Challenging Personality Challenging Personality DisorderDisorder

Dr Matt Bruce, Clinical PsychologistDr Matt Bruce, Clinical Psychologist

Belinda Coulston, Forensic PsychologistBelinda Coulston, Forensic Psychologist

FIPTS Community TeamFIPTS Community Team

Challenging views of PDChallenging views of PD‘‘Patients with borderline personality [disorder] have unique Patients with borderline personality [disorder] have unique character problems that make treatment extremely difficult. They character problems that make treatment extremely difficult. They are often negativistic, demanding, and self-destructive…They are often negativistic, demanding, and self-destructive…They frequently have an insatiable need for special attention. (Kaplan, frequently have an insatiable need for special attention. (Kaplan, 1986, p. 429)1986, p. 429)

‘‘It’s easier to label these people as – and maybe it’s safer to think It’s easier to label these people as – and maybe it’s safer to think that they are - a different species, that they are not human beings that they are - a different species, that they are not human beings like us, like you or me. (DSPD nurse, Bowers, 2002, p.38)like us, like you or me. (DSPD nurse, Bowers, 2002, p.38)

‘‘They will try to manipulate, play one against the other, which They will try to manipulate, play one against the other, which they are expert at because they have been doing that for far they are expert at because they have been doing that for far longer than anyone can imagine’ (DSPD nurse, Bowers, 2002, longer than anyone can imagine’ (DSPD nurse, Bowers, 2002, p.40)p.40)

What are the challenges?What are the challenges?

A colleague is in tears because of a client’s negative reference to her family

A client won’t come to another

group session unless a

facilitator is removed

A client calls his care coordinator

stating that he is going to kill himself

and then hangs up

Patients refuse to engage in treatment until the attitudes of other group

members is “sorted”

A client has

“sacked” his therapist

because she was 5 minutes late

for a session. He has already

“sacked” his family, wanting

no more contact, because they

commented that visits had

been difficult for

his mother

A client is continually calling the office for support and demanding

that he is called back by numerous members of the care team

A client is demanding that he is

re-housed immediately, threatening

to take an overdose if it doesn’t happen

A client states that he will only talk to the most

experienced and qualified members of the team.

A client swoops into his

session on roller blades

wearing a black cloak

and dark sunglasses

A client stands outside the

office listening to his music through

headphones and singing loudly

What Makes PD Challenging?What Makes PD Challenging?

Murphy and McVey (2003) identified five core themes Murphy and McVey (2003) identified five core themes they believed to underpin the challenges of working with they believed to underpin the challenges of working with clients with PD:clients with PD:– Clients are Clients are less reinforcingless reinforcing and more demanding and more demanding

than mental illness clientsthan mental illness clients– The role of caring for clients with PD is high in The role of caring for clients with PD is high in

relational conflictrelational conflict– Working with clients with PD is Working with clients with PD is traumatisingtraumatising– Staff Staff trainingtraining does not adequately prepare nurses for does not adequately prepare nurses for

such worksuch work– Staff require Staff require specific skills and qualitiesspecific skills and qualities

Manipulation and PDManipulation and PD

Patients with personality disorder are notorious for their Patients with personality disorder are notorious for their capacity to manipulate staff and split staff groups or capacity to manipulate staff and split staff groups or hospitals (Murphy & McVey, 2003)hospitals (Murphy & McVey, 2003)

Manipulation by patients with PD has been viewed as the Manipulation by patients with PD has been viewed as the most significant challenge to individuals working in PD most significant challenge to individuals working in PD servicesservices

Bowers (2002) found that 75% of staff reported Bowers (2002) found that 75% of staff reported manipulative behaviour as constituting the greatest manipulative behaviour as constituting the greatest difficulty they faced working with individuals suffering from difficulty they faced working with individuals suffering from PDPD

Manipulation Hexagon Cont.Manipulation Hexagon Cont.

BullyingBullying: includes a variety of methods used to exert pressure on staff member : includes a variety of methods used to exert pressure on staff member to comply with patients’ expressed wishes and desiresto comply with patients’ expressed wishes and desires

CorruptingCorrupting: Tempting staff members with the fascination of the forbidden or : Tempting staff members with the fascination of the forbidden or direct corruption through escalating bribery, using money, drugs or other favours direct corruption through escalating bribery, using money, drugs or other favours as paymentas payment

ConditioningConditioning: The increasing erosion of the professional and objective nature : The increasing erosion of the professional and objective nature of the staff-patient relationship (e.g., flattery, show of vulnerability, sympathy, of the staff-patient relationship (e.g., flattery, show of vulnerability, sympathy, protection, humour, assertion of PD perspective)protection, humour, assertion of PD perspective)

CapitalisingCapitalising: This involves exploitation of available systems by the patient to : This involves exploitation of available systems by the patient to the fullness possible extent using lies and deceptionthe fullness possible extent using lies and deception

ConningConning: This refers to exploiting the ignorance, lack of knowledge, or basic : This refers to exploiting the ignorance, lack of knowledge, or basic presumption of trustworthiness, mainly of new staffpresumption of trustworthiness, mainly of new staff

DividingDividing: Can be understood as the creation of antagonism and conflict others : Can be understood as the creation of antagonism and conflict others by telling lies, falsehoods or exaggerations of different sorts to different partiesby telling lies, falsehoods or exaggerations of different sorts to different parties

Manipulation Hexagon Cont.Manipulation Hexagon Cont.

Instrumental manipulationInstrumental manipulationDefined as transparent in motivation. Mobilised to acquire objects Defined as transparent in motivation. Mobilised to acquire objects that cannot be easily gained in any other way. This form of that cannot be easily gained in any other way. This form of manipulation is very common in secure-prison environments as manipulation is very common in secure-prison environments as staff are often seen as representing a system which holds them staff are often seen as representing a system which holds them captive against their willcaptive against their will

Interpersonal manipulationInterpersonal manipulationDefined as reflecting absent, obscure, bizarre, trivial goals, or Defined as reflecting absent, obscure, bizarre, trivial goals, or that the strategy is so self-defeating that aim must be that the strategy is so self-defeating that aim must be unconscious. Such manipulation is therefore thought to be unconscious. Such manipulation is therefore thought to be mobilised in order to express the desire to dominate and acquire mobilised in order to express the desire to dominate and acquire feelings of self worth; to be intimate with the person being feelings of self worth; to be intimate with the person being manipulated; to express anger/rage in response to staff manipulated; to express anger/rage in response to staff members’ reactionsmembers’ reactions

Staff Responses Staff Responses

FailureFailure

AngerAnger

CompassionCompassion

AvoidanceAvoidance

MistrustMistrustCareCare

BlameBlame

ManipulationManipulation

FrustrationFrustration

EmpathyEmpathy

ShameShame

GuiltGuilt

CoercionCoercion

Burn outBurn out

InsightInsight PunishmentPunishment

ResentmentResentment

NeglectNeglectSympathySympathy

ConfusionConfusion

IsolationIsolation

AnxietyAnxiety

AbsenteeismAbsenteeism NegativityNegativity

IncompetenceIncompetenceFearFear

UnderstandingUnderstanding

Explanations of patients’ behaviour Explanations of patients’ behaviour 1.1.

Individuals with PD are manipulative and deceitful in order to Individuals with PD are manipulative and deceitful in order to cheat and use other peoplecheat and use other people

They acquire enjoyment and pleasure out of causing pain and They acquire enjoyment and pleasure out of causing pain and distressdistress

They are inherently bad and like to provoke others as a gameThey are inherently bad and like to provoke others as a game

The manipulative act was a personal attack. It reflected the staff The manipulative act was a personal attack. It reflected the staff members inherent weaknesses making them feel very shamefulmembers inherent weaknesses making them feel very shameful

Trying to divide staff by inventing incidents that did not take Trying to divide staff by inventing incidents that did not take place is an attempt to get us into trouble and undermine our place is an attempt to get us into trouble and undermine our professionalismprofessionalism

Explanations of patients’ behaviour Explanations of patients’ behaviour 2.2.

‘‘Manipulative’ strategies are deployed to activate, explore Manipulative’ strategies are deployed to activate, explore and master disturbances in the early attachment relationshipand master disturbances in the early attachment relationship

The early primary needs were never voluntarily or intuitively The early primary needs were never voluntarily or intuitively met by the attachment figure/s. met by the attachment figure/s.

Their attachment figures were, and subsequent relational Their attachment figures were, and subsequent relational templates are, often frightening, chaotic and unpredictable. templates are, often frightening, chaotic and unpredictable.

The use of excessive splitting and projection has been The use of excessive splitting and projection has been developed from a very young age in order to feel safe and developed from a very young age in order to feel safe and generate the sense of a cohesive selfgenerate the sense of a cohesive self

Patient Responses to…Patient Responses to…

FailureFailure

ShameShame

ConfusionConfusion

IsolationIsolation

AnxietyAnxiety

AbsenteeismAbsenteeism

FearFear IncompetenceIncompetence

ResentmentResentment

Patient Responses to…Patient Responses to…

AngerAnger

AvoidanceAvoidance

MistrustMistrust

BlameBlame

ManipulationManipulation

FrustrationFrustration

CoercionCoercion

Burn outBurn out

PunishmentPunishmentNeglectNeglect

NegativityNegativity

Patient Responses to…Patient Responses to…

CompassionCompassion

CareCare

EmpathyEmpathy

InsightInsight

SympathySympathy UnderstandingUnderstanding

Interpersonal ChallengesInterpersonal Challenges

The essence of these patients’ difficulties is The essence of these patients’ difficulties is interpersonal disturbancesinterpersonal disturbances

It is essential that the specific nature of these It is essential that the specific nature of these challenges is clearly formulated in order to be challenges is clearly formulated in order to be correctly understood and overcomecorrectly understood and overcome

Most significantly, these challenges should be Most significantly, these challenges should be viewed as important viewed as important communicationscommunications about both about both patients’ and staff members’ internal states, patients’ and staff members’ internal states, beliefs and perceptionsbeliefs and perceptions

Conclusions Conclusions

The challenges faced by staff who care for and treat people The challenges faced by staff who care for and treat people with PD are complex and demandingwith PD are complex and demanding

Staff views about the nature and course of PD has an Staff views about the nature and course of PD has an enormous impact on how they manage these challengesenormous impact on how they manage these challenges

It is important when working with patients with PD to It is important when working with patients with PD to interpret challenges as opportunities for gaining a better interpret challenges as opportunities for gaining a better understanding of their specific relational difficulties. Looking understanding of their specific relational difficulties. Looking for the need that the behaviour may be attempting to meetfor the need that the behaviour may be attempting to meet

For example, rather than interpreting a patients’ behaviour For example, rather than interpreting a patients’ behaviour as ‘attention seeking’, it may be more advantageous to as ‘attention seeking’, it may be more advantageous to understand it as ‘attachment seeking’ understand it as ‘attachment seeking’

References References

Bowers, L. (2002). Bowers, L. (2002). Dangerous and Severe Personality Dangerous and Severe Personality Disorder. Response and Role of the Psychiatric TeamDisorder. Response and Role of the Psychiatric Team, , London: RoutledgeLondon: Routledge

Kaplan, C. A. (1986). The challenge of working with Kaplan, C. A. (1986). The challenge of working with patients diagnosed as having a personality disorder. patients diagnosed as having a personality disorder. Nursing Clinics of North America, 21Nursing Clinics of North America, 21, 429-438, 429-438

Murphy, N. & McVey, D. (2003). The challenge of Murphy, N. & McVey, D. (2003). The challenge of nursing Personality-disordered patients. nursing Personality-disordered patients. The British The British Journal of Forensic Practice, 5,Journal of Forensic Practice, 5, 3-18 3-18