Issues and Concerns in The Treatment of Personality Disorders

• Slow progress in therapy
• Suicidal behavior
• Patient contracting
• Transference and countertransference
• Clear boundaries
• Changing roles
• Resistance
• Subacute withdrawal
• Symptom substitution
• Somatic complaints
• Therapist well-being

Safety is an anchor for patients with borderline personality disorder, for whom abandonment and fear of rejection are often core issues. To engage and assess these patients, the therapist should acknowledge and join with the patient's need for safety. The therapist's absence, even for brief periods, can prompt acting-out behavior.

Acting-out behavior is a maladaptive survivor response that expresses a need for safety. Therapists should identify each patient's motivation for recovery, which may be rooted in safety. Further, therapists should discover what safety means to the patient.

Therapists can learn how patients create their own feelings of safety by asking them about safe spots, magic getaway places, closet-sitting, rocking or other repetitive movements, or other techniques the patient may use to generate a sense of security. To help patients with borderline personality disorder establish and maintain a sense of safety, therapists can continually ask patients: "What do you need right now?" "What do you want right now?"

Therapists may work with patients to develop a patient-generated list of the conditions that they need in order to feel safe. Therapists may ask patients: "What would have been helpful (in a specific situation) to make you feel safe?" Through teaching cognitive skills to promote patients' sense of safety, therapists can help patients with borderline personality disorder to assume personal responsibility for their own safety.

Written and verbal contracts can identify specific ways to help patients stay physically and emotionally safe and to prevent relapse. Written and verbal contracts for safety should be developed during the assessment process with simple and clear behavioral responses regarding the management of unsafe feelings and behaviors. These contracts can be very simple and direct:

• "If I feel like I want to get drunk, I will call my sponsor."
• "If I feel like getting loaded, I will go to the next NA meeting."
• "If I feel like hurting myself, I will call a crisis hotline and go to my sister's house."
• "I will report self-harm thoughts and behaviors to the therapist at the next session."

When assessing a patient, the therapist is attempting to understand and view the patient within a holistic framework. Areas of assessment may include a history of AOD and mental health treatment, suicidal planning, dissociative experiences, psychosocial history, history of sexual abuse, and a history of psychotic thinking. Some patients may also require a neurological examination.

The assessment of patients with borderline personality disorder should look for a history of self-harm. Behaviors such as AOD use should be described as unsafe behaviors. However, clinicians should help people with borderline personality disorder to avoid black-and-white thinking, such as right/wrong and good/bad, and all-or-nothing styles of thinking. Specifically, the assessment should include the following:

• A history of previous treatment, including psychiatric medications administered, and a description of what worked and what did not work in treatment, as well as information on why the patient left earlier treatment. Patients are not always a reliable source of information about themselves, and therapists should evaluate this information accordingly. The treatment history can help the therapist avoid unnecessary repetition of treatment strategies, such as skill-building activities in which the patient is already competent (for example, relaxation strategies). The history taking is an opportunity to examine patients' strengths and weaknesses.

• A list of potential means available to patients to injure themselves in their own homes, such as a large supply of medication.

• History and evidence of dissociative experiences, such as trance states, rocking, flashbacks, nightmares, and repressed memories. Any and all parts of a memory can be repressed. One model for assessing dissociation and identifying repressed memories is the BASK model. The BASK model is a quick way to check what part of the memory is missing, and whether or not it is Behavior, Affect, Sensation, or Knowledge. Survivors of abuse may detach themselves from their feelings so that they recall memories of abuse in a robot-like fashion.

• Attachment to a special object. Anniversary reactions are also common to survivors of abuse, whose memories or feelings may be triggered by certain dates, events, or objects. For no apparent reason, the survivor may become sick or suicidal when faced with a situation similar to a past reminder of abuse.

• History of fugue states and losing time. For example, patients with borderline personality disorder might start watching a movie and suddenly reorient later in the middle of another movie, with no clear memory of the elapsed time.

• Psychosocial history and history of sexual abuse. It is common for people to feel as if they were sexually abused without having any actual memories of the abuse or trauma. Questions should be framed in a manner that facilitates the acquisition of all relevant information. By asking open-ended questions while paying attention to the patient's body language, the therapist may be able to draw useful conclusions.

• Neurological workup of individuals who have a history of self-mutilating behaviors that could have resulted in cognitive impairment such as head-slamming. Some psychologists will conduct neurological screening; in other cases, a neurologist should be consulted.

• Psychotic-like thinking and history of suicidal behavior, especially under intense stress. Psychotic-like thinking may be evident during episodes of trauma and stress. For example, a patient may state, "The walls are bleeding."

Safety issues are at the core of crisis stabilization. To ensure the patient's safety or to detox a patient, a brief psychiatric hospitalization may be necessary. Issues to be addressed during crisis stabilization might include an unwillingness or inability to contract for safety. A written release of medical information is important to coordinate care with physicians and addiction counselors.

At this stage, therapists should avoid psychodynamic confrontations with patients and should not engage patients in further therapy for abuse or trauma. The treatment focus should be on addressing the patient's need for safety, especially important with patients who have borderline personality disorder. More complicated and emotionally charged material should be deferred until the patient has better skills to manage emotional pain.

It may be helpful to describe out-of-control crisis behavior as a survivor response. Therapists and patients should avoid rigid black-and-white thinking. Describing events or issues as being more helpful or less helpful may circumvent the inflexibility of seeing life's challenges and problems only as black and white, while ignoring the numerous grey areas of experience.

During crisis stabilization, the continued use of written and verbal contracts is critical. These contracts should be rooted in the here-and-now, and should offer patients practical ways to manage crisis behavior. The contracts must focus on safety. Contracts written on 3-by-5-inch cards that they can carry and read when necessary are very helpful for patients with borderline personality disorder. Contracts should be simple and concrete and should emphasize problem-solving skills.

Therapists should work on relapse management strategies that are clear and concrete, such as: "Before I use cocaine, I will call my sponsor." At the same time, therapists should encourage patients to be honest about relapse. Therapists should assume a posture of concerned support about relapse and view it as an opportunity to learn from past mistakes and strengthen relapse prevention skills and the therapeutic relationship.

The family -- as defined by each patient -- should take part in this process. It may be useful to encourage contracts with family members. These contracts can dissuade family members from assuming dysfunctional roles such as the victim, the persecutor, and the rescuer. The family should learn how to set boundaries with the patient, and should learn not to play certain roles, especially the role of rescuer.

In individual therapy, issues stemming both from borderline personality disorder and from AOD use may emerge. Issues related to unsafe behavior or AOD use will continue to be important. Longer-term care is a stage in which teaching the patient skills, such as assertiveness and boundary setting, can be useful.

Patients may need to be educated about survivor issues without exploring more psychodynamically based issues. Patients should be oriented to a survivor framework, but therapists must build slowly before engaging patients in retrieving painful memories.

The abuse survivor should demonstrate the necessary skills to benefit from psychotherapy. Patients should tell the therapist when they are not ready to discuss certain issues. Once patients are ready to do so, the integration of psychodynamic material and trauma therapy may begin. There is no pressing need for the retrieval of early memories of trauma. Rather, the focus of therapy may be on behavior rather than memory.

Therapists might try to frame acting-out behaviors as survivor behaviors. Complications at this stage can include a variety of compulsive and impulsive behaviors, such as eating disorders (obesity, anorexia, bulimia), compulsive spending and money mismanagement, relationship problems, inappropriate sexual behaviors, and unprotected sex (in regard to STDs and pregnancy). Other maladaptive behaviors include sexual impulsiveness, which can cause confusion about sexual identity dramatized in experimental sexual relationships, adding to the crisis and drama on which people with borderline personality disorder often thrive.

Therapists may want to consider limiting access to educational material about adult children of alcoholics (ACOAs) for patients with borderline personality disorder. Reading some ACOA material and self-help books and participating in self-help support groups may be detrimental to some patients' recovery. For some patients, self-labeling can become counter-productive -- and in worst-case scenarios, it can lead to self-fulfilling prophesies.

For example, books suggesting that some people self-mutilate in order to relieve pain may teach patients with borderline personality disorder to self-mutilate. Some books offering "inner-child work" lead the patient through age-regressive exercises that can cause an overwhelming flood of feelings the abused patient may not yet be ready to manage.

Therapists should remember that progress in treating patients with borderline personality disorder and AOD problems can be slow. There may be many setbacks. Rather than looking for enormous changes in personality or behavior, therapists should look for small, measurable signs of improvement.

In addition, therapists may want to consider the following in treating patients with borderline personality disorder:

• Using mini-contracts for each session to encourage the patient to stay focused.
• Immediately asking patients about any crises that have occurred, reviewing the entire week, not just a particular day.
• Stating the purpose of each session.
• Running through a checklist can be helpful. A list might include: homework, failing tests, arguments with others, interactions with the criminal justice system, problems in school or work life, family relationships and friends, relapses, thoughts of self-harm, nightmares, flashbacks, painful situations, and bad memories. Questions should be specific.
• Encouraging patients to keep mood and dream journals (especially during survivor work) between sessions for brief comments on mood.
• Conducting survivor work only after daily living skills are successfully demonstrated.
• Keeping and dating all correspondence and notes from telephone conversations. Having previous conversations documented can help to remind the patient of earlier agreements and conversations.

There are special issues concerning work with people with borderline personality disorder in group therapy. Therapists should consider the following:

• Making contracts for all members to stay in the room.
• Making contracts for group rules that promote safe behavior and not hurting oneself or others.
• Working with transference and countertransference issues.
• Discussing thoughts and feelings about other group members as they arise.
• Setting time limits at the start of each session.
• Making mini-contracts for those who have issues to work on in each session.
• Having group members sign contracts for abstinence and reporting self-harm and AOD use to the group.
• Making contracts for confidentiality.
• Disallowing participants to form intimate or exclusive relationships. Supportive activities, such as calling one another during crises or attending 12-step meetings together, are acceptable and should be encouraged.
• Evaluating safety issues in screening people with borderline personality disorder for group therapy. Patients should be safe from predatory, manipulative behavior of others, and should not engage in such behaviors themselves.
• Promoting same-sex groups.

Although 12-step involvement is important for patients with borderline personality disorder, some may not be immediately able to attend 12-step meetings. Some patients may find it more helpful to participate in pre-12-step practice sessions. These patients should be helped to organize their thoughts, to practice saying "pass," and to create safety in a 12-step meeting. Counselors may want to use the step work handout as a treatment tool for working with people with borderline personality disorder (see Exhibit 7-2 and Chapter 6 on use of 12-step meetings).

Patients should be encouraged to join same-sex 12-step groups when possible. People with borderline personality disorder may find it helpful to use same-sex sponsors as guides to recovery. When possible, therapists should educate the sponsor about survivor behaviors. The sponsor may even attend a therapy session to learn why the patient is taking medications. Antidepressants or lithium may be an important part of the patient's recovery. Explaining how medications are helpful may enable sponsors to help improve medication compliance.

Some sponsors may have problems setting boundaries. Such sponsors should not be paired with borderline patients. If they must be paired, however, they need to understand how important boundaries are in helping borderline patients feel safe. Understanding this may keep them from taking on borderline patients, who may be more than they can handle. Material in the step program should be limited to the here-and-now. Patients should not engage in dealing with sexual abuse issues until they are ready.

Longer-term care should include specialized 12-step work. In using step one ("We admitted we were powerless over alcohol -- that our lives had become unmanageable.") with patients who have borderline personality disorder, therapists should encourage patients to recognize that powerlessness does not mean helplessness. Instead, patients should focus on gaining personal control over AOD use. Faith and hope concepts used in 12-step work may also be difficult for this group to comprehend or integrate.

An aftercare plan for patients with dual disorders is essential. This plan should integrate rather than fragment strategies for treating the patient. It should include methods to coordinate care with other treatment providers. Relapse prevention is critical and should be managed through careful planning throughout treatment. Relapse should be defined as engagement in any unsafe behavior such as AOD use, self-harm, and noncompliance with medications. Relapse prevention should focus on preventing AOD use and recurrence of psychiatric symptoms.

Patients should be encouraged to participate in 12-step groups and other self-help and support groups such as Adults Molested As Children (AMAC), Incest Survivors Anonymous (ISA), and Survivors of Incest Anonymous (SIA).

Acute hospitalization may be necessary during suicidal crises. Again, the emphasis of treatment should remain on safety. Outpatient therapy should continue. AOD treatment should be obtained when appropriate. Therapists should be wary of triangulation in coordinating with other professionals.

Rachel was 32 years old when she was taken by ambulance to the local hospital's emergency room. Rachel had taken 80 Tylenol capsules and an unknown amount of Ativan in a suicide attempt. Once stable medically, Rachel was evaluated by the hospital's social worker to determine her clinical needs.

The social worker asked Rachel about her family of origin. Rachel gave a cold stare and said, "I don't talk about that." Asked if she had ever been sexually abused, Rachel replied, "I don't remember." Rachel acknowledged previous suicide attempts as well as a history of cutting her arm with a razor blade during stressful episodes. Rachel reported that the cutting "helps the pain."

Rachel denied having "a problem" with AODs but admitted taking "medication" and "drinking socially." A review of Rachel's medications revealed the use of Ativan "when I need it." Rachel used Ativan three or four times a week. She reported using alcohol "on weekends with friends" but was vague about the amount. Rachel did acknowledge that before her suicide attempts, she drank alone in her apartment. This last suicide attempt was a response to her breakup with her boyfriend. Rachel's insurance company is pushing for immediate discharge.

Question -- Should Rachel be discharged? Where should she be sent? Exhibit 7-3 shows a recovery model for treatment of borderline personality disorder.

Clinicians should be careful to avoid mislabeling patients. Although some women may have antisocial personality disorder, they receive this diagnosis less often than men. Instead, they may be misdiagnosed as having borderline personality disorder. Among the male prison population, 20 percent may have antisocial personality disorder. However, once they are abstinent, many AOD-using offenders may not meet the criteria for antisocial personality disorder.

In engaging the patient with antisocial personality disorder, it is useful to join with the patient's world view, which may include a need for control and a sense of entitlement. In this context, entitlement refers to people who believe their needs are more important than the needs of others. Entitlement may include rationalization of negative behavior (such as robbery or lying). People with antisocial personality disorder may evidence little empathy for their victims. If incarcerated, they may believe they should be released immediately. In an AOD treatment program, they may describe themselves as being unique and requiring special treatment.

The primary motivation of the patient with antisocial personality disorder is to be right and to be successful. It is useful to work with this motivation, not against it. Although this motivation may not reflect socially acceptable reasons for changing behavior, it does offer a point from which to begin treatment. Wanting to be clean and sober, to keep a job, to avoid jail, and to become the chair of an AA meeting are reasonable goals, despite a self-serving appearance. Therapists may help patients by working with patients' world view, rather than by trying to change their value system to match those of the therapist or of society.

Patients should understand their role in the process. In engaging patients, therapists may want to use contracts to establish rules for conduct during treatment. The contract should explicitly state all expectations and rules of conduct and should be honored by all parties. Such an approach can be useful with people with antisocial personality disorder, who often view relationships as unfair contracts in which one person attempts to take advantage of the other. Therapists may find that once a level of interpersonal respect has been established, working with antisocial patients can lead to important gains for the patient.

In addition to an objective psychosocial and criminal history, the following steps may be useful in assessing the antisocial patient:

• Taking a thorough family history.
• Finding out whether or not the patient set fires as a child, abused animals, or was a bed-wetter.
• Taking a thorough sexual history that includes questions about animals and objects.
• Taking a history of the patient's ability to bond with others. Therapists can ask: "Who was your first best friend?" "When was the last time you saw him or her?" "Do you know how he or she is?" "Is there any authority figure who has ever been helpful to you?"
• Asking questions to find out about possible parasitic relationships and taking a history of exploitation of self and others. In this context, parasitic refers to a relationship in which one person uses and manipulates another until the first has gotten everything he or she wants, then abandons the relationship.
• Taking a history of head injuries, fighting, and being hit. It may be useful to perform neuropsychological testing.
• Testing urine for recent AOD use.
• HIV testing.

The assessment should consider criminal thinking patterns, such as rationalization and justification for maladaptive behaviors. There is a special need to establish collateral contacts and to assess for criminal history and the relationship of AOD use to behavior.

Useful assessment instruments include the Minnesota Multiphasic Personality Inventory (MMPI), the Millon Clinical Multiaxial Inventory (MCMI), the PCL-R (Hare Psychopathy Checklist-Revised), and the CAGE questionnaire.

People with antisocial personality disorder may enter treatment profoundly depressed, feeling that all systems have failed them. Often, their scams and lofty ideas have failed and they feel exposed, feel like losers, and have no ego strength. They are at risk for suicide, especially during intoxication or acute withdrawal. They may require psychiatric hospitalization and detoxification.

They may become acutely paranoid. Containment in the form of a brief hospitalization may be indicated for patients experiencing acute paranoid reactions to avoid acting out against others. For less acute paranoid reactions, therapists should try to avoid cornering patients, disengage from any power struggle, offer lower stimulus levels, and create options, especially if those are supplied by the antisocial patient. During this phase, clarification without harsh confrontation is recommended.

When patients with antisocial personality disorder have crises, therapists should become cautious and careful. During crises, these patients may engage in dangerous physical behavior in order to avoid unpleasant situations or activities, and therapists should avoid angry confrontations.

It is helpful to view the process of working with antisocial patients as a process of adaptation of thinking rather than the restructuring of a patient into a person whose morals and values match those of the therapist or society. Therapists may benefit from modifying their own expectations of treatment outcomes, and realize that they may not help some patients to develop empathic and loving personalities. It is enough to guide patients to lead lives that follow society's rules.

Individual therapy offers the therapist an opportunity to point out patients' errors in thinking without causing them to feel humiliated in the presence of the therapy group. Other issues for individual therapy may include continued relapse management and identity of empathy. Three key words summarize a strategy for working with people with antisocial personality disorder: corral, confront, and consequences.

Corral.

Corralling with regard to patients with antisocial personality disorder means coordinating treatment with other professionals, establishing a system of communications with other professionals and with the patient, contracting patients to be responsible for their AOD use in the recovery program, monitoring information about the patient, and working toward specific treatment goals. Patients may benefit by signing agreements to comply with the treatment plan and by receiving written clarification of what is being done and why. Interventions and interactions should be linked to original treatment goals.

One approach to treatment that adds to the notion of "corralling" is to "expand the system." Spouses, family members, friends, and treatment professionals may be invited to participate in counseling sessions as a way to provide collateral data. This is sometimes called "network therapy."

Confront.

In confronting antisocial patients, therapists can be direct without being abusive. They can be clear in pointing out antisocial thinking patterns. They can remark on contradictions between what patients say and what patients do. Random AOD testing is essential for monitoring patients. Honest reporting of AOD use should be an active part of treatment.

Consequences.

Patients should bear the consequences of their behavior. For instance, violation of probation or rules should be recorded. Patients who are offenders should be encouraged to report behavior that violates probations, thus taking responsibility for their own actions. Positive consequences that demonstrate to patients the benefits of appropriate behavior should also be designed and incorporated into the treatment plan. Financial incentives and opportunities for power or recognition can be a key element of treatment.

Case management may involve coordinating care with a variety of other professionals and individuals, including those in the criminal justice system, AOD counselors, and family members. Therapists need to make it clear to patients that the therapist must talk to other providers and to family members. Thus, it is helpful for patients to sign releases of information for all people involved in their treatment.

The question of terminating therapy can be a puzzling one for therapists treating antisocial patients. The patient may frequently express a desire to end treatment. This desire should be closely examined to determine whether it is a manifestation of patient resistance or whether it is a valid request. There is some question about whether it is appropriate to terminate therapy with patients who have antisocial personality disorder who may need ongoing treatment. Reasons for termination may include noncompliance with treatment, continued drug use without improvement, any aggressive behavior, parasitic relationship with other patients, or any unsafe behavior.

Patients with antisocial personality disorder compulsively try to break rules. If a treatment plan is not devised to work with a person who wants to redefine rules, termination should be considered and transfer to more appropriate care should be arranged.

Continued thinking-error work, as described in Exhibit 7-4, may help patients to identify various types of rationalizations that they may use regarding their behaviors.

Group therapy is a useful setting in which people with antisocial personality disorder can learn to identify errors not only in their own thinking, but in the thinking of others. The group can help identify relapse thinking. For example, when an individual begins to glamorize stories of AOD use or criminal and acting-out behaviors, the group can help to limit that grandiosity. Therapists may also ask people with antisocial personality disorder to discuss feelings associated with the behavior being glamorized.

Role play exercises can be useful tools in group therapy. However, therapists should be careful to prevent patients with antisocial personality disorder from using newly learned skills to exploit or control other group members. In group therapy, patients with antisocial personality disorder can be encouraged tomodel prosocial behaviors and learn by practicing them. Role play exercises can help these patients to focus on their shortcomings rather than on the faults of others.

AOD therapists should avoid creating groups that consist entirely of patients with antisocial personality disorder. Such groups are best conducted in very controlled settings in which therapists have control over the environment.

Patients with antisocial personality disorder may be asked to sign contracts that establish healthy and nonparasitic relationships with other group members. This means not becoming romantically involved with other members, not borrowing money from them, and not developing exploitive relationships.

Therapists themselves should try not to become obsessed with being manipulated or tricked by group members. Such power struggles are not helpful.

A key to treating people with antisocial personality disorder is to be flexible within an array of containment interventions. Therapists should have the ability to quickly move a patient from a less controlled environment to a more controlled environment. Patients benefit from sanctions that match the degree of severity of behavior. Sanctions should not be "punishments" but responses to the need for containment and more intensive treatment. Antisocial patients need a range of treatment and other services: from residential to outpatient treatment, from vocational education to participation in long-term relapse prevention support groups, and from 12-step programs to jail.

When patients with antisocial personality disorder shed aspects of the disorder, they may become more dependent. Therapists often try to limit such dependence. However, with regard to antisocial patients, such a transition should be allowed rather than confronted. It often represents a healthy change. Feelings of dependency are easily frustrated at this stage, and disappointment may result in relapse.

Mark was 27 years old when he was arrested for driving while intoxicated. Mark presented himself to the court counselor for evaluation of possible need for AOD treatment. Mark was on time for the appointment and was slightly irritated at having to wait 20 minutes due to the counselor's schedule. Mark was wearing a suit (which had seen better days) and was trying to present himself in a positive light.

Mark denied any "problems with alcohol" and reported having "smoked some pot as a kid." He denied any history of suicidal thinking or behavior except for a short period following his arrest. He acknowledged that he did have a "bit of a temper" and that he took pride in the ability to "kick ass and take names" when the situation required. Mark denied any childhood trauma and described his mother as a "saint." He described his father as "a real jerk" and refused to give any other information.

In describing the situation that preceded his arrest, Mark tended to see himself as the victim, using statements such as "The bartender should not have let me drink so much," "I wasn't driving that bad," and "The cop had it out for me." Mark tended to minimize his own responsibility throughout the interview. Mark had been married once but only briefly. His only comment about the marriage was, "She talked me into it but I got even with her." Mark has no children and currently lives alone in a studio apartment. Mark has attended two meetings of Alcoholics Anonymous "a couple of years ago before I learned how to control my drinking."

Question -- What might the court counselor recommend to the judge as an appropriate treatment plan for Mark?

Exhibit 7-5 shows a treatment tool for use with patients who have antisocial personality disorder.

In trying to engage and assess patients, therapists should remember that patients with narcissistic personality disorder will have certain traits that should be addressed therapeutically. Therapists should try to join with patients' hypersensitivity and need for control by saying such things as "I'm impressed with what a bright and sensitive person you are. If we work as a team, I think we can help you get out of this spot."

Patients with narcissistic personality disorder often have a need to be the center of attention and to control events. They crave affection and admiration from others. They are perfectionists (about themselves). They may try to create dramatic crises to obtain attention to return the focus to themselves. As with patients with antisocial personality disorder, entitlement issues are very important. Patients with narcissistic personality disorder feel as if everyone and everything owes them -- without any contribution on their part.

It is helpful for therapists to work with these personality traits in therapy. Working with narcissistic motivations for recovery, such as an improved appearance or a desire to continue in a job or to make romantic and sexual conquests, may help the patient to change inappropriate behaviors. Therapists may benefit from working with, rather than against, ego inflation. Therapists who try to squelch the narcissistic ego may be met with rage. Therapists should position themselves as trying to help the narcissistic patient reach his or her goals.

Therapists may work with patients to identify thinking errors that interfere with the patient's ability to work. These errors may include beliefs such as "Everybody loves me." Therapists may need to work with patient's victim-stance thinking. An example of such thinking is "Everybody is out to get me." The antisocial thinking-error work described in the previous section (see Exhibit 7-4) can be a very effective tool for working with the narcissist.

To manage narcissistic rage and depression, therapists may contract for patient safety as well as for the safety of others. The therapist may offer the patient a combination of empathy and reality testing. For example, when patients say, "Everything is messed up," or "Everybody is causing me trouble," therapists may empathize with patients, while also indicating the reality of the situation and the need for behavior change.

Some examples of items to cover during the assessment include:

• A psychosocial history, including early childhood beliefs with regard to looks, behaviors, and thoughts
• A history of AOD use
• A sexual history to identify the ability to be empathic with partners
• Early Memory Procedures test (EMP)
• CAGE questionnaire
• Millon Clinical Multiaxial Inventory (MCMI-II)
• California Personality Inventory (CPI).

Therapists may need to assess patients' defenses, and to put those defenses to therapeutic use. For example, when a patient blames the police for "setting me up," the therapist can mention that the best way to avoid being set up again is to not drink and drive.

Patients with narcissistic personality disorder have a central concern with being perfect. For these individuals, the disease concept approach can assist in recovery by removing blame from the patient and conceptualizing the illness as a biochemical disorder. This can help to lessen the feelings of failure which can be a barrier to treatment.

People with narcissistic personality disorder may become depressed when they feel deeply wounded, when their systems have failed them, and when they sense that their world is falling apart. When wounded, they are at the highest risk for acting out against themselves and others. When in a narcissistic rage, patients may become homicidal, feeling a need to seek revenge. This rage comes from the intensity of the narcissist's wound. The counselor needs to work carefully with this rage and to avoid getting into power struggles.

When these patients are in suicidal crises, patients should sign contracts for safety. Safety may include brief psychiatric hospitalizations that are goal oriented and designed for stabilization.

When working with HIV-positive patients with narcissistic personality disorder, therapists may establish contracts with them to engage in safer-sex practices. Often sexual prowess is part of the narcissistic ego-inflation. Their need to see themselves as great lovers, coupled with self-centeredness, puts them at high risk for sexually transmitted diseases.

There will be an ongoing need to manage the rage and depression of patients with narcissistic personality disorder and their need for attention, control, and admiration. Continued attention to self-centeredness and the need to work the 12 steps is essential. Step work designed for people with antisocial personality disorder (as previously described in Exhibit 7-5) can be helpful for patients with narcissistic personality disorder. Similarly, the individual and group approaches to the treatment of patients with antisocial personality disorder can be used for patients who have narcissistic personality disorder. Indeed, it may be helpful to view the patient with narcissistic personality disorder as a hypersensitive patient with an antisocial personality disorder.

People with narcissistic personality disorder may benefit from group therapy. In group therapy, therapists may need to set time limits in a firm but pleasant manner, pointing out the need for all patients to have group time. At the start of each session, therapists should make a contract with patients with narcissistic personality disorder to encourage prosocial behaviors and to avoid attempts to dominate, control, or compete for attention with other group members. Some behaviors to contract for might include:

• To limit the time that they can speak during group sessions
• To not interrupt others while they speak
• To respect other group members' time and feelings
• To give responses to other group members
• To receive responses and feedback from others.

It is important not to smash the narcissistic ego or to attack the narcissistic patient within the group. It is more useful to comfort and confront the narcissist simultaneously: "I understand that the part of you that is sensitive is wounded to hear that the group does not believe everything you are saying." Continue to work with the narcissist's defenses, not against them.

For patients with narcissistic personality disorder, the least restrictive treatment environment is preferable. It permits patients to feel that they are in control. These patients should be moved quickly from inpatient to outpatient levels of care. If they do not like the treatment, they will stop participating. Thus, it is critical not to overpathologize the patient's disorder with constant criticism. However, acute hospitalization for psychiatric emergencies (such as homicidal or suicidal plans) may be necessary.

Narcissistic patients generally enjoy the attention they receive through involvement in outpatient treatment; retention in the program is easily accomplished. Long-term outpatient involvement is critical to maintain narcissistic patients' prosocial behavior and sobriety. Therapists who strive to build narcissistic patients' strengths and who pay close attention to them in therapy will find them active participants in the recovery process. In addition to their personality disorder and AOD use disorder, some patients may engage in compulsive sexual or spending behaviors that should be addressed therapeutically.

Tip for Narcissistic Patients A helpful exercise for patients with narcissistic personality disorder is to ask them not to say anything during a specific number of 12-step or self-help groups, but to simply listen. Once this has been done, narcissistic patients should discuss their feelings with the therapist in response to the exercise.

Bill is a 45-year-old male who was referred by his employer to the company's employee assistance program (EAP). The employer was concerned about Bill's temper, his difficulty accepting criticism, and his difficulty in getting along with other staff. At the EAP appointment, Bill's appearance was that of an extremely well-groomed man who paid exceptional attention to his dress and attire. His manners were impeccable, although he was critical of the receptionist at the EAP's office for not offering him coffee when he came in. Bill was friendly but cool toward the EAP counselor, tending to gloss over the importance of his boss's concerns.

When the EAP counselor asked him for more specifics about his problems with his coworkers, Bill became extremely defensive and hammered away in a raging attack on his coworkers and their jealousy of his success. Bill felt that his boss was a well-intentioned but incompetent person who frequently made mistakes. Bill also felt that his boss didn't appreciate the caliber of his work or the time he put into his work. Bill took pride in his perfectionism, attention to detail, and firm and inflexible beliefs.

Bill was not married, although he reported that he had come close a few times only to discover that these women had "fooled him" in one way or another. Bill reported to have only one male friend and indicated that he much preferred the company of women to men. Bill denied having any "problem with drugs" but did indicate that he uses marijuana and cocaine recreationally. Bill reported using alcohol most weekends and occasionally drinking to the point where he "forgot" what happened.

Question -- What should the EAP counselor suggest as a treatment plan to address employer concerns over Bill's behavior?

As in working with all patients with personality disorders, therapists should attempt to join with the world-view of patients with passive-aggressive personality disorder, rather than work against it. Therapists may try to work with patients' need for safety and with their ambivalence toward recovery. Therapists should work with patients' indirect displays of anger and assertiveness.

Passive-aggressive patients try to avoid commitment and responsibility. All interventions should be focused on the patient's needs, wants, and desires, a strategy that promotes treatment compliance.

Areas to address in the assessment include the following:

• Survival skills and self-care assessment
• Monitoring of use of over-the-counter drugs, such as NyQuil, Dexatrim, Benadryl, niacin, laxatives, and tryptophan (somatic illnesses are often medicated with these chemicals)
• Information on all other professionals and medical providers being seen for treatment
• Psychosocial and AOD history, and mental status
• Coexisting anxiety disorders
• Medication evaluations for antidepressants or other nonaddictive substances
• Identification of the patient's typical passive-aggressive maneuvers or "scripts."

Useful assessment instruments include the MMPI, CAGE, or MAST, to assist clinical review and/or to evaluate substance abuse.

Often, several issues must be managed during crises experienced by patients with passive-aggressive personality disorder, such as responses to abusive relationships, obtaining safe housing, and receiving emergency psychiatric admissions for suicidal crises. These patients may need to be detoxified from benzodiazepines and other sedative-hypnotics. To manage various crises, therapists may need to insist that patients provide release of information authorizations for all providers of care. This can help the therapist to coordinate services. Verifying all prescribed medications can prevent medical emergencies and improve patient responsibilities.

Patients who have AOD use disorders that involve prescription drugs will find it helpful to inform their prescribing physicians of their involvement in treatment and recovery efforts. This helps to stop the supply of psychoactive medications, to learn assertive behavior, and to teach personal responsibility for recovery.

Patients with passive-aggressive personality disorder require skill building in several areas including: assertiveness, boundary setting, anger management, and identifying and expressing their feelings directly. They will also need to work through sexual intimacy problems. This might be done in a same-sex group, individual therapy, or marital or couple therapy. Treatment planning should include goals and objectives that are reasonable and measurable. For example, a goal may be set to increase the length of time during which a patient is abstinent between relapse episodes. An excellent focus for the skill-building part of therapy is developing the ability to express anger through assertiveness rather than through indirect acting out.

Passive-aggressive patients may engage in compulsive behaviors including eating disorders and compulsive shopping and spending; money management problems, as well as AOD relapse, may also occur. Throughout treatment, therapists should continue to monitor the patient's use of alcohol, prescribed and over-the-counter medications, and other drugs.

In individual therapy, therapists may help patients to express their emotions directly. Therapists can encourage patients to process comments made when the patient appears to be passive or disinterested in the process. Therapists can prompt patients to express their needs, wants, and desires directly without waiting until a later session. Therapists can use written and verbal contracting as an ongoing therapeutic method. Therapists should not apologize for setting and enforcing limits and reinforcing boundaries between the passive-aggressive patient and the program staff.

Patients with passive-aggressive personality disorder should be encouraged to join same-sex support groups. This helps them identify strongly with same-sex peers and prevents relationships built on a mutual need to avoid recovery. Group therapy sessions provide patients an opportunity to develop ways to manage hostility.

When hostility manifests itself during group sessions, therapists may manage it by commenting on the hostile behavior, asking other group members to comment, and asking the patient to respond. The therapist may then quickly assess the patient by asking: What do you need? Who can you ask for it? When can you ask for it? The patient can then rehearse appropriate behavior in group.

Parents can be taught not to assume these dysfunctional roles. Patients who are also parents may need to be taught parenting skills to help them avoid creating destructive relationships with their children. Passive-aggressive parents need direct methods for dealing with their children's behavior so that children do not develop personality and emotional problems themselves. Children raised by parents who are overcontrolling, unpredictable, and hostile can develop antisocial or dissociative defenses and styles.

Once patients with passive-aggressive personality disorder have managed to work through primary issues, therapists may want to use opposite-sex models who can demonstrate appropriate types of behavior. Learning how to set limits on opposite-sex facilitators helps with generalization of newly learned skills.

Control is an essential feature of the passive-aggressive personality. Therapeutic work that centers on step one of the 12 steps can be helpful. Therapists should remember to emphasize that patients can gain certain types of control by giving up other kinds of control. Step work discussed in the section on borderline personality disorder (Exhibit 7-2) can be helpful.

Patients may benefit from participation in 12-step programs for their AOD problems and for relationship dependencies and conflicts. Patients should be educated about avoiding romantic involvement with other group participants, and especially escaping a bad relationship by becoming involved in a new relationship.

Inpatient hospitalization may be necessary for detoxification of patients who have AOD use disorders that involve sedative-hypnotics such as the benzodiazepines. Ongoing therapy for substance use and psychiatric issues can be done on an outpatient basis with a combination of individual same-sex group therapies and integration into 12-step or self-help recovery groups.

Brief inpatient psychiatric stays may also be necessary to deal with psychiatric emergencies such as overwhelming depression, anxiety, or suicidal ideation or behavior.

Patients may need assistance to locate shelters and safe housing when domestic violence is a problem or threat. A primary care physician is essential so that medical management can be provided and coordinated with psychosocial treatment. A complication to recovery for many passive-aggressive patients may be compulsive eating or spending problems. Ongoing assessment and treatment of these issues as part of the overall treatment plan are encouraged.

Jane was 37 when she sought marriage counseling with Dr. Myers. She attended the initial appointment with her husband. Both Jane and her husband were vague and nonspecific about what they needed from couple counseling. Jane was quiet until the last 10 minutes of the appointment when she started crying, stating that "nothing was going to help." Jane's husband, confused but accommodating, tried unsuccessfully to comfort Jane who withdrew to a chair in the corner of the office, refusing to talk. Dr. Myers contracted with Jane to meet with her individually for three sessions to assist in developing a better understanding of her unhappiness and frustration in the marriage. Both Jane and her husband agreed.

Jane attended the first session on time and was "ready to get to the bottom of this problem." Jane openly discussed her own "dysfunctional family," discussing parents who were both alcoholic and physically abusive. Jane discussed her difficulties dealing with feelings of depression and fear. Jane further reported how frustrated and upset she got whenever her husband criticized her or when he was angry at her.

Jane reported having thoughts of suicide, although there was no plan or history of any attempts. Jane found it helpful to have a "glass of wine" when anxious and reported to have a prescription medication that she can take for "her nerves" when she gets overwhelmed.

Further discussion revealed Jane to be getting a prescription for alprazolam (Xanax) from her family doctor. She was vague about how much alprazolam she used but said she took it "several times a week." Jane complained about recent weight gain. She felt if she could get her weight under control, "everything else would be fine." Jane reported to be drinking only juices and coffee and using over-the-counter diet pills when she got too hungry. She was somewhat defensive about her drinking and use of medications and preferred to discuss issues related to her husband. At the end of the session, she commented, "I hope this helps my marriage and my husband's drinking" and she left. Jane missed the second appointment, calling 3 days later stating she had "forgotten about the appointment." Jane attended the third appointment but was 25 minutes late.

Question -- What should Dr. Myers' treatment plan consist of and what should she do next?

Tips for Use With Passive-Aggressive Patients To show patients the effect of letting hostilities and needs build up internally, the therapist can blow up a balloon until it nearly bursts, letting it fly around the room. This demonstrates visually what it is like to let overwhelming feelings build up. The therapist should be willing to sit in silence, forcing the patients to respond. Watch for patients enabling other group members' codependency. Relationship issues are a cornerstone of the passive-aggressive patient's problems.

It is easy for therapists to assume dysfunctional roles with patients who have personality disorders. Also, because of the chaos that may accompany treatment, important patient information may be missed. Maintaining ongoing and up-to-date contacts is essential for all patients with personality disorders. The following are tips to remember in coordination of care of patients with personality disorders.

Primary case manager.

Frequently, patients with personality disorders have many different people and systems in their lives. The identification of one key person as a gatekeeper for information can greatly improve coordination of care and reduce interagency conflicts.

Legal issues.

Providers should obtain releases of information to monitor any new involvement in the criminal justice system or to be aware of the disposition of old charges. Issues of divorce and child custody may need to be monitored in the sessions, with the goal of having the patient spend an appropriate amount of session time on these topics.

Managed care.

Typically, managed care does not provide benefits for patients with personality disorders. Many patients with personality disorders also meet criteria for psychiatric disorders such as depression or anxiety. Brief stays in hospitals and limited insurance coverage need to be realistically evaluated so treatment goals match benefits and assets available for care.

Funding issues.

Reimbursement for the treatment of patients with dual disorders may not include patients who have personality disorders. Often, a coexisting diagnosis of depression or anxiety is appropriate. For billing or funding purposes, listing the AOD problem as the primary illness may be an option.

Staffing and cross-training.

All staff benefit from training in AOD treatment in general, and in working with AOD-using patients with personality disorders in particular. Integrated treatment for coexisting disorders is most effective.

Medical issues.

Patients participating in inpatient AOD treatment should have a complete physical examination. Outpatients should have a current (within past 30 days) physical examination on file. Physical examinations are particularly important for patients who have coexisting medical problems or who are HIV positive. HIV testing should be encouraged.

Integration into 12-step self-help groups.

It is important to encourage 12-step participation as a means of ensuring long-term recovery. Therapists and patients should discuss patients' objections to participation in these self-help group meetings. Patients should be encouraged to find 12-step groups with which they are comfortable.