Here are some tips for detecting a personality disorder in a client: - Pay attention to their interpersonal relationships - are they problematic, unstable, or chaotic? This could indicate Cluster B PDs. - Look for rigid, maladaptive coping patterns. Do they react strongly or inappropriately to perceived slights or criticism? This could point to Cluster A or B. - Assess their moods - are they unstable, dramatic shifts in emotion? Again, this suggests Cluster B. - Consider their self-image. Do they have distorted, unstable or fragile self-image? This is common in Cluster B PDs. - Take a developmental history. Did problems start in childhood or adolescence? PD

1. Asian Problem Gambling Treatment Forum
Working with Mandated and
Personality Disordered
Asian Problem Gambling Clients
May 2010
ABACUS Counselling, Training and Supervision Ltd

2. Part One:
Mandated Clients

3. Quiz
Forcing Problem Gamblers to receive help is
unproductive and doesn’t work
• No
Forcing PGs to seek help is wrong and unethical – no
one should be forced to seek help
• No
There are confidentiality problems – I can’t tell
Corrections that he/she didn’t turn up
• No

4. Quiz
Forcing Problem Gamblers to receive help is
unproductive and doesn’t work
• No
Forcing PGs to seek help is wrong and unethical – no
one should be forced to seek help
• No
There are confidentiality problems – I can’t tell
Corrections that he/she didn’t turn up
• No

5. More Quiz
I will destroy my therapeutic alliance with my client if
he/she knows I have to report on him
• No
Other therapists don’t have to do this
• Yes – common with AOD and others
Why not wait until they are ready to seek help without
compulsion?
• Because they may not come – only 2%-5% at most seek
help, and only after severe consequences to themselves
and family

6. Exercise 1: Jimmy
• Jimmy is 22 yoa Chinese man. He has been referred to you by
Diversions. He is 30 mins late for an evening appointment and you
have only 30 mins to see him before the office closes. He says he has
been ordered to see you for counselling because he was caught shop
lifting a book he needed for University studies. (He gambled the
money his parents gave him for books.) He says he has learned his
lesson and could you sign a letter to say he has attended.
• In groups, brainstorm your priorities for the next 30 mins and then rank
them in order, presenting reasons for your prioritisation. (Eg Should
you spend 30 mins explaining what counselling is? What your
organisation does? Who you are? Go through exclusion procedures?
Discus gambling harms? Assess self harm? Do screens?)

7. Who are Mandated Clients?
• Correction clients
– Diverted
– Community sentenced – intensive supervision
– In custody
– Paroled
• Those with cases pending – needing to show motivation
• Employer referred – e.g. banks
• Sky City and other venue excluded – attending for re-
entry reasons - may feel mandated
• Those under threat of matrimonial separation

8. What Do They Have In Common?
• May have high external motivation, low internal
motivation to reduce or stop gambling
• May have poor insight into the harm of their gambling to
self or others
• May be angry at ‘having to come’
• May not give a truthful overview of problems
• May try to impress you that they are not gambling or
intend to stop, when they only want to avoid
consequences
• May really be willing to change, but relapse as soon as
pressure is off

9. Reasons Why May Be successful
• They often attend in crisis
• Crisis is a good time to change because
– They can more readily see the consequences of their
gambling (sometimes need help with this)
– May have time and motivation to attend therapy –
time in therapy correlates positively with behaviour
change
– May have support to attend therapy (transport, other
costs if Court ordered)

10. Future Mandated Numbers?
Probably increase because
– Trend towards intensive supervision and home
detention sentences with Court referral
– as understanding grows that low community risk and
limited custodial space
– Awareness that although losses may be high, typical
PG can’t provide reparation
– Multiply needs of typical PG can only be provided in
community e.g. AOD, depression

11. Setting the Boundaries
• Why:
– because there will be distrust, uncertainty otherwise
(‘Who’s side is he/she on, I wonder?’)
• When:
– as soon as possible
• How:
– useful here to use MI
– Acknowledge their situation
– They still have options

12. Setting the Boundaries
• Contract with disclosure requirements spelt out
• What if they don’t attend for good reason but notifying
Corrections will have consequences?
• Will this destroy any therapeutic connection?
• What if we think they are lying to us to get rid of the
referral requirements?

13. Addressing Resistance
• Rolling with resistance
• Arguing or confrontation is counterproductive, can be
barrier to change. “Don’t like being told what to do!’
• Acknowledge as normal, natural, understandable
• How do we do this?
One way Motivational Interviewing: OARS

14. OARS
Open-ended questions
(Can’t just answer yes or no) helps to gather
information - note any desire or reasons for change,
identifies their own thoughts and concerns
Affirmations
To reinforce positive aspects of their behaviour and
acknowledge efforts toward change
Reflective listening style
Use reflective listening instead of “telling”
Summarise strategically

15. MI Reflective Listening
Reflective listening
responding with a statement allows them to agree or
disagree and to further clarify
• Simple reflection is a “close” repetition of their words
• Complex reflection is in your words
– rephrase (to emphasise) - but can also add their words
(‘Sounds like even though you try to …..’)
– matching their emotion (they feel understood); can reflect
implicit feelings – more than they said (but not more than they
meant)
– undershooting (to understate can make them elaborate)
– overshoot or exaggerate (overstating can make them pull back)
double sided reflection (“on one hand… on the other..”). Start
with status quo, end with side favouring change

16. Exercise 2: Liam- Video
Watch this video noting examples on worksheet

17. LIAM VIDEO: OARS
Open Ended Questions:
Affirmations:
Reflections:
Simple
Amplified (exaggerating but not extreme, sarcastic)
Double sided
Shifting focus
Agreement with a twist
Emphasis on their personal choice and control
Summaries:

18. How Will Therapy Differ?
• Surprisingly little if rules set out
• May focus more upon earlier stages of behaviour change
• Any questions?

19. Difficult Clients
Who and Why: difficult clients may have reasons –
– Your approach
– They may have co-existing problems
– They may have serious social problems
– They may have personality problem
When: may feel they have little control over their lives
– (quote from Bill Miller re lack of control)

20. De-escalating threats or violence
• Menacing clients
• Do we have to deal with this as part of our therapy?
• How do we lower the level of threat?

21. Exercise 3: Role Play Bing and Ivy
• Ivy arrives with her husband Bing. On the referral sheet from
the Helpline it says Ivy made the appointment to talk about
Bing’s pokies gambling. Ivy “gets scared” when Bing gets
angry with her and the children when he loses. Its says she
will “try to get her husband to come with her”. In the reception
areas Bing is heard angrily talking to Ivy, telling her that she
has tricked him. He thought the meeting was about their
son’s school trip. Bing says he wants he will meet with you
now to explain how stupid his wife to have made the
appointment.
• Role play - one acting as the therapist, another two as Bing
and Ivy. Use strategies to deescalate the situation and ensure
safety.

22. Part Two
Personality Disordered
Clients

23. General PD Criteria
• Enduring emotion/behaviour different to their culture
• Obvious in any 2 of the following:
– Thoughts
– Emotion
– Relationships between them and others
– Impulse control
• Rigid and spreads across many social situations
• Causes distress or problems to the person
• Established early in life and long lasting
• Not caused by another mental health condition
• Not due to drugs or physical condition

24. Personality Disorders
What are they?
– Pervasive and inflexible emotions/behaviours
– Generally start in childhood or adolescence
– Stable
– Causes distress or impairment
– Differs markedly from cultural norms
Grouped into 3 clusters
– Cluster A (odd)
– Cluster B (dramatic)
– Cluster C (anxious)

25. Common coexisting PDs with PG
Personality Disorder PGs (lifetime) Non-PGs
(lifetime)
Paranoid PD 24.1% 3.4%
Schizoid PD 15% 2.7%
Schizotypal PD 29%-38% 3%
Borderline PD 3%-70% 2%
Conduct disorder 41% 7%
Histrionic PD 13.1% 1.5%
Antisocial PD 23.3%-40% 2%-4.6%
Narcissistic PD 11%-57% 1%

26. Common coexisting PDs with PG
Personality Disorder PGs (lifetime) Non-PGs
(lifetime)
Avoidant PD 14% 2% 0.5%
Dependent PD 3.2% 0.5%
Obsessive-compulsive PD (1%) 28.5% 6%
Passive Aggressive PD 14%-35%
Any personality disorder 19.7%-92.7%

27. Exercise 4: PD Symptoms
In groups, match the symptoms or criteria against the
Personality Disorder cards

28. Personality disorders are commonplace
in addictions: How do I detect a PD?
Personality disorders are commonplace in addictions:
• Has the client got odd, dramatic or anxious behaviours?
• Are they rigid perceptions of themselves or the world that
care causing them problems?
• Did these perceptions start early in their lives?
• Not situation specific, ‘shorter’ term (e.g depression,
anxiety)
• Client may have low awareness that it is problematic

29. Exercise 5: Rick
• Rick is a 35 year old male who has been referred to your
service by the Court following being sentenced to Intensive
Supervision for misuse of client funds he managed for his
employer. When you meet him he says that his ‘problems’ are
in the past, and that his situation only occurred because the
client was too stupid to see the ‘investment’ through to the
end (unauthorised share levered contracts). He talks of his
ability to make millions for others, and that his skills are not
appreciated. He asks what qualifications you have and,
leaning back smiling, asks have you ever had a client like
him?
• What personality traits/disorder is he displaying?
• What boundaries and safeguards should you as a counsellor
establish?

30. Exercise 6: Gary
• Gary is bought to this session by his mother who sits in the
waiting room. He is in his early 20’s, is ‘between jobs” after
dropping out from study. As you do the initial assessment,
Gary says the pokie and Casino venues “all know him” and try
to “gang” up on him because he wins too much using a
complicated system he will not reveal. He says he will not
give you his date of birth as it will probably end up getting and
shared with the Casino and the government and he doesn’t
want them to have any more information than they already
have. He asks you what you have written down so far and
who the notes are for.
• What personality traits/disorder is he displaying?
• What boundaries and safeguards should you as a counsellor
establish? In small groups discuss how you might work with
Gary.

31. Summarising the Day
Mandated clients:
– Common and becoming more so
– Intensive supervision, diversion, exclusion orders
– Proven strategies show they can be helped
– Aims may coincide = avoiding the consequences of
problematic gambling
– Is insight necessary?

32. Summarising the Day
Difficult clients
– Why are they difficult?
– Strategies involve avoidance of confrontation,
acknowledgement and setting boundaries
– Is ‘difficult’ an obvious example of client resistance, a
commonplace place for PG clients

33. Summarising the Day
• Personality disorders
• What they are
• Which ones are commonly found with PG
• What is the effect when they coexist?
• Approaches
• Windup