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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
• 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