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Institutional Example: A Prototypical Skilled Nursing Facility

Three dominant personality traits are suggested as being central to what defines the ideal nursing home resident. These traits address (a) the degree of the resident's characteristic dependency; (b) how much he or she reflects what is "usual and expectable" for a person of that age, gender, and location; and (c) how comfortable that person is functioning as a member of a highly interactive community.

The "fit" to that system can be identified by first noting where along each trait continuum the individual would be expected to fall (marked by X) and then noting where along the continuum the trait is most valued by the system (marked by Y). The alignment of X and Y indicate the "goodness of fit" between the individual and the system:

Autonomous X Y Dependent

Individualistic XY ...Conventional

In this example, the resident (X) would likely be a reasonable fit with the system. However, certain problems might be anticipated. For example, he might need more privacy than the institution generally provides and his need for autonomy and self-control may also not be adequately met. His tendency toward conventional ways of thinking and being would be highly adaptive to the system as this trait is one that is highly valued.

The clinician's individual psychodynamics also affect the movement of the patient between personality style and disorder. This is addressed in countertransference especially to those with difficult personalities. These emotional responses raised in a clinician by a patient have their origins in early relationships, most typically with one's parents. These responses become reactivated and then are reflected in what we "do" (i.e., think, act, or feel) in response to the encounter. These reactions can be positive or negative, but, either way, they affect how we respond to and treat the individual. Examples of positive countertransference include parental and protective feelings, heightened self-esteem, a feeling of specialness, and the development of rescue fantasies. For example, the feeling that we can be the one to help a dependent personality take more responsibility for her actions and achieve greater courage of her convictions is satisfying. We feel that we can repair the characterological fault line where others before us could not, even when we know we cannot. Additional confounds in treating the older adult with a personality disorder are the emotional reactions evoked in us because of the patient's age. Professionals are not immune to ageist contributions to counter-transference.

Examples of negative countertransference with difficult personalities are legend, including feelings of frustration, fear, powerlessness, rage, and the engendering of fantasies of retaliation and escape. As with treating younger people with personality disorders, the mental health clinician is especially likely to experience powerful reactions to the personality disordered patient of any age because powerful reactions are engendered in the patient. The key here is to recall that the reactions evoked in us are often pathognomonic of the personality disorder itself. The manifestation of the personality disorder requires a referent, whether this is task, context, or relationship, and the clinician provides the opportunity for an intimate relationship. Powerful feelings are one way to diagnose the disorder, as are the experience and performance of our professional work in ways that are a departure from our norm.

Consider the "pull" of the individual with a dependent personality for us to go beyond suggesting ways in which she might help herself to actively coaching and directing her every step of the way. Consider the "pull" of the hostile narcissistic personality to deny him the attention and feedback he desperately seeks. It is very difficult to express positive regard when we feel vengeful. Finally, consider the unusual level of worry and concern experienced about the individual with Borderline Personality Disorder who is hinting at self-harm or possibly suicide.

Individual Example

Whether the system of care refers to an individual or to an actual system, the underlying premise of GOF remains the same. That is that each "system" favors certain personality traits and devalues others. For example, a visiting nurse is assigned home visits to an elderly man with brittle diabetes. The nurse is responsible for evaluating him and for designing his treatment plan, monitoring the responses, and making any indicated changes. Her patient is "managing his levels" with outstanding attention to detail, thereby making her job very easy. He is fastidious with his record keeping, the recording of his diet, time of his meals, time and dose of all medications, as well as noting the effects of any changes in the regimen. He is clearly likely to become a favorite patient of this nurse. However, if this same man were to become a resident in a skilled nursing facility, his appraisal may be very different. He could be expected to micromanage the staff at every turn. No institution could be so unvaryingly precise in the timing of medication distribution or in attention to the intricate details of his status and responses. At best, he would be perceived as an annoyance by staff. He would likely come to be regarded as "difficult" when his anger and anxiety escalated in response to his lack of control and the institution's inattention to detail, which had historically served to inhibit his internal experience of distress and outward expression of pathology. In time, he likely would be diagnosed with Obsessive-Compulsive Personality Disorder.

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