Therapeutic Interaction with an Older Personality Disordered Patient

Abstract

This study reflects an assessment of the relationship between change in defensive functioning and change in the therapeutic interaction during an eight-year treatment episode of an older personality disordered woman. The patient, Ms. Q, possessed schizoid, avoidant, and depressive personality disorders as well as major depression as assessed by the Millon Clinical Multiaxial Inventory-III (MCMI-III). At the end of the treatment episode, Ms. Q still possessed an avoidant personality disorder and significant depressive personality traits but no longer possessed clinically significant schizoid traits or major depression. Ms. Q made significant positive change in her adaptive defensive functioning as assessed by the Defense Mechanism Rating Scale (DMRS). Through time-series analysis it was discovered that positive change in adaptive defenses was predicted by increases in a specific type of therapeutic interaction as assessed by the Psychotherapy Q Sort (PQS). In this therapeutic interaction the therapist in a didactic and advice-giving manner highlighted the patient's role in a problem in a clear and coherent way that could be perceived as tactless. Time-series analysis revealed a reciprocal relationship in which positive changes in adaptive defenses predicted further increases in that particular quality of therapeutic interaction.

Personality Disorders in Late Life

“…Given its dimensional basis and age-specific design, the HAP may be the most appropriate single instrument to use. Finally, evidence suggests the efficacy of several types of psychotherapy for treating PDs in older adults, including dialectical behavior therapy, psychodynamic psychotherapy, and cognitive therapy such as schema-focused therapy and cognitive model for behavioral interventions (Fassbinder et al, 2016; Josephs et al, 2014; Lynch et al, 2007; Osterloh et al, 2018; Videler et al, 2014). We recommend using dialectical behavior therapy and schema-focused therapy in older adults with PDs able to engage with therapy, and we recommend using cognitive model for behavioral interventions if the patient has cognitive impairments or other barriers to directly engaging in therapy.…”

“…A study of expert consensus indicated that personality-changing, adaptation-focused, and supportive-structuring treatment approaches are useful overall in geriatric psychiatry (Rosowsky et al, 2018). Psychotherapies studied in treating PDs in older adults include dialectical behavior therapy (DBT), psychodynamic psychotherapy, and cognitive therapy such as schema-focused therapy and cognitive model for behavioral interventions (Fassbinder et al, 2016; Josephs et al, 2014; Lynch et al, 2007; Osterloh et al, 2018; Videler et al, 2014) (see Table 2).…”

“…Psychodynamic psychotherapy was also studied in older adults. In a case study of an older adult with schizoid, avoidant, and depressive personality disorder, psychodynamic psychotherapy using a didactic manner induced remission of the patient’s schizoid traits over 8 years (Josephs et al, 2014). However, psychodynamic therapy may not be appropriate for patients with low motivation, limited capacity for self-reflection, or significant cognitive impairment (Balsis et al, 2015).…”

Interaction structures formed in the psychodynamic therapy of five patients with borderline personality disorder in crisis

“…The factor analysis yielded four conceptually interpretable factors (i.e., interaction structures), which accounted for over 34% of the total variance. This low percentage is consistent with other researchers using the PQS (35% – Coombs et al ., , p. 238; 43% – Jones et al ., , p. 387; 37% – Jones & Price, , p. 39; 34% – Jones & Price, , p. 47; 42% – Jones & Pulos, , p. 313; 38% – Josephs & Fatzer, , p. 17). Note that only eigenvalues ≥1 were also considered to determine the number of factors.…”

Agency in avoidant personality disorder: a narrative review

“… Josephs et al (2014) describe a successful confrontation of relational difficulties in the therapeutic relationship in their case study: When the therapist confronts the patient with her help-rejecting complaining stance and her passivity’s role in her interpersonal problems, helps her find new ways of solving them and supports her engagement, the patient uses more adaptive defenses such as self-observation. She can self-reflect on how her help-rejecting complaining serves her poorly.…”