I just finished co-presenting a three day crisis intervention workshop (www.crisisinstitute.com) with my colleague Dr Mike Condra. This is a workshop we offer every October in Kingston and we meet dozens of crisis intervention workers from across the country who come to retool and hone their skills.During this workshop, I am often asked questions related to working with clients who are chronically in crisis.
Most helpers say that they find clients in chronic crisis to be the most draining clients to work with: their seemingly endless demands, high needs, difficulty self-soothing and sometimes poor problem solving skills. The fact that we will work incredibly hard to set up a referral link for them and then the clients will sometimes sabotage the help they are being offered. The self-destructiveness, the splitting...
I have spent a lot of time pondering this challenge and seeking training on working with high need clients, and have the following suggestions for anyone wishing to continue helping such clients and retaining a respectful, helpful stance while not burning out.
1) Let's reframe success: I think that we need to re-evaluate what we consider to be progress or success in therapy with high needs clients. I call this "working with the toenail of the elephant". If, in the middle of a session, you find yourself feeling frustrated and stuck, re-assess your goals. Are you trying to fix the whole elephant at once? Clients in high emotional distress often see many issues as equally urgent and we can get swept away in the energy of this emotional disorganization. Focus the session on the smallest toe of the elephant and work from there.
2) Labeling - Rethinking the use of damaging diagnoses such as Borderline. Are we using the term borderline to refer to the high level of emotional disorganization a client is experiencing, or are we saying borderline to morse code "manipulative, frequent crisis, difficult, treatment resistant" to colleagues? What does it mean for a client to receive that diagnosis when they seek help in the future? Why are men almost never given the borderline diagnosis?
I recall when I was studying at Columbia University my instructor, Dr Farber, told us that borderline personality disorder (bpd) should really be renamed ptsd as the stats on the number of clients with bpd who have experienced childhood abuse and neglect was in the 90%. If this is true, and bpd clients are nearly all trauma survivors, doesn't it then make sense that they use poor self-soothing techniques at times?
3) Do some reading/attend workshops. There are some good books on this topic, as well as some excellent workshops working with clients in chronic crisis.
John Briere, trauma expert and gifted researcher and presenter offers a deconstruction and reconceptualisation of the concept of BPD. He will be presenting in Toronto in November (see sidebar for information) and I highly recommend attending his training for tools and new ideas on this topic and on trauma therapy in general.
Any presentation by the school of Narrative Therapy (Michael White and others) offers a truly refreshing look at "treatment resistance".
If you have other suggestions, feel free to post a comment at the end of this blog entry.
Books:
James Masterson has written a very powerful book called "THE SEARCH FOR THE REAL SELF: Unmasking the Personality Disorders of our Age" (1988). Interestingly, in a personal communication with John Briere, where I asked him how he felt about Masterson's book, he replied that he felt Masterson wasn't compassionate enough towards clients with personality disorders and he found him too labelling. I have to agree with Briere, but Masterson still provides a very helpful angle that focuses on empathy and compassion and uses attachment theory to better understand why some clients are so emotionally disorganised. So, caveats aside, the Search for the Real Self still remains #1 on my book shelf.
Here is a description of the book, excerpted from Masterson's own website:
"Some are outwardly charming, confident, and apparently successful; others are obviously struggling with feelings of inadequacy; while still others lead lonely, isolated lives. All of these individuals suffer from today's characteristic personality disorders - borderline, narcissistic, or schizoid - caught in a knot of self-destructive behavior that eventually sabotages their lives.
Many compensate for their inability to know themselves or establish meaningful relationships with others by forming superficial friendships and pursuing empty life-styles focused on competition for status rather than personal satisfaction, or resorting to alcohol, drugs, and impersonal sexual encounters. Their inner torment has long confounded themselves as well as their colleagues, family, lovers, friends, and even the professionals to whom they turn for help.
Now, in this long-awaited book, renowned psychotherapist James F. Masterson provides the keys to understanding these previously untreatable disorders which have become the classic psychological disturbances of our age, afflicting thousands of modern Americans.
The volume begins by explaining how the healthy real self develops and how it functions to enable the individual to adapt successfully to life's challenges and opportunities, express deepest needs and desires, and find true fulfillment in love and work.
Masterson then describes how the impairment of the real self early in life leads to a personality disorder: when the child's self-expression is not adequately supported, he or she may experience powerful feelings of rejection and fear of the "abandonment depression," precipitating the creation of a protective yet ultimately harmful "false self" whose function is to suppress these painful feelings at the expense of true self-fulfillment, intimacy, or even a clear perception of reality.
Drawing on vivid case histories from his practice, the author examines how this false self behaves at work and in relationships. The narcissist is often intensely competitive and domineering, demanding constant adulation from others to support his inflated false self. The borderline can be clinging and manipulative and frequently pursues an unfulfilling "instant intimacy" with a distant or unavailable partner. The schizoid remains cold and aloof, often immersing himself in work or in a wholly imaginative alternative world rather than engaging in any relationship which would threaten to engulf his fragile sense of himself.
Offering practical guidance and real hope for therapeutic success, Masterson delineates the most effective treatment approaches to help borderline, narcissistic, or schizoid personalities overcome their trauma, reconstruct their psyches, and rejoin the mainstream of life. He exposes the common pitfalls and explains how to develop the necessary and appropriate therapeutic alliance to treat each personality disorder.
While therapy offers hope of overcoming the impairment of the real self, it is not the only area in which the real self can emerge. Individual creativity also offers a valuable avenue for self-expression. In analyzing the behavior of artists with personality disorders, Masterson offers surprising insight into the lives and works of Jean-Paul Sartre, Edvard Munch, and Thomas Wolfe, whom the author respectively refers to as the philosopher, painter, and novelist of the abandonment depression. However, it is not only the creativity of artistic genius that expresses the real self. Masterson argues that the real self is reflected in everyday innovation and creative problem solving which enable us to experiment in work and in love, to find and achieve the sense of a personal meaning essential for a fulfilling life."
(From www.mastersoninstitute.org)
Another excellent resource is Scott Miller. Miller is a clinical psychologist, workshop presenter extraordinaire, co-director of the Institute for Therapeutic Change (www.talkingcure.com) and co-author of "The Heroic Client" a book that looks at empirically valid therapeutic approaches and "what works" in therapy. If you have a few minutes to spare, go visit his website and see for yourself.
I would also suggest reading or re-reading Judith Herman's pioneering book: Trauma and Recovery and Pearlman and Saakvitne's hefty tome Trauma and the Therapist: Countertransference and Vicarious trauma in psychotherapy with incest survivors.
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