The document discusses the importance of using the Psychodynamic Diagnostic Manual (PDM) to better understand clients with borderline personality organization and avoid potential ethical issues. It describes how the PDM framework helps clinicians recognize clients who may pose risk management problems or ethical dilemmas, understand borderline as a level of personality rather than a narrow set of symptoms, and provide a deeper understanding of difficult clients.

1. How the PDM Can Help Us Avoid Ethical Dilemmas Robert M. Gordon, Ph.D. ABPP in Clinical and Psychoanalysis a C.E. Ethics Workshop for the Department of Professional Psychology Chestnut Hill College Learn to recognize clients who can be a risk management problem and/or create ethical dilemmas. Learn that ‘Borderline’ is a level of personality organization that can be at the basis of any personality disorder. Learn how the adult Axis P of the PDM can help with a deeper understanding of difficult clients.

2. Cleaver-wielding man kills psychologist The Associated Press 2/13/2008 New York authorities plan to charge a Queens, N.Y., man with murder in the vicious hacking death last week of psychotherapist Kathryn Faughey, and assault for the simultaneous attack on Dr. Kent Shinbach, David Tarloff, 39, a former patient of Shinbach's, has been tied to the crime on Manhattan's Upper East Side by palm prints at the scene, eyewitness accounts and his own words…

3. NYC therapist slay spotlights risks as trial nears By JENNIFER PELTZ (AP) – Oct 10, 2010 Faughey's death focused attention on patient violence against mental health providers, but it has long been a concern in the profession. Surveys suggest about 15 to 20 percent of psychologists are assaulted by a patient at some point in their careers, said Phil Kleespies, a Boston psychologist who co-chaired an American Psychological Association group that examined patient violence.

4. “ I have often served as an expert witness in malpractice cases where psychologists had missed the psychopathic or borderline traits in patients. The DSM classifies antisocial and borderline personality disorders by precise and narrow symptoms. This is often misleading. Psychopathy can be a complex personality pattern that combines with or is obscured by other personality patterns, and borderline can be viewed as an entire level of personality organization that can be applied to the various personality disorders.” Gordon, R.M., (2007) PDM Valuable in Identifying High-Risk Patients. The National Psychologist, 16, 6, November/December, page 4.

5. Job consultant's against the grope in $10M suit BY BARBARA ROSS DAILY NEWS STAFF WRITER Monday, July 9th 2007, 4:00 AM “ A former model who claims that a prominent job consultant grabbed her bottom during a 2002 job interview will finally get her day in Manhattan Supreme Court this week as a jury starts to hear evidence in her $10 million lawsuit.”

6. Case of sex & the shrink Job hopeful says doc wanted her to strip - and that ain't all BY JOSE MARTINEZ DAILY NEWS STAFF WRITER Wednesday, July 11th 2007 “ An ex-model suing a Manhattan psychologist for allegedly groping her testified yesterday the shrink went from professional to pervert in a very hands-on job interview.” It took 5 years for this case to go to trial. During that time the psychologist was humiliated by the press and lost his job.

7. NEW YORK, July 12 (UPI) -- Psychologist Robert Gordon testified… "She holds herself out to be an indigo child from another planet who is made of light," Gordon told the Manhattan jury, adding, “She stated that she doesn’t trust men, even her 8 year old son. Her web site stated that she is from another planet and has special healing powers. In her deposition she stated that she didn’t need a license, that god told her to heal. Her PAI had her in the psychotic range.”

8. “ My Psychologist Abandoned Me!” Patient claiming millions of dollars in damages Middle age woman, with no history of psychological problems seeks help after her husband commits suicide. Psychologist gives the Beck Depression Inventory, it shows depression and the psychologist does CBT. He is symptom focused in his orientation.

9. Complaint to Licensing Board and Civil Suit for Damages At first the patient is sweet and appreciative. Calls psychologist frequently between sessions. Begins to stalk him and insist on an outside relationship with him. At his “rejection,” she becomes suicidal and requires hospitalization Psychologist refers her to other psychologists for treatment and does a termination session with her. Later she sues for abandonment. He did not manage her as someone with a dependent personality disorder at the borderline level personality organization.

10. Patient using sessions for sadomasochistic gratification Constantly testing the boundaries and insisting on frequent phone contact between sessions Threatening suicide, but refusing to be cooperative with the treatment plan Idealizing the therapist and fearing his abandonment while devaluing the treatment Infuriating the therapist with complaints about his not helping her, while she was resisting treatment (projective identification)

11. Admission notes at first hospital stay soon after start of treatment “… She was increasingly depressed and it seems that despite treatment with antidepressants from her primary care doctor and despite psychotherapy which had been started with Therapist Y in the past three months, the patient’s overall condition had continued to decline…”

12. Mental health outpatient note by subsequent therapist “ Therapist Y suddenly stopped her treatment so she started to harass him, follow him, follow him everywhere, go to his house, hide in the bushes, in short she was stalking him. So he called 911 and she was in jail last month for one week. When she got out she is going to sue Therapist Y for suddenly stopping her therapy…”

13. Mental health outpatient note by subsequent therapist con’t: “ AXIS I: Posttraumatic stress disorder. 309.81; AXIS II: Mixed personality disorder with borderline and obsessive-compulsive components… AXIS V: Global assessment of functioning 55; highest in past 65…”

14. Attorney for Therapist Y questions to me: 1. “As to whether Therapist Y appropriately terminated his treatment of Ms. Patient X.” “ He did appropriately terminate treatment in accordance with principle 10.10 of APA’s ethical code?”

15. Avoid claims of abandonment and know 10.10 Terminating Therapy (a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit , or is being harmed by continued service. (b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship. (c) Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate.

16. Whether Therapist Y appropriately terminated his treatment of Patient X. Continued: “ The APA ethics committee and state licensing board hearing both rejected Patient X’s complaint. She was not benefiting from treatment and he was ethically bound to terminate treatment if the patient is not benefiting. He gave her the names of other therapists. He is not responsible if because of her psychopathology she doesn’t want other therapists and she doesn’t want to get better.”

17. 2. “Whether the treatment provided by Therapist Y was appropriate.” “ Yes it was. He appears to provide primarily cognitive behavior therapy ... However, the problem was not that there was inappropriate treatment but Ms. X was uncooperative and resistant to treatment.”

18. 3. “As to whether you believe Patient X suffered any harm as a result of the termination of treatment with Therapist Y .” “ No. Patient X still continues to express her rage and her mental illness towards anybody she interprets as having betrayed her, abandoned her or rejected her. This is a continuation of her psychopathology but not a reaction to the actual termination of treatment. She has not changed. Her GAF has remained in the same pattern of compensation and decompensation for years.” (Showed chart)

20. Importance of a Psychodynamic Understanding of Personality The PDM was introduced to 192 psychologists in a several ethics and MMPI-2 workshops (65 Psychodynamic, 76 CBT and 51 Other) Over all the psychologists gave the PDM a 90% favorable rating. Gordon, R.M. (2009). Reactions to the Psychodynamic Diagnostic Manual (PDM) by Psychodynamic, CBT and Other Non- Psychodynamic Psychologists. Issues in Psychoanalytic Psychology, 31,1, 55-62.

21. The Psychodynamic Diagnostic Manual Over-all level of personality organization (Healthy, Neurotic or Borderline) Personality patterns and disorders (Temperament, conflicts, affects, cognitions and defensives) Specific capacities of mental functioning (learning, relationships, self regard, affective experience, internal representations, differentiation and integration, psychological mindedness, a sense of morality) The subjective experience of symptoms

22. Kernberg’s Levels of Personality Organization 1- Normal flexibility and adaptation 2- Neurotic level of personality organization 3- Borderline level of personality organization: – High level borderline – Low level borderline 4- Psychotic level of personality

23. Borderline Personality Organization Basic Characteristics- Kernberg Identity Diffusion No integrated concept of self No integrated concept of significant others Primitive Defenses – Splitting – Idealization/devaluation – Projective identification – Omnipotent control – Denial Variable Reality Testing

24. Healthy Defense Mechanisms Anticipation Affiliation Altruism Humor Self-Assertion Self-Observation Sublimation Suppression

25. Neurotic Level Defenses Displacement Dissociation Intellectualization Rationalization Isolation of Affect Reaction Formation Repression Undoing

26. Borderline level Defenses Idealization / Devaluation Omnipotence and Omnipotent control Denial Projective identification Splitting of self-image or image of others Acting out Projection

27. Psychotic Level Delusional projection Psychotic denial Psychotic distortion

28. Borderline Personality Organization: Clinical Implications- Kernberg Nonspecific ego weakness Lack of impulse control, poor anxiety tolerance, disturbed object relations, • Difficulties with work and love • Sexual pathology (Two levels: inhibition of all sexual functioning; chaotic sexuality) • Pathology of moral functioning

29. Kernberg’s Differentiation of Personality Organization Preceded the PDM Neurotic Borderline Psychotic Identity + - - Integration Defensive + - - Operations Reality + +/- - Testing

30. The PDM’s Determination of Personality Organization or Severity of Personality is Based on Seven Capacities To view self and others in complex, stable, and accurate ways ( identity ); To maintain intimate, stable, and satisfying relationships ( object relations ); To experience in self and perceive in others the full range of age-expected affects ( affect tolerance ); To regulate impulses and affects in ways that foster adaptation and satisfaction, with flexibility in using defenses or coping strategies ( affect regulation ); To function according to a consistent and mature moral sensibility ( super-ego integration, ideal self-concept, ego ideal ); To appreciate, if not necessarily to conform to, conventional notions of what is realistic ( reality testing ); To respond to stress resourcefully and to recover from painful events without undue difficulty ( ego strength and resilience ).

31. P Axis This dimension has been placed first in the PDM system because of the accumulating evidence that symptoms or problems cannot be understood, assessed, or treated in the absence of an understanding of the mental life of the person who has the symptoms.

32. Personality Patterns and Disorders P Axis The PDM classification of personality patterns takes into account two areas: the person's level of severity by personality organization, and the characteristic personality pattern or personality disorder.

33. Once the level of Personality is Determined (neurotic or borderline), then Consider the Type of Personality Disorder P101 . Schizoid Personality Disorders P102. Paranoid Personality Disorders P103. Psychopathic (Antisocial) Personality Disorders P103.1 Passive/Parasitic P103.2 Aggressive P104. Narcissistic Personality Disorders P104.1 Arrogant/Entitled P104.2 Depressed/Depleted P105. Sadistic and Sadomasochistic Personality Disorders P105.1 Intermediate Manifestation: Sadomasochistic Personality Disorders P106. Masochistic (Self-Defeating) Personality Disorders P106.1 Moral Masochistic P106.2 Relational Masochistic

34. P107. Depressive Personality Disorders P107.1 Introjective P107.2 Anaclitic P107.3 Converse Manifestation: Hypomanic Personality Disorder P108. Somatizing Personality Disorders P109. Dependent Personality Disorders P109.1 Passive-Aggressive Versions of Dependent Personality Disorders P109.2 Converse Manifestation: Counterdependent Personality Disorders P110. Phobic (Avoidant) Personality Disorders P110.1 Converse Manifestation: Counterphobic Personality Disorders P111. Anxious Personality Disorders

35. P112. Obsessive-Compulsive Personality Disorders P112.1 Obsessive P112.2 Compulsive P113. Hysterical (Histrionic) Personality Disorders P113.1 Inhibited P113.2 Demonstrative or Flamboyant P114. Dissociative Personality Disorders (Dissociative Identity Disorder/Multiple Personality Disorder) P115. Mixed/Other

36. P Axis

37. Psychopathic, Sociopathic, Antisocial or Dissocial? The DSM-IV-TR states that psychopathy and sociopathy are obsolete synonyms for “Antisocial Personality Disorder.” The World Health Organization stance in its ICD-10 refers to psychopathy, sociopathy, antisocial personality, asocial personality, and amoral personality as synonyms for “Dissocial Personality Disorder.” The PDM uses “Psychopathic” to relate to the personality not just symptoms, and considers all the terms as basically interchangeable .

38. Psychopathy and Narcissism Otto Kernberg (2004) believed psychopathy should fall under a spectrum of pathological narcissism, that ranged from narcissistic personality on the low end, malignant narcissism in the middle, and psychopathy at the high end.

39. The P Axis- Personality Disorders Considers the Following Factors: Temperamental, Thematic, Affective, Cognitive, and Defense patterns

40. P103. Psychopathic (Antisocial) Personality Disorder P103.1 Passive/Parasitic P103.2 Aggressive Contributing constitutional-maturational patterns: aggressiveness, high threshold for emotional stimulation Central tension/preoccupation: Manipulating/being manipulated Central affects: Rage, envy Characteristic pathogenic belief about self: I can make anything happen Characteristic pathogenic belief about others: Everyone is selfish, manipulative, dishonest Central ways of defending: Reaching for omnipotent control

41. Psychopathic P.D. (PDM) Not all psychopaths are antisocial. Many are successful and social in certain roles (intelligence, law enforcement, attorney, clergy, etc.) Want power for its own sake Pleasure in exploiting and duping others Good at reading the emotions of others, but not their own Lacking a moral center of gravity Lose interest in people once no longer useful to them Lack of remorse Need high external stimulation Organized mainly at the borderline level, and often combines with other personality disorders or patterns (Paranoid, Sadistic, Narcissistic, etc.)

42. Aggressive Subtype Explosive Actively predatory Often violent

43. Passive/Parasitic Subtype More dependent Less aggressive, usually non-violent Manipulator Con artist

44. Fargo (1996) a car salesman has hired two men, an aggressive psychopath and a passive/parasitic psychopath, to kidnap his wife for a ransom of $1 million that he hopes to get from his rich father in-law.

45. The Psychopath in Therapy

46. The Kiss Case Example: In 1996 a patient claimed to have suffered damages resulting from her having been kissed by her psychiatrist. The psychiatrist acknowledged that he briefly participated in the encounter--but he denied that the brief mistake had resulted in damages. He had expressed his apologies to the patient in a note. The interesting question, since plaintiff and defendant largely agreed about the facts, what the jury would consider an appropriate award to the plaintiff whose prior writings, introduced as evidence, indicated that she was very experienced sexually.

47. The Kiss The incident occurred during a treatment session when the patient suddenly kissed the psychiatrist, and the psychiatrist initially failed to resist. After a brief period of kissing, the psychiatrist testified that he realized that he was making a mistake and stopped the inappropriate behavior. He said he expected to discuss his mistake in subsequent sessions, as well as to explore the meaning of what had occurred for both the patient and the therapy. However, he never got that opportunity, as the patient set in motion a civil law suit within a day of the event. The patient was ultimately awarded nearly $160,000 by the jury (and was not covered by malpractice insurance).

48. Formula for Disaster Therapist (Hy2 + Pa3) + Patient (Pd) = Therapist -$$$$$

49. Treatment They tend to be very manipulative during treatment and tend to lie and cover up personal faults in themselves and have little insight into their behavior patterns. They tend to exhibit short-term enthusiasm for treatment, particularly after an incident which has brought them into contact with society or the law, however, once this anxiety is relieved and reduced, They frequently drop out of treatment and fall back into the same patterns that brought them into treatment initially.

50. Treatment There is neither a cure nor any effective treatment for psychopathy; there are no medications that can instill empathy, while psychopaths who undergo traditional talk therapy only become more adept at manipulating others. Harris, Grant; Rice, Marnie (2006). "Treatment of psychopathy: A review of empirical findings". In Patrick, Christopher. Handbook of Psychopathy. pp. 555–72.

51. Why the Psychopath is a risk in treatment They are very hard to detect. They are con artists. They are experts at sizing you up and exploiting your issues. They can be charming one moment, and dangerous the next. They can seduce you and then destroy your career. They will make false claims against you for the money.

52. 10.10 Terminating Therapy (a) Psychologists terminate therapy when it becomes reasonably clear that the client/patient no longer needs the service, is not likely to benefit, or is being harmed by continued service. (b) Psychologists may terminate therapy when threatened or otherwise endangered by the client/patient or another person with whom the client/patient has a relationship. (c) Except where precluded by the actions of clients/patients or third-party payors, prior to termination psychologists provide pretermination counseling and suggest alternative service providers as appropriate.

53. Risk Factors in Litigious Patients Borderline Personality Organization Psychopathic traits History of acting out Poor Relationship History

54. What to do? Be aware of the diagnosis- Learn the PDM! Keep strict boundaries and ground rules, Use frequent clarifications of roles and rules of therapy, Use confrontations to help with impulse containment, Take ‘protective’ notes, Get a consult, If you are frightened or uncomfortable, you do not have to treat the patient. Refer to a more appropriate facility.