Routes into Treatment

Older adults with a personality disorder who seek professional help generally present for symptom relief or to address a specific problem. The problem often reflects interpersonal conflict. They frequently come to treatment secondary to the loss of au tonomy and control or on the strong suggestion of another person on whom they must depend (e.g., an adult child, a housing manager, or a primary care physician; Kean, Hoey, & Pinals, 2004). They do not generally self-refer for psychotherapy because their psychopathology is experienced as syntonic.

Other catalysts to their presenting to treatment include usual, age-related events (i.e., physiological and socioenviron-mental), as well as special events engendered by their personality disorder (Kean et al., 2004). Usual physiologic changes include illness (both chronic and acute), weakening, general slowing, sensory decrements, reduced energy and stamina, and functional decline. Socioenvironmental changes include losses of significant roles and relationships, context changes, and changes in tasks that are required of them. In addition, there exist stage-appropriate existential catalysts, which may develop from an awareness of mortality and concerns about death and legacy.

Role changes and changes in their relationship network also often serve as catalysts. Changes in health status, especially an awareness of a life-threatening condition, can serve to activate, or reactivate, maladaptive behaviors. These potential catalysts, which lead the patient to present for treatment, all indicate that the stressor has outstripped the individual's ability to effectively cope. Frequently, the level of distress escalates after the loss of a significant person who served specific functions relative to the personality disordered individual and affected the actual symptom presentation of the personality pathology.

Let's consider three major types of these functions: buffering, bolstering, and binding. Recognizing and understanding these functions offers great significance for the treatment plan. If a function that limited the expression of pathology is lost, an effective treatment plan would be wise to introduce compensatory or substitute measures whenever possible.

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