Personality Disorders: learning how to engage better · human behaviour disguised as treatment”...
Transcript of Personality Disorders: learning how to engage better · human behaviour disguised as treatment”...
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Personality Disorders:
learning how to engage better
Dr Andrea Williams Consultant Psychiatrist in Psychotherapy
Personality Disorder and Homelessness Team
NHS Greater Glasgow and Clyde
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• 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
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WHY?
• Controversies over classification
• Stigma
• Staff feel unskilled
and
• Something “funny” going on..…
(some psychotherapy ideas can help us)
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“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)
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“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
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Splitting
tension and disagreement
Person
with PD
Good
staff
want to
rescue
Bad Staff
more
punitive
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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
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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
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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
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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
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“Malignant Alienation”
M Whittle 1997
Process of deterioration in relationships with
staff
Failure of therapeutic alliance
Patient perceived as difficult/ manipulative
Precedes suicide
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What can training achieve?
Change in:
knowledge
skills
attitude
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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
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Can people keep in mind the possible
origins of “difficult” behaviour?
and think about development/
early attachment
attachment
genes
temperament
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Can people shift to a more empathic position?
empathy
curiosity
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The importance of early relationships
The Still Face Experiment
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Synapse density over time Corel, JL. The postnatal development of the human cerebral cortex. Harvard University Press 1975
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Treatment/ Management (BPD)
• Growing evidence for psychotherapy
approaches
• Long-term, fairly intensive treatment
• Not widely available
• Growing consensus on GENERAL
PRINCIPLES for good care
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Managing BPD
Empathi
c
consistent
boundarie
d
Cold/
hostile
inconsisten
t
Un-
boundaried
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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
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Staff Temperament
• Patient
• Compassionate
• Sensitive
• Robust sense of self
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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
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• 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
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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
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