HANDOUT: PERSONALITY TRAITS SEEN IN THE HARD-TO-SERVE CLIENT: CHALLENGES FOR THE TREATMENT TEAM Stella L. Blackshaw M.D. FRCPC Professor of Psychiatry University of Saskatchewan

Outline Case History #1, “Kevin” Defense mechanisms used by clients with severe personality disorders Recognizing Splitting and Projective Identification Managing Splitting and Projective Identification

Outline Case History #2, “Margaret” Help-seeking / help-rejecting Chronic suicidal ideation and it’s management

“Kevin” - PERSONALITY CHARACTERISTICS BORDERLINE: Intense, unstable relationships. Unstable self-image. Recurrent suicidal threats. Unstable mood (intense but brief episodes of dysphoria). Difficulty controlling anger.

“Kevin” - PERSONALITY CHARACTERISTICS NARCISSISTIC: Pre-occupied with fantasies of success or brilliance. Believes he is special or unique. Requires excessive admiration. Has a sense of entitlement. Shows arrogant, haughty behaviours or attitudes.

Borderline Personality “Organization” (Kernberg) Characterized by : “Poor ego function” (impulsivity, poor reality testing) Predominant use of immature or primitive defenses: - Denial - Splitting - Projective Identification

SPLITTING - An Unconscious Defense Against Anxiety Splitting of self or others into “all good” or “all bad”. Less anxiety-provoking than viewing self or others ambivalently. Is manifested as polarized attitudes: - towards different people - towards the same person but at different times - towards the self at different times

PROJECTIVE IDENTIFICATION 3-Step interactive process (Ogden): - projection of a (strongly negative or positive) mental representation onto the other person, - believing it to be true (in the moment) and acting towards the other as if it were true, - thus inducing the other person to act in a way consistent with the projection. (a self-fulfilling prophecy)

Recognizing Splitting and Projective Identification The Client: - presents him or herself differently to the same person at different times. - presents differently to different people. The Helping Professional: - may be idealized at one time, devalued the next. - hears the client idealizing or devaluing other staff members. - has intense feelings and may find themselves reacting to the client in ways “not like me”.

Recognizing Splitting and Projective Identification (cont.) Members of the Treatment Team: - have polarized opinions of the client (“are we talking about the same person?”). - take polarized positions about management (“rescue and nurture” vs “confront and set limits”). - have strong feelings about the client and feel strongly about their therapeutic position.

Minimizing Adverse Effects on the Team Be aware of strong countertransference feelings, either nurturing or punitive. Do not get caught up in the patient’s idealization (or devaluing) of you. Do not collude with the client’s devaluing (or idealization) of other team members. Discuss as a team and assume that each member of the team is a reasonable and competent clinician.

CHRONIC SUICIDAL IDEATION Often seen in clients with a history of sexual abuse and Complex PTSD (Herman). A way out, keeping suicide as an option is a comfort, suicidal ideation is a coping mechanism. A communication strategy, (“I feel desperate,- do something!”). Often will not contract for safety, “I can’t promise”, (usually honest!).

Validate feelings of distress, reduce need for patient to prove their distress. Give hope, but minimize polypharmacy and dependency. Problem-solve around other coping strategies and focus on patient’s strengths. Note: easier said than done because of help-seeking / help-rejecting pattern. Management of chronic suicidal ideation (Linehan)

Chronic suicidal ideation - when to worry more: Change from usual presentation. Recent loss, especially of supportive relationship. NOTE: Document reasoning for admitting or not admitting to hospital, e.g. “chronic suicidal ideation with no known change in circumstances, history of hospitalization resulting in regression”.

Work as a Team Resist the urge to be overly critical of others’ management of these challenging patients and difficult situations!

References 1. Gabbard,Glen O. “Psychodynamic Psychiatry in Clinical Practice” 4th Edition. American Psychiatric publishing Inc Herman,Judith L. “Trauma and Recovery”. Basic Books Linehan,Marsha M. “Cognitive-Behavioral Treatment of Borderline Personality Disorder”. Guilford Press Livesley,John W. “Principles and strategies for treating personality disorder”. Can J Psychiatry, Vol 50, No 8, July McWilliams,Nancy “Psychoanalytic Diagnosis”. Guilford Press 1994