Relationship ManagementSpectrum The Personality Disorder Service for Victoria

Adapted from “Relationship Management of the Borderline Patient”By David Dawson, M.D.

Harriet L. MacMillan, M.D.

Early Childhood to Current ContextConceptual Leap

So far we've associated personality disorder symptoms to developmental deprivations

oinvalidating environments,

oearly childhood abuse,

oneurobiological developmental implications

Relationship Management

While holding to a rich developmental formulation of personality disorder, treatment intervention is focused less on developmental origins and more on current enactments

Unstable presentations are seen more in the light of iatrogenic reinforcement within treatment systems

Dramatic and Dysregulated states the considered the product of the interplay between patient and treatment context.

The Self-System

Those who have consistent “good enough” relationships, throughout childhood and adolescence, developed self systems that are relatively

ounconflicted,

ostable,

oclearly boundaried

This leads to normal regulating capacities

oemotions,

othoughts

orelationships

This is due to there being a set of stable experiences that are effectively encoded into both explicit and implicit memory systems.

These guide internal and external states.

This provides a stable flow of historical (internalised) experiences which in turn allows for a continuous stable self-definition

Personality Disordered People and Early Relationships

The Impaired Self-System.

This leads to conflicted, unstable, poorly boundaried past experiences lack an internal reservoir of stability.

Memory systems are impaired (implicit memory particularly so), and they suffer associated neurobiological deficits that impair emotion regulation

Self systems relating to continuity, unity, embodiment and agency are impaired.

Without the reservoir of inner stabilising experience, they are inordinately dependant on current time interpersonal relating for self-definition.

Without relationship on tap they easily panic and become symptomatic (e.g. abandonment anxieties)

BUT…

In the absence of historical warmth safety and reciprocity, their experience of relating is one of a battle ground for survival and control

Relationships quickly become the place where maladaptive relationship strategies are enacted

Conundrum: self system not adequate for autonomous functioning thus need for literal presence of “other”, but early maladaptive relating quickly becomes activated in relation to other, creating withdrawal and alienation. (Freud - repetition compulsion: Pavlov - conditioned response)

Maladaptive Relationship Strategies

Argument

Passive resistance,

Non-cooperation,

Threats,

Chaos,

Self-harm

Suicidal enactments

Conclusion:

Here and now relationship is desperately and repetitively sought to compensate for poor internal capacity for self definition

Without this client becomes anxious and symptomatic (abandonment anxiety).

But the very relationship vital for self definition becomes quickly characterised by re enactments of early dynamics: argument, passive resistance, non-cooperation, threats, self-harm etc.

Emerging Relationship Dynamic

CompetenceIncompetence

Inter-DependencyArgument

Intimacy Passive resistance

Spontaneity Non-cooperation

Awareness Threats

Responsibility Chaos

Stability/Permanence Self-harm

Suicidal enactments

Three Goals of Relationship Management

•Do no harm

•Reduce chaos and curtail the distorted relationship between patient and health care institutions

•Consider Therapy

The worst and most damaging behaviors of personality disordered patients occur when the competence - incompetence dynamic is being enacted

“Incompetence” behaviors become dangerous currency in the repetitious negotiation over control and power

The aim therefore is to stimulate switch from patient incompetence to patient competence.

Switch Method - “No-therapy” Therapy

Therapy often becomes the unhelpful arena for enactments of the competence - incompetence dynamic power play (repetition compulsion)

Yet withdrawal of helping relationship elicits extreme abandonment anxiety as the patient becomes desperate for a “self defining relationship

Offering a form of therapy without the content addresses the relational need while avoiding the competence-incompetence dynamics

Dawson and MacMillan call this “No Therapy” Therapy

“Not-therapist’s” Role

The Therapist is inherently caught up in distorted interpersonal negotiations i.e. he/she assumes stance of responsibility, control and competence leaving the client in their favored role of incompetence

The “Not-therapist” explains to clients that their job is not to help… but to determine what kind of help they might benefit from, what they want, from this or other agencies.

No Therapy Assumptions

It is assumed that the patient is responsible and competent person.

Patients are given ultimate control over the definition of their problems and proposed remedies.

Proposed remedies that promote or reinforce the patient’s assumption of incompetence are not taken up.

“Not therapist” needs to tolerate personal doubts and anxieties…it will take time for the client to end the currency exchange (give up the repetition) and adopt competency.

The “no-therapy” therapyoffer:

Regular contact “Not sure if I have any useful advice, but I could listen”.

Emphatic neutrality without anxiety or concern.

No probing, uncovering, offering advice, guidance and interpretation.

No access or only very limited access hospital admissions

“Not-therapist” in order to aid client and distance her/himself from the therapist role, spends time noting, clarifying, specifying and defining the client’s problems and wishes as they revealed; nothing can be left vague and abstract.

Demands or threats are often met with benign silence followed by limited inquiry such as “so …what might help right now”

Slowing down the pace of interview and using silence can help patient switch to competency.

Suicidal Impulsiveness.

The directive, problem solving approaches used successfully with acutelysuicidal clients can actually increase risk of self-harm and suicidal behavior with chronicallysuicidal personality disordered clients

Leading to a battle over power and control

Leaving the client with a sense of relationship loss (anxiety symptoms)

Reinforcing the idea that the client needs to be rescued (incompetence)

Self harm therefore needs to be tolerated

Hospitalization is reserved for management of acute symptoms of high prevalence mental illness (typically psychosis, major depression).

Requires specialist psychiatric evaluation

Prerequisites for Applying This Model

A belief that client is at least potentially competent and responsible.

Self Awareness; must not use this approach as covert way of getting rid of patient.

Compliance with organisational context (roles, policies, tolerances)

Regular external supervision or consultation.

Whole system agreement with approach to prevent conflict, mixed messages and splitting.

Stance and Techniques

Avoid assigned role position (power-competent)

Always assume the client is a responsible, competent adult

Overtly present and discuss the social contract

Assume a warm benign but neutral position

Overtly set absolute limits or boundaries according to agency role, resources and polices

Set consequences you are able to deliver

Be carefully honest

Apply principles to all issues (medication, mutilation, suicide impulses, drug/alcohol abuse, length of sessions

Bring family members and other helpers, other agencies and third parties into the approach if possible

Otherwise apply the same management principles to them.