For Designing a Treatment Plan

As we have highlighted in earlier chapters, older adults with personality disorders in general are likely to have problems fitting into formal institutions such as hospitals, rehabilitation facilities, and skilled nursing facilities. Generally, the more formal the institution, the more rigid the template defining the personality traits of those favored by the system. The staff working in these institutions also reflect this template for them to be valued by the system. Thus the GOF model can be conceptualized as one of parallel processes, identifying the favored/devalued worker as well as the favored/devalued patient (resident).

Informal systems, by comparison, are generally better able to tolerate greater deviance in the template than are the formal systems. This allows the patients (residents) more degrees of freedom before they are diagnosed with pathology. These informal systems (e.g., church groups, neighbors, or kinship networks) are thus less likely to identify a personality disorder in favor of accepting the individual's personality style.

The goals for treatment include what should be included as well as what should not be included. What should not be included is a goal to restructure the individual's personality. What should be included, generally, is whatever it is that can be anticipated to ease his or her way at this point in life and, more specifically, whatever it is that can be anticipated to enable him or her to secure and accept what help is indicated.

The purposes of treatment include the relief of symptoms, the accommodation of necessary change, the tolerance of interdependence, and the support of healthy narcissism. To conclude this chapter, we offer several guiding questions for psychother-apeutic work.

The first question to guide the treatment plan is: Where is the pain? For the older adult with a personality disorder, the pain often lies between the individual and the system (or individual) providing care.

The next guiding question is: Where might we enter the system to maximally reduce distress (pain) and minimally meet resistance? How might the system be asked to accommodate the patient (resident), and how might the patient (resident) be asked to accommodate the system? This is not suggesting an adversarial stance. Rather, the goal is to relieve distress, which is being experienced by both.

The next question is: What is the smallest movement, amount of change, required to reduce the distress?

The final question is: How would this change be recognized? To address the guiding questions, consider these possible treatment/intervention options:

■ Change the demand on the individual to be more congruent with his style. For example, can the system be flexible in changing the demand that "men must wear ties and jackets in the dining room" so that the individual(s) whose identity is "a casual guy" or someone who challenges dress codes on principle will not get into a regular struggle with staff at mealtime? Can the physical therapy department allow the individual with strong privacy needs to do her exercises in her room or in the PT room when others besides the therapist are not around?

■ Put the dominant, positive traits to work. It frequently appears that difficult older adults become more difficult when their dominant traits become "unemployed." The intervention then suggests putting these traits back to work in an adaptive way or, at least, in a less maladaptive way. Recall the man with Obsessive-Compulsive Personality Disorder being cared for at home by a visiting nurse. His dominant traits were put to work in that setting and the "fit" was excellent. This changed when the man was placed in a facility where these same traits were now tolerated and became unemployed resulting in a poor fit in that setting. The message is, where possible, to put the dominant traits to use in a positive way.

■ Inhibit the expression of the negative traits. This can be accomplished in two ways. One way is to avoid "fanning the flames" by what is done, or not done, to provoke the individual. This refers to the strong reactions individuals with personality disorders can induce in us, indeed in entire systems. The use of supervision and consultation can be helpful for purposes of processing and assisting our self-monitoring so that we are less likely to act out their psychopathology or to punish them for it.

■ Provide what "went missing" and has been identified as the precipitant in the escalation or worsening of their condition. Often this harkens to the loss of someone in their life who had served the functions of buffering, bolstering, or binding for them. The interventions suggested then are to address the loss and to resupply the function in some way that fits the current situation.

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