Personality Disorder Risk and Protective Factors
There are multiple risk and protective factors that contribute to the development and avoidance of personality disorders. In treatment, we often overlook examining the risk and protective factors, but these are critical components that can hinder or promote therapeutic success.
A risk factor is a variable associated with an increased probability of developing a particular disease or disorder, in this case, a personality disorder. The precise cause of personality disorders is not known, but certain factors seem to increase the risk of developing or triggering personality disorders. Risk factors are often evident in childhood and put the individual on a trajectory of pathology to develop a personality disorder later in life.
The more risk factors an individual has, the greater the probability he or she will develop a personality disorder. There is no single factor that is causal for developing a particular personality disorder. Personality disorders are typically derived from several adverse environmental experiences in combination with genetic factors (Huff, 2004). The seven risk factors (Lenzenweger, 2010; “Personality Disorders,” Mental Health America, 2013; Silk, 2003) included in the checklist that follows are not hard-and-fast rules but singular components that are additive to the overall probability of developing a personality disorder.
Just as there are risk factors that promote personality disorders, there are protective factors that insulate an individual from developing them. These protective factors can also be used during the course of treatment as resources to help your client get through difficult times. Knowledge of your client's protective factors can enhance the treatment that is being done to control and attenuate the behavioral expression of the personality disorder(s), whether it is borderline, antisocial, histrionic, and/or narcissistic personality disorder.
Protective factors come from many different aspects of an individual's life and his or her genetic makeup (Huff, 2004). Protective factors can also be developed from the client's past, present, and current therapeutic experience. Utilizing aspects of the protective factors that are present assists the therapist during times of crisis and when therapy becomes highly stressful. These are client resources that the therapist can use to help the client move through difficult times and that can and should be enhanced during the course of treatment.
One of the most critical protective factors is having a secure attachment base. Secure attachment has been linked with acceptable emotional expression, strong peer relations, positive social skills, greater understanding of other people's emotions, greater sharing, less aggressive and antisocial behavior, closer friendships, being well liked by others, and better academic performance.
The following case study illustrates how to best use the information gathered from the checklist (on page 18) in treatment.
Yolanda is a 27-year-old woman who has been in treatment for the past five months and has been accurately diagnosed with histrionic personality disorder. Her parents passed away following a home invasion when she was seven-years-old. She was then placed in foster homes, where she was abused and found that the best way for her to feel safe was to be “in the spotlight.” She has difficulty maintaining employment, friendships, and romantic relationships.
Yolanda completed the Risk and Protective Factors Checklist and identified the following: verbal, physical, and sexual abuse during childhood, loss of parents through death or traumatic divorce during childhood, family history of personality disorders or other mental illness, being well liked by others, good grades in school, ability to read well, and exposure to positive role models.
Yolanda has several risk factors we need to be aware of, as she has just lost another job. She was let go because she slept with her boss in the hopes of earning a very high-profile promotion after being at the job for only three months. She tells her therapist that losing this promotion is just like losing her parents and being sexually abused all over again because she feels lost and forgotten. You know that her father was diagnosed with major depressive disorder and had Cluster B traits. Yolanda tells her therapist that she feels as though she cannot continue on this path and that her future is becoming more uncertain and “blurry. “ The therapist mentions her ability to meet new people, how she is often liked by others, and how she is able to learn new skills and create opportunities for herself. As Yolanda and her therapist discuss these issues, the therapist asks her about her positive role models. Yolanda states that she sees her therapist as a positive role model with whom she feels connected, and that that she is connected to her and that she can be open and honest when she loses opportunities and when life becomes “blurry.”
The case study illustrates the key factors that are exacerbating and attenuating Yolanda's issues. The most salient portion of the checklist in this example is that Yolanda marked those factors herself—the therapist did not have to spend time in treatment looking for risk and protective factors. The checklist helped save time in treatment and also provided useful data to both Yolanda and the therapist to prevent what could have been a significant deterrent to therapeutic success.
Next Steps
The Risk and Protective Factors Checklist can be given directly to the client, or the therapist can fill it out for the client. An alternative method is for both client and therapist to fill it out separately and then compare what factors they each indicated. This provides an opportunity for client and therapist to discuss risk and protective factors that are impacting the client currently and may illuminate the root of symptoms present in the client's life.
In the checklist, factors related to secure attachment are indicated by double asterisks (**) and risk factors are indicated with one asterisk (*).
Risk and Protective Factors
Directions: Put a check mark (✓) in the box next to the factor(s) listed here that has occurred in your life. Some of these factors are from your childhood, whereas others are from what is going on now and from your therapeutic experience. Once you have completed the form, return it to your therapist so you both can review it to identify areas of focus during treatment.
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A family history of personality disorders or other mental illness *