Personality Disorders:

learning how to engage better

Dr Andrea Williams Consultant Psychiatrist in Psychotherapy

Personality Disorder and Homelessness Team

NHS Greater Glasgow and Clyde

• People with personality disorder have by

definition a high rate of self harm

• 10% lifetime risk of suicide

• More difficult to engage with than people

with other mental health diagnoses

• Evoke strong emotional responses in staff

WHY?

• Controversies over classification

• Stigma

• Staff feel unskilled

and

• Something “funny” going on..…

(some psychotherapy ideas can help us)

“the sufferer who frustrates a keen therapist by

failing to improve is in danger of meeting primitive

human behaviour disguised as treatment”

Tom Main – the ailment (1957)

“because borderline patients use defences likely to

evoke powerful emotional states in the therapist,

countertransference reactions often develop rapidly,

with great immediacy and intensity”

Otto Kernberg

Splitting

tension and disagreement

Person

with PD

Good

staff

want to

rescue

Bad Staff

more

punitive

Attachment Framework Bowlby, Adshead (1998)

• Staff as attachment figures

• Attachment behaviour results in attaining

or maintaining proximity to an attachment

figure

• Biological basic survival instinct

Attachment (cont)

• Attachment bonds develop with staff

• Problems when attachment behaviour

stimulated: separations, change of staff,

discharge

• DSH often after an interaction with person

the patient is attached to

Attachment - Institutional

• Attachment difficulties can also be

expressed by institutions as ambivalent

expectations

• Services encourage dependence and

independence at the same time, or quickly

in succession

Learning from Enquiries

• Common theme of poor communication

• Fertile ground on which projections of

disturbed pts acted out

• Team reflects internal fragmentation

• Pt’s worst fears about containment of

destructive impulses realised

• Become frightened/ hopeless/ violent

“Malignant Alienation”

M Whittle 1997

Process of deterioration in relationships with

staff

Failure of therapeutic alliance

Patient perceived as difficult/ manipulative

Precedes suicide

What can training achieve?

Change in:

knowledge

skills

attitude

Can people think more about what is going

on for the person with personality

disorder?

and for themselves,

and their teams?

reflective practice

transference and

countertransference

splitting

Can people keep in mind the possible

origins of “difficult” behaviour?

and think about development/

early attachment

attachment

genes

temperament

Can people shift to a more empathic position?

empathy

curiosity

The importance of early relationships

The Still Face Experiment

Synapse density over time Corel, JL. The postnatal development of the human cerebral cortex. Harvard University Press 1975

Treatment/ Management (BPD)

• Growing evidence for psychotherapy

approaches

• Long-term, fairly intensive treatment

• Not widely available

• Growing consensus on GENERAL

PRINCIPLES for good care

Managing BPD

Empathi

c

consistent

boundarie

d

Cold/

hostile

inconsisten

t

Un-

boundaried

Staff Attitude

• Enthusiasm for the work

• Willingness to work in a team

• Ability to maintain hope in face of adversity

• Inquisitive and curious stance

• Ability to focus on patient’s subjective

experience

Bateman & Krawitz 2013

Staff Temperament

• Patient

• Compassionate

• Sensitive

• Robust sense of self

Principles for managing a crisis

• maintain a calm and non-threatening attitude

• try to understand the crisis from the person’s point of view

• explore the person’s reasons for distress

• use empathic open questioning, including validating statements

• Identify the onset and the course of the current problems

• seek to stimulate reflection about solutions

• avoid minimising the person’s stated reasons for the crisis

• refrain from offering solutions before receiving full clarification of the problems

Partnership working

• Improve knowledge, understanding and

attitudes within and between

organisations

• Share work on crisis planning

• Understand why this is not easy, but is

particularly important for this patient group