Both in and out session, I have witnessed some of the most obscene, ornate, loud and grandest displays of behaviour from the clients I work with, and also from colleagues alike who are therapists themselves. I have come to understand that untoward behaviour is real term in mental health – and depending on our tolerance and acceptance of certain extreme behaviours – we can be sensitive or just simply disapprove of these outrageous displays.
One such example is centre staging, which isn’t just about the magnitude and lengths gone through by the person exhibiting the display to create a circus of drama and hysteria around him. Instead, the most difficult aspect of centre staging to target as a therapist is the seductive pull and mystique about gazing upon such outrageous behaviour from our clients or colleagues.
These displays are traditionally rooted in creating one giant emotional and behavioural maelstrom for what can be, a number of purposes, all maladaptive. Indeed, centre staging can create countertransference for workers and peers who find themselves trapped in within the lives of their patients, and in one great turn of irony, finding themselves front and centre in the turbulent life of their clients where the object of his madness is your playground and you must be the client’s ultimate saviour.
I am reminded of one patient who moved into an adult home after living independently for her entire adult life, even while symptomatic. All the sudden the client’s mental status was in complete free-fall, and she began perseveration over her ongoing capacity to perform even the most basic of ADLs (activities of daily living) and maintain liveable conditions in her flat she had been living for most of her adult life.
Clearly at this point, myself and our treatment team were scrambling to figure out how someone could have decompensated so quickly and lose all hope in the process? As our team began to answer these questions, we realised we already in the seductive pull of a borderline and histrionic diagnosable patient in full blown psychiatric crisis.
When we discover ourselves being at centre stage in our client’s life, working harder at introspection and self-reflection, the countertransference can and will build on the therapist. Now, this client began to experience further free fall and consigned to move into an adult home and receive round-the-clock care such as help toileting, meal preparation, transportation to doctors visits in the surrounding community, and an in-house case manager assigned from the building.
The impulse of borderline patient who has histrionic traits to self-sabotage goes deep; it can be extremely confusing for the patient experiencing the symptom, and even more beguiling, profoundly amotivational for someone with a long history of loss and relapse. For the borderline patient now ready to loss it all for ‘one last’ opportunity for attention, sympathy and guilt, this patient decided our team wasn’t helping her because we let ‘this’ happen, and it was our fault as providers fallout to allow this patient to make persistently bad decisions, and put maladaptive reasoning put into action.
I have met also PTSD diagnosed chronically homeless people who would become very symptomatic, loss everything over and over again, and then experience a spike in his PTSD symptoms from the retraumatiation. For a person treating the displays and emotional outbursts, it can be very hard to separate out the extreme nature of some client’s self-destruction during a break, episode, or momentary bad turn in their path to recovery. Some clients can be very, very loud, and so agitated that it becomes not only dangerous to be in close proximity for both parties, but may become a physical risk, potential legal risk if one party needs to press charges on the person whom lost behavioural control. To tease out when this is the case, or when just supportive listening and maintaining an open stance in engagement is the most beneficial in creating the best outcome for the patient in treatment.
So, in these cases, what works? How do you treat chaos and inconsolable behaviour? The trick is, you don’t. In cases like these, listening, some re-direction, and disputing irrational cognitive distortions as they surface in the dialogue is the best you are going to do unless you unlock the mystery to solving the puzzle with no clear answer. Rolling with the resistance as best as possible, without accumulating too much countertransference, will go a long way in the patient feeling heard and listened to when they were in crisis. You may not have solved their problem, as it is usually extremely complex, and there is no long-term solution aside from not being too reactive and triggering to the client feeling out-of-control.
Hopefully, you the clinician feel in control of the situation, because clients can sense and are in touch when clinicians are afraid of their clients and feeling like they’ve lost control of the intervention. Modelling self-control, and providing some verbal self-assurance may be just what’s needed in the moment.
Maxwell Guttman teaches social work at Fordham University. He is also a mental health correspondent for Psychreg where he shares his insights on recovery and healing based from his lived experience of schizophrenia – a journey which started as an undergraduate student at Binghamton University. His diagnosis of schizophrenia wasn’t formally recognised until he was admitted to the state hospital in upstate New York. On his spare time, Max blogs on self-management at Mental Health Affairs. You can connect with Max on Twitter @maxwellguttman