These vidoes have been curated to support services and practitioners working with consumers, families, partners and carers of people with personality disorder, emerging personality disorder, symptoms or traits, and those working with young people with complex mental health issues, including personality disorder, trauma history, self-harm and suicidal behaviour and difficulties with affect, identity and relationships. They are not listed in any particular order.

View more lived experience videos.

Implementing the Project Air model

This video describes a model of stepped care for personality disorder developed by the Project Air Strategy. Mental health clinicians discuss their experiences with implementing the stepped care model, the relationship between brief and longer term treatment, and how the model can benefits clients.

Project Air Strategy Model of Stepped Care in Personality Disorder 

This video describes a model of stepped care for personality disorder developed by the Project Air Strategy. Mental health clinicians discuss their experiences with implementing the stepped care model, the relationship between brief and longer term treatment, and how the model can benefits clients. 

Professor Brin Grenyer: Welcome to this brief intervention program. It really is an opportunity to discuss our experience of staged care in the treatment of personality disorders. When clients come in in crisis they often see acute care and then many clients just need some psychological assistance to get back up on their feet, to reinforce some of the skills that they have, to give them some protective strategies to prevent them from coming back into crisis again and really, to help them integrate back into the community. So that's where the brief intervention program that we've developed is discussed today.  Here we have clinicians describing their experience of setting up this staged care, the brief intervention model, how it relates to the acute care services, and how it relates to the longer-term treatments. 

Question: What is the role of the brief intervention clinic? 

Wendy Smith: The brief intervention is beautiful for changing, I guess, risk management into a therapy approach. So as a brief intervention offering three or four sessions that focus on practical skills that the person can actually use for the situation that they're in, and drawing together, I guess, in the presence of a caring other, their existing resources, assisting  families as well to have some information and provide support for their family member. 

Question: Why are clients given a “Gold Card” and how do they get help? 

John Pullman: People could present in some kind of crisis they were literally given a gold card. We went with that. We kept up a roster and you were on the roster - you didn't have to be a crisis team worker. In fact, brief therapists came from the other community teams. Basically you're on a roster. So for me personally, I think I was on twice a month, the Monday and a Thursday twice a month, and I just went to the counter at that time and saw somebody showed up looking confused and carrying a gold , and if they did I registered them we got going. So it was very simple, which is one of the beauties of this service. It's such a simple and robust process - you present in crisis, somebody gives you some encouragement, gets you through. It gives you this thing, if you can find your courage and show up there's somebody just smiles it and gets working. It's probably a lot more simple for getting help and support for people than in a lot of other processes. 

Question: What is the benefit for clients? 

Rhia Forsyth: I like the brief intervention because it offers an immediate treatment source for people presenting in crisis. And quite often in the public mental health system, understandably, we've got wait lists, and you know we don't always have available resources, so things can be one week, two weeks, four weeks wait, whereas with the gold card clinic we have two standing appointments all the time. So we have one on a Monday at 11:00 and one on a Thursday at 11:00, so we can immediately offer an appointment to someone without having to check, or to wait until the weekend is over. So I really find that helpful. 

Question: Is it an easy model for clinicians to learn? 

Rhia Forsyth: I also find it helpful because it's manualized as well too, so you know once you've done the gold card clinic a couple of times you don't really have to prepare as much as well - so you've just kind of got a formula in your head. You go in you do the survey, you talk about the crisis, and you're working on the care plan. So in a way it's quite easy. As a clinician as well - you can walk into it without a lot of preparation, once you've done it a couple of times. 

Question: What staff do you need? 

Carryn Masluk: Well I think you need a coordinator. You certainly need a consultant and otherwise clinicians, and that's pretty much it. And our consultant really is available for those fortnightly consult meetings and also I guess if there's something that I feel like I cannot answer I need to have that extra support as well. So I would say coordinators, consultants and clinicians. 

Question: How do you choose a clinic coordinator? 

John Pullman: The coordinator is not just somebody who keeps the stats - they do have to think a little bit strategically. They've got to think a little bit about the motivation of the people that are coming along. Again, it's context dependent whether you'd have a team leader do it or it's just somebody's job, or whatever, but whoever does it has got to have some sense of feel for people, and for how people progress, and for the fact that people, have what is that the ‘clinician fraud syndrome’, and all that kind of thing, and they need encouragement. 

Question: What are the strengths of the model? 

William Wolfenden: There are lots of strengths with the brief intervention. I really like the structured nature of the whole model. It focuses on recent events for the consumers, which is often what they, the consumers want to talk about. They don't want to talk about what's been going on for them years and years ago. They want to focus on what's brought to this crisis. And it also provides a lot of tools and strategies for the consumers to take away. It empowers them to kind of take control of what's going on for them, and provides lots of tips to do so. It also includes the families and carers which is great to see that it's not, even in a brief intervention, that it’s not kind of disregarded. 

Rhia Forsyth: Some of the things that clients say the most is that they find it helpful because we can immediately offer an appointment, and when people present in crisis they're really wanting something tangible. So people find it very helpful to be given an appointment card, and say, look you know we can see you again in two days. I think they also like that it's very practical as well - and can take away a care plan. And sometimes when people have completed the brief intervention and then they might call the acute care team back a month, or six months, or a year ago, anyone can prompt the person and say “look, do you still have your care plan?” or “we've got a copy of the care plan on file”, and actually go through the strategies - go through the early warning signs - and then they don't feel like they have to start their story all over again. It's very practical base because lots of the time people in crisis will say “look nothing's working. I don't know what to do.” So it's very grounding to have a piece of paper and say “try A, try B, try C”. 

Question: How does the brief clinic relate to longer term treatment? 

Wendy Smith: The gold card clinic can be a referral pathway to longer term treatment as necessary, and so I guess some it really provides both. It's not like we lose the longer-term treatment options, but I think that the gold card clinic is really a better treatment option for those people that research tells us are just going to need three or four sessions in a situational crisis, and actually not require further intervention longer term intervention right at the moment. I think also it actually puts a warm and human face to a first-time user of services. It introduces the idea of a therapeutic approach, and I guess because, built in to the brief intervention is that idea of ongoing referral pathways as needed. 

Question: What are some challenges in implementation? 

Carryn Masluk: I was sort of concerned at that time about workload primarily and what that with me, myself and the DBT team that existed, and then also around really whether the service would actually help clients that have these personality disorders traits because, I guess these are chronic long-term conditions. So you know what I found though is that in terms of the treatment I think there has been such a gap between, or for those people that are presenting in crisis, and between those people getting treatment -having appropriate treatment. So I think the BLIP program services those clients they feel like they've been you know they've been taken seriously. They listen to about what it was that happened for them, and then be given some skills to get them back on track, and I think the feedback has been really good in that regard. And in terms of our clinician workload, certainly I think you know when people we've got about ten clinicians on our team and everyone you know is asked to put their name down for a week when they're available. So I don't think it has added that much in terms of workload for clinicians. So I guess my fears have been allayed. 

Question: How do brief and longer treatments relate to each other? 

Wayne Borg: I've worked in community mental health for a number of years and so I provide longer-term interventions for the people, for clients, and when I first came into the brief intervention it was a cultural shift for me, I guess. It was a little shift for me in terms of my approach and I realized that I don't have a real lot of time here to be working with this person in front of me, but I still want to be hearing them. I want to be present. I'm want to validate. I'll be empathic. I want to have, I want to be able to teach them some skills as well. I don't want to just be responding to a crisis presentation. And so it was like - okay how do we, how do we get what we need to get done in three sessions? Three hour sessions - hourly sessions? And so at first it felt strange but it worked. It worked really well. And what I've found is that my approach in the short-term interventions has actually helped me in my longer-term treatments as well. So I sometimes think, okay, there are some things that I need to get - we need, to get done in this session today - this is in the long term treatment - what do I need to move toward? So brief intervention has influenced the way I work in longer term treatment. Long term treatment has somewhat into influence how I work in the brief intervention and what I mean by that is that that thing on empathy, validation, active listening skills and teaching skills etc. It's all doable. It can happen, whether it's brief or long term. 

Question: Does the model benefit clients of a health service? 

Carryn Masluk: I think the intervention fills the gap for our service so certainly there's been clients historically that presented to the service with suicidal or self-harm behaviours or in crisis, that we're not seeing or followed up, and so you know at least in this program we offer them a service once they're presenting that they can be seen very quickly. There they can be taken seriously in terms of what what's happened, and can be offered some skills or some things to get them back on track very quickly. And you know, we find the results of doing that very effective. So I think it's nice and it's about our program, because I work on the DBT program as well to, I guess, orient those people that we feel might be appropriate for our longer-term treatment to talk about the diagnosis and orient them to longer term treatment options and then get them assessed for that as well.

 

Transference Focused Psychotherapy   

Professor Otto Kernberg (New York) talks about transference focussed psychotherapy (TFP) for personality disorder.

Otto Kernberg talks to Project Air Strategy 

Question: What is Transference Focused Psychotherapy (TFP) for Personality Disorder? 

Well,  transference focused psychotherapy is psychoanalytic psychotherapy that utilizes the technical instrument of the psychoneurotic technique, in particular the interpretation transference analysis, technical neutrality, counter transference utilization and attempts to permit the activation in the therapeutic situation of this rate of internalized object relations of these patients - interpreting each of those that become dominant in the action in terms of self-representation and the object representation activated and played-out respectively by patient and therapist, considering that when these internalized object relations are split they rapidly tend towards reversal of roles in terms of patient not only enacting the self-representation projecting the object representation of the therapist, but identifying with the object representation and projecting the self-representation of the therapist. 

We try to analyse systematically this internalized object relations that rapidly can be divided into idealized or good ones and the prosecutorial bad ones, and that initially split off from each other. But in each of these idealized and persecutory segments we try to analyse the role reversals that the patient carries out, the objective of which is the gradual developing awareness on the part of the patient that he really harbors identification, both with self and the author of the interaction, which makes it less frightening in the case of the persecutory relationships and makes it less of an unrealistic idealization with the idealist one. 

Over time, as the patient has a better tolerance of the awareness that he  incorporates, these mutually split-off relationships ,we interpret the defensive function of those splitting operations in order to integrate them - permits a passage if you want to incline a language from paranoid schizoid position to a depressive one, gradually obtaining integration of total object relation the tolerating that the self is both good and bad and other sub both good and bad, leading eventually to an integrated sense of self, and an integrated sense of significant others. 

In other words, to normal identity formation which is the strategic objective of the treatment. We want to transform borderline personality organization into normal identity by this method. So strategy consists in permitting the activation of this object relations rather than interpreting them. The techniques are the use of the psycho narrative techniques that have certain differences from the way in which they apply to standards or analysis. And then we have a number of so-called tactical manoeuvres which is dealing with frequent complications -psychotic regressions, severely paramount regressions in the transference, affect storms acting out repetition compulsion, and the complications in the behavioural complications in terms of eating disturbances, and the social behaviour of various degrees and types of depression and anxiety. 

The external organization of the treatment is two sessions per week, 45-minutes each, so the frequency is significantly lower than that of psychoanalysis, higher than that of many types of supportive Aubrie and brief psychology psychotherapists, and we try at the beginning of the treatment to create a specific frame that consists of tasks given to the patient - free association -  and a attitude of the therapist’s evenly suspended attention modification to some extent of beyond supplementation to intervene without memory nor desire. 

I think that in essence describes the treatment.

Being in psychotherapy

Mahlie Jewell, consumer advocate with lived experience, talks about being in psychotherapy and her relationship with her clinician.

Being in Psychotherapy: Mahlie Jewell’s experience 

I was in a very volatile way at that time and my self-harm was out of control. And so I think what helped was that it never phased her, it never scared her, it was not something that she'd not seen before, so she was fine with it. She was very delicate in the way that she dealt with it. Her language was incredibly considered. That was one of the things that I really noticed with her is that she didn't, she didn't use language that other people did. She would actually get really angry when I call myself crazy. I'm invasive with that word, but she just knew, watching, and she's done it for a long time and she had all of that those internal boundaries there. She had boundaries and really clear boundaries and she knew all my tricks, and she doubled them before so you know she would outwardly say to me, you know, “I’ve been trying to test how far I'm going to go and I'm telling you that this is where I'm going to go, and that's not going to change”. And then I started to realize that boundaries are safety actually, and that I really like boundaries even though I didn't think I did. But it was just her experience and just the fact that I never got the feeling that I was too much for her, that I was too complex, you know, she was also very, very strong about continuity of care so she was really aware that she needed to be there and then and so she was able to give me really a firm commitment and say “look, I'm not going to go anywhere for this period of time and she did. 

So I think there were a lot of things that made her wonderful, but I think her experience, her continued education, and she had a very good way of learning from the consumers as well, and she would always kind of say that to me and say “you know you're teaching me things here”. And yeah, I think little things like they ask my opinion about things, and you know about their processes, and wanting to get feedback about that, it just made me feel valued. And I think when I felt valued as well then that helped my self-esteem really, and it helped me get better. 

It's funny because most people don’t realize the power of that relationship. My first clinician was the third person in my life who ever told me that they were proud of me, and that was massive for me. And so I needed to you know I was kind of for one for one moment I had someone who was proud of me and who was kind of on my side. And so I think there was lots of times when I could have slipped further backwards and I probably didn't do it because I wanted to keep their pride in me. 

So that's a massive thing, when you don't have that, and then think, maybe a lot of people who don't realize, what a lot of clinicians maybe, don't realize, the people they're dealing with, probably have never felt that emotion either. They've never had somebody who thinks they're amazing and who thinks that they’re smart and articulate. You know, there's a lot of negativity that's geared towards people with borderline and they can be so powerful by just actually doing some really strength based work with people - so strength’s based is the key!

Recommendations for effective care

NSW Health Clinical Nurse Consultant, Joe Russ, talks about his experience nursing borderline personality disorder (BPD) clients who present to the emergency department in crisis, and recommendations for effective care.

Joe Russ talks about his experience nursing clients with personality disorder who present to the hospital emergency department in crisis 

Question: How do you help a person when they are in crisis? 

Firstly we'll identify why they came in, what was the initial trigger that brought them to hospital - brought them to a feeling of despair and distress, and then try to identify solutions; what's worked for them before, how we can identify other things that will make them feel safe, therapies or clinicians or activities they can partake in that's going to make them feel more comfortable with themselves rather than at odds with the world. I found this very successful so try very hard to meet the client's needs, or help them to find their own solutions, and that seems to be very effective also. 

We generally have a high discharge rate for borderline personality disorder clients because it's been found admissions don't work, unless it's a critical issue. So identifying the problem, helping them to identify their own solutions, rather than telling them what they should do, is very, very effective. 

Question: What else do you recommend in the emergency department? 

What I always tell the nurses in ED is to lead with a cup of tea, because I find just that initial giving and showing human compassion is enormously effective in settling the client's, maybe agitated behaviour, or maybe demonstrative demanding behaviour. A cup of tea and a warm blanket or a sandwich makes a huge difference and brings them a feeling a sense of empathy. And they really relate to that really strongly. It's hugely successful, it works 99% of the time and I find even the most volatile situations, I can talk the client down with an offer of a cup of tea and a discussion about it. 

Question: What is your advice to clinicians working in hospital emergency when a person with borderline personality disorder presents in crisis? 

In terms of my fellow clinicians, and particularly in the emergency department, I think it's really important that they recognize, not just that a borderline personality is a human being, but they are human beings suffering, through no fault of their own, and they can actually have comorbid depression or other mental illnesses, or circumstances that are out of their control.

Some of which they can attend, they can address, but some are out of their power or capacity to control at this point in time, and that everybody, everybody goes through periods of time in their lives when they are in crisis. Persons with borderline personalities have more crisis, they have more drama, and they have more demonstrative issues that they can't manage. It's really developing a compassion and awareness that we're all on this same trip. They suffer more than we do, and being aware of that helps people to just lend a little more compassion and empathy.

Psychotherapy

Professor Anthony Bateman (UK), consultant psychiatrist and psychotherapist, talks about psychotherapy for antisocial personality disorder and challenges for therapists.

Project Air Strategy talks to Professor Anthony Bateman about Psychotherapy for Antisocial Personality Disorder. Professor Bateman is Consultant Psychiatrist and Psychotherapist. 

We developed mentalization based therapies specifically for antisocial personality disorder simply because it was useful in borderline personality disorder, but in effect we have a lot of people who comorbid for both disorders, and in our clinical services actually there was a problem with that overlap. So people who were more antisocial or actually quite distinct from those who are more borderline personality disorders. So we decided to separate them. 

Having done that, we of course had to have some view about what the mind states of people with antisocial personality disorder were like - as people actually have a disregard for others. They actually have a disregard for their own safety very often. They're not very interested in other people's views and perspectives, or mental states. 

We know that they misuse sort of emotions of other people. Generally they may trigger emotions and then use them or exploit them and so on. All this is described in the literature and we think that those sorts of attitudes, those sorts of behaviours, and those sorts of relational problems that they have, are fundamentally based on their problems in mentalizing. So, in fact, we used that to generate a treatment program for targeting areas of mentalizing problems for people with antisocial personality disorder. 

We start the groups with agreements between us all, which we call a code of conduct. You know how we're going to relate here; what's our values as individuals in this group, and what are our values we're going to try to follow in the group? And we have a series of examples with them about what how we might behave and how we might not behave; how we expect each other to behave, and we specify those.  So we can always come back to that if it starts going wrong - that actually we simply don't do this here and so on, and they're quite good respecting their own codes of conduct if they've generated them. 

Question: Do people with antisocial personality disorder want to change? 

Well that's a great question because when you first see them they have no interest in thinking differently whatsoever. So the first task is always to actually try to engender a process whereby you're solely taking their mind states into account. You're simply exploring their views, their values, their perspective on what's happened to them - what is happening to them, their perspective on their current relationship, however they perceive it, and to take that absolutely seriously on face value and explore, you know, a lot of detail and depth until they have a sense that you see things from their perspective. 

You can't do anything else at all. Once you've done that you then subtly or gently move away to actually push them to consider others’ mental states in various ways or well, in fact, others’ emotional states very often, because they're not very good at seeing other people's emotions, or at least responding to them in a feedback system. So, for example, if they see someone else is a little scared, they don't care. When people without antisocial personality disorder see someone they're making is anxious or scared they tend to get a feedback system which alters their behaviour so we spend a lot of time getting them to consider these sort of feedback loops, particularly about others’ emotional states. And we do that now primarily in groups, and the reason for that is of course that peer pressure and that your social personality disorder gangs, for example, actually can function incredibly well. 

They're very good at gangs. They organize them. They have a proper hierarchy. They understand each other's roles. They know how someone's going to respond and so on. So we simply set up a gang, in a sense, except is called a therapeutic group. And then we get them to start considering each other - about what they're doing, what they're like, how they see each other and so on. 

Question: What are the early group processes? 

The low-hanging fruit you see early on is actually their recognition of other people's emotional states. When they start in the group they have no interest in looking at others particularly. Trying to read what their mental state might be from how they're presenting or how they're expressing something and we focus a lot on that early, and actually they begin to realize it's incredibly informative that if you bother to look at people, if you bother to say what's behind that smile, laughing at in a genuine curiosity, they actually begin to work out that this is quite useful actually. And they then of course they may try to misuse it later. You never know. But nevertheless, they're very quick at picking up that actually, you can ask people things, you can check things out, you can understand what people's emotions are a little bit, rather than just seeing them as a threat or something like that. 

Question: What are some group challenges? 

The vast majority of people with antisocial personality disorder spend an inordinate amount of energy trying to deactivate their attachment systems if possible because attachment creates a

lot of trouble.  So once their attachment systems are activated they're in trouble. All sorts of things - dependency of need, desire you sort of mean of other people - and that, of course, is very problematic for them because they're very self-organized. They don't like to need someone else, if you like. They're autonomous in that sense, so mostly they tried to deactivate them. 

The problem with antisocial personality disorder individuals is they can't, they don't know very well, because they tend to be disorganized so burst out all the time in different ways. So, in fact, what we do with this is get them first to begin to actually scrutinize and think about the relationship processes – just what are they like, how do they go, what happens. We get them to do that and we give them information about attachment and attachment processes, and then we get them to actually map them, and so on. And we actually give them what we call a relational passport. It is simply a little thing about their own attachment processes really. They discuss that in the group. And of course, in the group they actually are mostly activated so their dismissive processes are activated. Their attempts to deactivate are activated if you see what I mean and we alight on those in the group. One of the other focuses of the group is looking at those as they do them with us, and within, with each other. 

Question: What changes in therapy? 

The Safe Zone they step into is, to a large extent, they become less reactive to others, so they're less sensitive, they're less likely to make assumptions about other people's malign mental state, they don't assume somebody's against them too quickly, and things like that. So they're much less reactive. Once they're less reactive they're able to maintain the stability of their own mental state so they don't feel so threatened by other people, and they actually get better at reading other people. So they differentiate not everybody's an enemy - some people actually are friends or they've got benign motives and so on, and they feel better about that, generally speaking. 

Question: What are the challenges for therapists? 

People worry about fearfulness and reactivity for the therapist and sense of feeling controlled or coerced or tricked or lied to, and these sorts of phenomena, which are sincerely an issue. But actually, the ones that cause quite a bit of trouble in terms of therapeutic work, one is that a reaction where the counter responsiveness is actually to start minimizing events we simply listen to these things and gradually you begin to get the sort of sense of well, “he only stabbed him once” and he said “ok, yeh, that’s okay then”.  You know, you sort of get drawn into this idea that certain events, actually they minimize - they say well it's only this”, they say “he only beat him up” and “oh that’s all right then” and you start generating this sort of response where things become minimized, all right. Now that can actually happen in things like your reactions to other things in borderline personality disorder of course, but it's quite common in antisocial personality. They minimize what they do, as if they're perfectly okay. 

The second one, which links, is that they use a lot of humour and to be honest they're the best comedians you've ever met. They draw you into this comedic act sort of situation where you lose sight of the fact you're delivering therapy, and you have these sort of great jokes being made about things, often which I've a slight macabre element in them, and things like that, and it's very easy to create a certain humorous sort of action which actually avoids the seriousness of things and it's easy to lose that and you have to watch out for counter responsiveness down those two lines, certainly.

Recovery journey

Project Air Strategy talks to Åse Line Baltzersen on her recovery journey: ‘Recovery from personality disorder is a journey’. A rich and inspiring story from lived experience.

Project Air Strategy talks to Åse Line Baltzersen on her recovery journey: ‘Recovery from personality disorder is a journey’. Watch this rich and inspiring story from lived experience. 

Question: How did getting a diagnosis help you? 

As I got deep diagnosis when I was about 20 years old, for the first time I realized or I learned more from my clinicians that, it wasn't something wrong with me, which is something I've felt my entire life-  that it was something I was just a failure, something was wrong with me since I couldn't fix myself. But as I got the diagnosis I realized that it's more about that I have certain issues or problems, but they are problems that can get better as I work with them, and with the clinicians, so together we could make things better when we knew where the problems were. 

Question: Was there a turning point in your recovery, after reaching “rock bottom”? 

Strange thing is that what I thought was rock bottom, it really wasn't, but that moment when I thought I had hit rock bottom I was on my way to do something insanely stupid. But then it hit me like ‘this is not who I am’. And that day I decided that I wanted to survive. I kind of realized that I'd been trying to die my entire life and I hadn't, and the sense was that I really didn't want to die, but I didn't know how to live either. So I kind of made the decision that day that I was going to give it a real shot and give recovery a real shot. And this kind of stayed with me through what essentially became rock bottom, and then later, in recovery, as I got treatment for this. So that decision was crucially important for me just to realize that I was going to fight, because recovery is a fight. 

Question: What advice would you give others about the recovery journey? 

My first advice would be to give yourself as many shots as possible, because recovering is not a process where you just go up and up and up and up and up. There will be…well I guess I'm not exaggerating when I said for everyone, it will be a battle, where sometimes you move forward, sometimes you can feel as if you're falling straight back to start. But as you slowly progress you will never go back to start. It keeps evolving and you keep learning new strategies and more things about yourself. 

So not giving up as you have a relapse of any sort- just kind of, it's a balance between being self-compassionate - that shit happens, let's move forward. At the same time I find kind of not accepting excuses because at times it's hard to differentiate between an excuse and what is just pure, what's called ‘shit happens’. It's the personality disorder, kind of, in the steering wheel, so just give yourself as many shots as possible and learn from everything that you can. 

Question: Any other advice about recovery? 

You're not your diagnosis in any way. No matter where you are in the process; either starting the recovery process or maybe just coming to terms with having a personality disorder. It does not in any way define you. It says a little bit about certain areas that someone struggles with to a greater or lesser extent, but it doesn't say anything about anyone as a person or your future hope. When I started out - it's actually 10 years since I started treatment today - I would have never imagined being a CEO of two companies and actually working and getting a higher education. I never thought I was there. I couldn’t even read the newspapers’ headlines at that time. So that diagnosis did not define me but it gave me treatment options, which led me to where I am today. I was not able to do it on my own and I think that's the first step - to accept help or, if necessary, actually fight for that help.

Effective treatment

Professor Alan Fruzzetti talks about families, carers & effective treatment

Professor Alan Fruzzetti talks about families, carers & effective treatment 

Question: How should families respond when a relative is diagnosed with Borderline Personality Disorder? 

When a family member has recently been diagnosed with borderline personality disorder I think family members feel quite scared about what that means. There's a lot of terrifying information on the internet about this, most of which, by the way, is quite inaccurate. So what I tell families is this is actually a very hopeful moment because, to have an accurate assessment, to classify accurately as borderline personality disorder is actually quite hopeful. We have in 2015, for the first time, we have multiple treatments that work, and that wasn't true even 30 years ago. So it's actually good news, as surprising as that might sound. 

Question: What is the most important skill for new therapists? 

New therapists working with people with borderline personality disorder need a variety of skills to be effective, not least among them would be an open mind to actually bring themselves to the interpersonal situation so that they can enjoy the person - enjoy the human being that they're working with. In addition to understanding and seeing the suffering and the pain that's involved, actually to be able to have both sides of that is very important. 

Question: What comments do you have about diagnosis? 

Diagnosis of borderline personality disorder is very confusing. It's confusing to patients and their family members and, believe it or not, it's very confusing for therapists. Part of the reason is that there's an ongoing debate within the field of psychiatry and psychology about what borderline personality disorder is. That's confusing. It's a heterogeneous disorder that means

that one person with borderline personality disorder can look very different and have a very different set of problems than somebody else with borderline personality disorder. And probably most importantly, the fact is that borderline personality disorder rarely stands by itself. People with borderline personality disorder typically have two, three, four or more, other diagnoses they carry around with the. This can be very confusing for everybody. 

Question: Has stigma changed over the years? 

Stigma has been following borderline personality disorder around like a dark shadow for as long as there has been borderline personality disorder as a diagnosis. It comes from a lot of different reasons - probably most among them is the fact that for so many years the mental health community was so ineffective at treating borderline personality disorder. Now that we have effective treatments, stigma has started to go down and so, stigma has actually been reduced quite a bit in the last 25 years or so since the first randomized trials of dialectical behaviour therapy were published. 

Question: What are the priorities to improve treatment? 

I think the priorities and treatment for BPT today are to expand the number of treatments that actually work for people suffering with borderline personality disorder. The number of treatments that we have with very good results that endure is still relatively small and don't necessarily help everybody. Borderline personality disorder is a very heterogeneous disorder, so in order to help people who meet the criteria for BPD we are going to need to have multiple different approaches to treatment to be able to help them broadly. 

Question: What do you wish you knew when you first started your career 30 years ago? 

I remember when I first heard borderline personality disorder back in the mid-1980’s, and there was an enormous amount of stigma attached to it, and although the providers that I was working with - a psychiatrist and psychologists - were often very stigmatizing, very judgmental about people with BPD, and I wish I could have gone back and told myself, but also them, that you know we're all human beings and the differences between people with BPD and people without BPD are actually much smaller than the things that we have in common. Everybody gets emotionally dysregulated sometimes - everybody does. But people with borderline personality disorder get more intensively dysregulated more often, and so carry with them a lot more pain and suffering. But the nature of the dysregulation is quite the same as it is for anybody.

Personality disorder and trauma

Delores Mosquera (Spain), psychologist and psychotherapist, talks about personality disorder and trauma.

Project Air Talks to Delores Mosquera about treatment of personality disorder and trauma 

Question: What is essential for good treatment of personality disorder? 

Compassion, capacity to deal with intense emotions, being able to do supervision, being able to work in a team, and curiosity, really wanting to understand. I think that's crucial. 

Question: Do most therapies integrate these same crucial ingredients? 

I think that in many approaches we use the same interventions but we use different names to talk about the work we do. So I think a lot of the things that are being explained now maybe they're more clear or meaningful but they have been influenced by many authors that have been speaking about this from my age, my time. 

Question: How do you integrate your treatment? 

I integrate. I have been influenced by like many approaches so I integrate DBT by conversation, schema therapy, but I mostly work with the MDR, I integrate everything from working with the MDR model. 

Question: What do new therapists need to be aware of in treating personality disorder? 

To be familiar with complex formalization. To be aware of the internal conflict. But it's not just about impulsive reactions or unstable changes. It is much more complex in some of the most severe cases. I need to understand what's happening inside, to get an idea of what's happening outside, and why. 

Question: What should therapists be looking for in identifying trauma? 

Yes, I always say that the criteria nine is one of the most ignored but I refer to the second part, this severe dissociative symptoms. I think that suspiciousness and it's very familiar for clinicians, but dissociation is not so familiar. So I think we really need to explore this aspect from the beginning. 

Question: When is the right time to treat trauma? 

Okay so we need to try to explore any traumatic situations from the beginning, but when we notice that the client is not really managing this okay or they are going into low psychosis, or getting overwhelmed, or they're not really connected to what they're answering, those might be signals, that person is not ready to go there. So we need to be attentive to the associative language so we can help them gradually to face. 

Question: Why is it important to intervene early with young people? 

So for younger people, although it can be more complicated because sometimes they don't have such a capacity for insight. It's also easier to work with them and have them involved in a normal life, go back to school, or get integrated, with people that have been like this for many years. It can be longer so I like I just try to be very honest about time and saying that the important issues can improve. I don't know how long it's going to take but I do know that they're likely better. 

Question: Can you explain how “being curious” is so helpful in therapy? 

I don't know. I think that many times I have been saved by really wanting to understand being curious about what's happening when a client is doing something that doesn't seem to make sense. To become curious I said “Wow, why is this happening?” I think this is something that could be very helpful for us because it avoids judgments and jumping to conclusions. 

Counter transference in treatment

Professor Jeffrey Hayes (USA) talks about understanding therapist counter transference in personality disorder treatment.

Professor Jeffrey Hayes: Understanding therapist countertransference in personality disorder treatment. 

Question: What is countertransference in personality disorder treatment? 

I've defined countertransference as those reactions that we have to patients that are based primarily in our own unresolved, or partially resolved, conflicts as a result of our own developmental histories, our own idiosyncratic reactions to patients that perhaps aren't widely shared by other therapists  - that somehow there's some recognition that the work that we do with patients, and I think particularly with patients of personality disorders, inevitably it's going to stir up some of our own issues, and all therapists have these reactions - it's not a function of being a trainee, there's no point in our careers where we become immune to these kinds of reactions. 

So the point is to understand that these reactions are going to be triggered within us, that they can get in the way of our work if we don't understand them, and it's really important to try and pay attention, not just to the client, but what's going on internally and between the client and myself in the moment, which is a tall order, but in terms of countertransference, you know, what am I feeling, what am I thinking, what's my body experiencing, sensing, and what am I actually doing with this client that raises some suspicions for me - that perhaps my own issues are at play here, and can I use my understanding of my own especially internal reactions to facilitate the work. 

So for example, if the client is provoking some sort of rage in me or anxiety in me, it's this what might be called objective countertransference, where the reaction is typical that might be shared by one of my classmates who would be seeing the same client wear the same type of patient, or is this reaction somehow a reflection on me because of my own developmental history - there's some way in which what the client is talking about, what the client is doing, what the client looks like, reminds me of someone, including possibly myself, that causes me to react rather than respond. And in particular, if I find that I'm behaving or thinking or feeling in a way that's atypical for me - I don't usually react this way to clients and I don't usually react this way to this client in my work with them - then there's real grist for the therapeutic mill here. How can I try and reflect on those reactions in the moment, if possible, so that I don't act out defensively, and how do I reflect after the session on my reactions either in supervision or with a classmate or on my own, in a way that my understanding might shed some light on the patient dynamics, on the relationship, and even on the course of treatment?

Good treatment

Mahlie Jewel, consumer advocate with lived experience, talks about the essential elements for good treatment for personality disorder and what you can expect from your therapist.

Mahlie Jewell talks about good treatment for personality disorder

Question: What are the essential elements of good treatment?

I think one of the main things to keep in mind is that we are human and a lot of us have been through some very traumatic experiences over a long period of time. And I think that compassion needs to be something they are thinking about in their dealings with us and I look at that as just treat me like you would treat your child or yourself or a member of your family. I think, also for health professionals that they do take an oath to ‘do no harm’, and to be really aware of the use of trauma informed practices should be the standard, and engaging with the consumer by asking what they need and not assuming what we need. And making sure they deliver that to the highest level they would give to someone in like, a cardiac ward or a neurological ward – to not look at it as any other type of illness, like cancer.

Question: What should you expect from your therapist?

It’s care. It’s the way that someone deals with you in a really genuine way, and genuinely wants to know what‘s wrong, how can I fix it, what do you need? I think that compassion to me, is understanding that perhaps you’ve had things in your life happen to you that were out of your control, and this is the only way you can be in control, and so, stop looking at it as a choice and look at it as a symptom of what might have happened in the past. So I think with compassion, you’ve got to put groups of people together, so someone who has trauma in their background isn’t any different to someone who’s been to war, and they shouldn’t have a different level of care and compassion around them. I can’t imagine them not being compassionate towards a soldier, not being compassionate towards a car accident victim, or someone who experiences an horrific crime. And so, I think compassion comes from within you and it’s genuine.

Question: How do you ask for what you need?

I often tell people that they best way for them to navigate through the system is to work within the system – so, to know your rights and to know your responsibility for the people around you, but to tackle that with solutions and not just complaints. So, if somethings happening and you are unhappy about it go to that doctor/clinician/mental health tribunal member with a solution. And so, don’t just go “I don’t like this happening to me” but say “this is what I prefer, and be really vocal about things like who you want to support you. That’s a massive issue. Not everyone is going to want their family involved even if they have contact with them. Some people have friends, employers, that don’t even know what’s happening with them. And so the whole thing here can get very scary, so I’m always big in saying, “who do you want to be here?” “who’s going to make you feel safe?” Don’t let somebody else tell you that – you tell them that.

Mahlie Jewell is a consumer advocate with lived experience of borderline personality disorder.

Living with BPD

Sonia Neale, mental health peer support worker with lived experience, talks about living with BPD and working with health professionals and emergency departments.

Sonia Neale talks about her lived experience of  Borderline Personality Disorder & working with health professionals & emergency departments 

Question: Was getting a diagnosis helpful? 

I wanted a diagnosis but some clients don't. I felt it was very helpful to me to go through all the nine criteria, realized that I fulfilled all of them, and then I worked on them and I found that that was the most integrating process for me. Not everyone wants to know their diagnosis and that's fine. 

Question: What skills do new therapists need? 

I think new therapists need to learn how to handle their own anxiety when talking to people with BPD. Essentially if they can hold their own anxiety in check then it's not going to be contagious to the person with BPD. I think validation skills, active listening skills, the ability to sit in those uncomfortable feelings, whether they're coming from the client or the therapist, need to be addressed and looked at. I think the new therapist needs to have his or her own therapy so that they can handle their own anxiety, know their own trigger points, and so the countertransference doesn't happen too often in therapy. 

Question: What do frontline staff need to know? 

Stigma is a huge problem, especially when people go to emergency departments, mainly because clinicians and mental health nurses, psychiatrists, psychologists sometimes are not up-to-date with new information and new, which essentially says the people with BPD can get better, and do get better, with the right treatment, and it's also when people come to emergency departments to ask the right questions, not “why did you do this” but “what happened to you, what happened to you before you did this”, so the right questions need to be asked. As well there needs to be hope for recovery because people do recover from BPD. 

Question: As a consumer, what would you like to tell emergency staff? 

I think education is the way to go. Increasing up-to-date information for people, having people with BPD, the peers with lived experience, to go into ED and have a talk to people - to say when I come in dysregulated, my behaviour is not who I am, there are times when I function perfectly well at home, but when I'm dysregulated this is the only place I can come to, you are the only people who can help me at this moment before better or newer services come into it, so what I want you to do is to be able to listen to someone's story and understand where they're coming from. People do not want to come into ED and be thought of as manipulative or attention-seeking, because if we want to live a life, this is not how we want to live it by keep coming to emergency departments.

Parenting with personality disorder

This short video follows the life of Sam and her three children. It shows the choices Sam has to make as a parent while struggling with personality disorder. It was developed as a training tool illustrating parenting strategies for caregivers with a personality disorder.

Parenting with a Personality Disorder 

(Background music)

Prof Grenyer: Hi I'm Professor Brin Grenyer and I lead the Project Air Strategy for Personality Disorders.  We work with mental health professionals and researchers to help parents get the information they need to deal with the challenges they face. We all love being parents, but it can also be hard at times, and personality disorders can make it even harder. 

Sam: Jack, don't open those eggs. 

Prof Grenyer: Today we'll meet Sam. Sam is a single mother with personality disorder and she has three children; Ethan, Jack, and Mia. We look at the choices that Sam has and ways to care and support children when struggling with mental health problems. 

Parenting with a Personality Disorder: A film for health professionals, parents, care givers & families 

Sam: I know what I do affects my kids. I could say it, yeah ,sometimes I just see in their eyes how much they need me and I - just everything's just so intense. I can't even think about them, you know, like I just feel so filled up with so many emotions and it's really hard to think about anything else. I hate myself. I just hate myself. 

Classroom conversation: (Girl) I need to find a way to regulate their environment. If they get too cold it might not work. (Boy) I’m working on something at home. I am. I've got to go. (Girl) Remember we need to get all this done by Thursday. (Boy) I know. (Girl) I'll call you. 

School bell. Text message Ethan to Mum: How are you feeling? 

Jack (knocks on door): Mum. Mummy please open the door. 

Sam: I'll let you in but you have to promise not to tell anyone, okay Jack, especially not Ethan. (Music) Sometimes it just it just happens but I don't even realize what I'm doing and I've already done it and I can't go back. Then I know that if I can learn how to deal with my problems then I won't have to put that on to my kids.

(knocking)

I'm okay Jack. I'm just washing my face.

That would be a lot better

Can you go check on Mia? 

Jack: Okay. (To Mia) Do you want to watch cartoons? 

Sam: Thanks for looking after Mia, Jack. You’re a big help. 

Ethan: Hey mom. 

Sam: Hey 

Ethan: Everything all right? 

Sam: Mm-hmm 

Voice giving instructions: You want to mount the sensor on the side of the warming chamber, way from the heat lamps. That way you get a more accurate temperature reading and have the best chance of a consistent result across……(Music

Ethan: Hey mum. Can we talk? 

Sam: I'd pull myself out hole, haul myself out until I have nothing left. 

Ethan: Jack, it's almost dinnertime 

Sam: No one gave me anything, you know, not me. Nobody helped me and I just keep thinking, why does Mia get everything when nobody gave me anything? 

Mia: Mummy! 

Sam (shouting): Stop your whinging!

I just get so angry and then I don't even realize what I'm doing. 

Mia: Mummy, come play with me. 

Sam: You want me to come play with you?

When I feel better, well when I feel better I to know that it's just about opening my eyes and really seeing her. You know, like really seeing her as her own little person, and when I can focus on her world and talk to Mia about what she's doing, that makes things a lot easier.

I like the way you used the orange with the red ones over here and then the pink ones over here, with the green, that's very nice. I'm gonna do that too. I'm gonna use some pink like you did and some green. And, shall I get a brown one too?   

(Blocks fall

Sam: It’s okay, we can rebuild it. Very good.

(Music, tap dripping) 

(Ruby text message): You still up?

(Ethan text message): Yep

(Ruby text message): Everything ok?

(Ethan text message): No

(Ruby text message): What’s wrong?

(Ethan text message): My mum is sick – erased -

(Ruby text message): Is it me?

(Ethan text message): No. Why would you think that? My mum has a personality disorder. It’s hard sometimes.

(Ruby text message): I’m sorry

(Ethan text message): It’s ok. See you tomorrow to finish our project?

(Ruby text message): Course. Can’t wait.

(Ethan text message): Me too. 

Music 

Sam – crying: All right! I already told you I called in sick and I need you to come over. I don't know, just, just to be here, to look after me. You don't even care if I live or die. Crying

Don’t say this to me right now when I really need you that is not true and never easy.

Ethan, don’t leave me alone today. Can you stay with me? Please stay with me. 

Ethan: Yeah. Jack, let's go. Mia, here’s your bag. I'll just take Jack and Mia up to school and I'll be right back. I'll be right back. Okay. 

Sam: I already told you I called in sick and I need you to come over, just to be here with me.

(music) Ethan is such a good kid. It's easy to rely on him too much. Sometimes I don't even realize how much he's doing around the house. I don't want him to miss out on being a kid.

Thanks for helping everyone get ready Ethan. 

Ethan: That's okay 

Sam: Just give me a minute. I'll get dressed to take you to school. 

Ethan: Mum, I’m not going. I'll stay here with you. I'll just take Jack and Mia up to school and I'll be right back, okay. 

Sam: No, that's okay. You've got your science project to work on. I'll be okay. I'll call the clinic okay. I'll be here when you get home this afternoon. 

Ethan: Okay. 

Sam: Right, Mia get your bag. Mummy’s going to get dressed. I'll be back in two minutes. 

Professor Grenyer: Parenting when you have a personality disorder provides extra challenges but it's important to know there are small steps you can take to make a positive difference. No one can be a perfect parent but it's important that our kids feel loved and protected. Our role is to talk to them about what is going on, protect them from harm, and ensure our children are able to be children. Talking these things over with a mental health worker can help you develop a treatment plan that's right for you and ensure a safe calm and loving family environment. 

Sam: It always seems really weird to me that in the hundreds of conversations I've had with therapists, not once have I been asked about my kids. You know, being a mother as my main role and raising kids is really hard - full-stop - let alone trying to do it dealing with personality disorder. I feel like other people are judging me, especially other parents. I guess I've avoided getting to know the other parents at the kids’ school. But my kids are what I live for. They are the reason I stick with my therapy and they motivate me to get better - so that I can be a better mum, so that so that we can have a better life than I had, because my mum pretty much left my brother and I to raise ourselves and our household was pretty violent, so I'm determined that my kids won't grow up the way I did. My worst nightmare is if I would pass something on to them and I really don't want them to have to deal with the struggles that I have. But I'm me and I'm their parent so I just try and be good enough every day and just, you know, focus on the positive and take positive steps towards what really matters in my life. 

I worry a lot that my kids could be taken from me but I know now that working with my therapists and being really honest about my struggles is the best way to keep us all together, because you know, my therapist and I work on my problems and that helps me be a better parent too. I just hope that I can keep making progress. You know, it's really hard, but I know that my kids really need me and I'm really important to them, and they bring just so much joy and happiness into my life. I just try and put aside my worries and enjoy time with them.

In conversation with BPD expert

Dr Shelly McMain (Canada), talks about borderline personality disorder including treatment, stigma, diagnosis and research.

Project Air Strategy in conversation with BPD expert, Dr Shelley McMain 

Dr Shelley McMain is a Clinical Psychologist and Head of the Borderline Personality Clinic at the Centre for Addiction and Mental Health - Canada's largest mental health and addiction teaching hospital. She is studying psychotherapy methods and outcomes for borderline personality disorder (BPD), concurrent BPD and substance use disorders (SIDs) and self-harm and suicidal behaviour. Recent projects have examined the effectiveness of Dialectical Behaviour Therapy for the treatment of concurrent BPD and SIDs. 

Question: What is the most important ingredient in treatment for BPD? 

I think the first message and I think, probably the most important ingredient, really to treatment delivery is being able to maintain compassion, and I think that that's been a key obstacle to effective treatment for BPD. And I think that health care providers need to learn how to be compassionate, especially when working with individuals who can challenge us, who can get us undone, who, you know, we can end up being very dysregulated with - to maintain compassion under those conditions. And I think there are ways of doing that, and I think several of the evidence-based treatments actually provide us with some guidance on how to maintain compassion. 

Question: Are we getting any better at breaking down stigma? 

I think unfortunately, I think stigma still continues to be a huge problem and barrier to treatment for people with the disorder. The situation has changed, dramatically, in a very short time span. I recall only 15 years ago it seems our, around that time, when in Canada anyways, that I'm assuming in Australia also, there were very few services for people with BPD, and part of that was due to the prevailing belief that people with the disorder weren't treatable, and what went along with that were a lot of negative attitudes towards this patient population. 

Unfortunately I think many of those beliefs persist, although they've changed dramatically in many ways. We're still working on changing those and I think that increasing awareness about the disorder, providing people with education about the fact that the disorder is treatable,  things that when we're in the field now, people anybody who's studying about BPD is now very aware of, but there's lots of healthcare providers that haven't yet received that information. A lot of consumers aren't aware. A lot of family members aren't aware. So increasing awareness through education I think is going to be a key strategy to combat the stigma. I think it will also help to raise and support for, that might help increase additional funding in the area of treatment. The resource allocation also in terms of research funding. 

Question: Any thoughts on diagnosis? 

Well I think that clinically, I think that putting aside the challenges in struggling or battling between what we should call this disorder, you know, what name to give it, or which symptoms should go along with it, I think that clinically there's real value in being able to attach a label to a set of symptoms. I think there's value in that, you know, we know that it's often very helpful for people to receive a diagnosis that can help validate their own experience. 

So for consumers, it can be helpful for them - it can be therapeutic in itself to receive a diagnosis for symptoms that you can't make sense of and I think that for clinicians, I think it's helpful in terms of guiding our treatment and guiding interventions for individuals. So I think that the diagnosis is also helpful in terms of providing a framework for also furthering our understanding empirically, so getting a better handle on what's the constellation of these problems and what's the prognosis of individuals with this constellation of symptoms can be best understood if we have some framework for organizing those symptoms. 

Question: What’s your view on the controversy around the Diagnostic and Statistical Manual of Mental Disorders (DSM-5? 

I think that everybody's aware in the field that change is needed and that there are things that aren’t satisfactory with the diagnosis. However I think that there certainly wasn't an agreement on how this field should move forward. I think that, part of the problem is that we're still in somewhat of an early phase in terms of actually understanding enough about the disorder to make empirically informed decisions. 

Question: How can we best improve care for people with BPD? 

Well we are, in in many ways, a terrific situation compared to where we were 15 years ago when we didn't have evidence-based treatment to offer people with borderline personality disorder, however the problem now that we're facing is we've got incredible demand for specialized services for people with BPD, which is terrific on the one hand, but the problem is we don't have enough of these services available. So we've got the problem of how to really increase access to specialized treatment for BPD, and I think one of the things we need to do is to increase the availability of specialized treatments, and this is going to involve doing more training and helping people helping ensure the healthcare providers are knowledgeable about how to deliver evidence-based treatment because we know that non specialized treatments aren't as effective as specialized treatments. 

However, having said that, I don't think that we're ever going to have enough healthcare providers who are able to deliver specialized treatment services, so I think that the other part of the solution is going to involve doing a much better job than what we have done in terms of training primary care health providers in the delivery of BPD informed treatment. 

Question: What are some of the good news stories in BPD treatment? 

There's several good news stories in terms of training. First, I think just the access to information. It's so much easier for people who are seeking training, not only access to health care providers, but just with the internet, and with the explosion of really terrific materials on the , you could be in a remote community and access excellent training online, so that's really occurred in a fairly short timeframe. 

I think that there's still lots to be done that, not only in training healthcare professionals, but also training people who can support people with the disorder, such as family members who can be trained to be more skilful with their loved ones, and certainly there's a lot being done in that regard. There are several peer support programs for family members. There's also peer support groups for consumers that can help them manage their own symptoms, and I think can be used effectively. 

Question: Where do we need to go in the future to improve treatment? 

I think that one of the biggest challenges right now, and it's largely being driven by the increase in demand for effective treatment, is that I think we need to work harder at improving efficiencies, and the challenge is, we don't actually have the data to guide our decisions about how to be more efficient. So we don't yet know what is the optimal length of treatment, nor do we really know much about what are the effective mechanisms of effective for empirically based treatments, and without that information we can't improve upon our existing treatments. 

So, certainly there's work being done in that regard and we're, in many ways, in the early stage of beginning to get a better handle on what are some of the mechanisms that are associated with outcomes. But I think there's much more work to be done and if we're going to have a much broader impact on you know people affected by the disorder. I think that we need to do more and I think we need to do it more efficiently, and I think we need to do a better job.

Narcissistic Personality Disorder

Professor Kenneth Levy (USA) talks about narcissistic personality disorder.

Dr Kenneth Levy Project talks to the Project Air Strategy about Narcissistic Personality Disorder 

The concept of narcissism has a long history, going back to the early Greeks. Clinical writers began interest and began having interest in narcissism as a clinical entity in the mid 1800’s and in the early 1900's writers started talking about narcissism at the threshold of a disorder, and it wasn't though, until Diagnostic and Statistical Manual (DSM) 3 in 1980 that narcissism was included as an official disorder in the American Psychiatric Association diagnostic manual. Typically the conceptualization that was developed at that point was based on ideas that came from Otto Kernberg and Ted Milan as well as Heinz Kohut, but focused mainly on the overt grandiose aspects of the disorder - people's concerne with power and wealth and beauty and ideal love, essentially having a pathologically grandiose sense of oneself. 

Although clinical writers had also talked about the other side of narcissism, this more vulnerable side and a number of critical varieties that also talked about the fact that the grandiosity that you see in narcissistic individuals serves a defensive function against the vulnerability in the end, the feelings of smallness. But the DSM at that time didn't include those aspects of it, and over a number of iterations of the Diagnostic and Statistical Manual, the DSM, we now have a definition that is actually quite similar to the initial definitions that focus in on the grandiose pathological sense of self, which seems to be the defining characteristic. It seems as if future editions based on the research that's occurring will incorporate the more vulnerable side of narcissism, seeing these two aspects of honourable in the grandiose aspects of narcissism as two sides of the same coin. 

Question: What are the two subtypes? 

Typically there are these oscillations between vulnerable and grandiose states. Kernberg wrote about this most centrally, however in the 1990’s in the early 2000’s there was a lot of research on subtyping narcissistic personality disorder where, through factor analytic studies, they identified the a grandiose subtype and a vulnerable subtype, and that led people to actually think of them as two different types. 

Question: Can grandiose & vulnerable narcissism exist in the same person? 

Yes, however in reality there are some people who might be predominantly grandiose or predominantly are over in their narcissism and some people are predominantly vulnerable or a covert in their narcissism, but typically patients vacillate between the two. That the grandiose narcissist when they face failure they become deflated and well aware of their deficiencies and in those moments they can actually be quite distressed and suicidal, and vulnerable narcissists, even in their presentation has being the most disturbed, the most upset, or the most aggressed upon, have a flavour of the grandiosity in terms of the worst in terms of having, in terms of their experiences. 

Question: Why does treatment take time? 

Narcissism is probably, after antisocial personality disorder, the most difficult personality disorder to treat, and ironically it's more difficult to treat than borderline personality disorder.

I say ironically, in part, because a lot of narcissism narcissistic personality disorder patients are actually functioning in many ways much better than patients with borderline personality disorder, but the there's such a strong defence against any feelings of vulnerability or weakness that it makes it very difficult for therapists to get through that and to actually be able to talk with patients about the kinds of difficulties that they might be having.

Borderline Personality Disorder

Dr Nancy McWilliams (USA) talks about borderline personality disorder, challenges, effective therapy and her experience as a therapist.

Dr Nancy McWilliams talks to Project Air Strategy about Personality Disorder.

Question: What are the current challenges to treating personality disorders effectively?

Theoretically and in clinical experience we know that you can't just medicate a personality, it's psychotherapy that's the treatment of choice for problems in personality, and that takes a while. It takes a relationship of trust, it takes a capacity of collaboration between two individuals that become a unique team to try to understand and change very deep set patterns.

Question: What has history taught us about effective therapy?

We have a vast literature on different kinds of ways of experiencing in the world and what the implications are for a therapeutic relationship. Even on such a simple matter as whether the therapist moves in to sit closer to the patient, or gives the patient a lot of space. More depressive people feel better when you do the former, the more schizoid people feel intruded on when you do that and they much prefer having space. Even simple things like that are important for therapist to know. 

Therapists who get taught about nothing but specific symptom syndromes, and what treatments have been found in some statistical majority of patients to be helpful, don't have nearly the repertoire of understanding of how to make a therapeutic relationship as those people who've been trained in individual differences.

I've had a lot of therapists come to me, I do a lot of supervision and consultation over the years, saying I got a lot of training about how to apply different techniques, but I didn't get training in the differences among individuals that I would be applying the techniques to, and I'm learning through hard experience that it makes a huge difference. So, for example, somebody will read the literature on self-disclosure and find that in general the therapists saying something personal about the self, statistically speaking, gets a good response from most patients, but if you do that with somebody who's narcissistic they will feel resentful, as if are you talking about “you”, ‘why aren't you listening to me’, and it will make the therapy worse, not better.

So there are numerous instances like that. With paranoid people you don't want to be as warm as you are with other patients, because they wonder why you're being so warm, what's your hidden agenda, why are you trying to seduce them, whereas if you're warm with a person who's depressive they think,’ finally I'm talking to a person that has a real feeling for me’. Those differences matter enormously and we need to put more emphasis on them.

Question: What do therapists need to become effective?

I advise young therapists to go as deeply as possible into their own knowledge of themselves via psychotherapy, but also via meeting about personality differences, finding supervisors that know how to talk this language. If you work with people with severe personality disorders, there's no surviving it without a lot of consultation and help from colleagues, because you get pulled into the painful affects, the painful feelings of the people who live in these difficult psychology's, whether it's paranoid or borderline or narcissistic, you need a lot of consultation.

I’ve been practicing 40 years and I still talk to colleagues regularly about the difficulties of the work. I am extremely grateful to have worked on my own personality and my own psychoanalysis. It not only helped me understand myself and find places in myself of borderline stuff, possessive stuff, schizo stuff, paranoid stuff, so that I had a greater range of empathy. It also gave me the ‘deep in my bones’ conviction of how helpful psychotherapy is - how much of a difference it makes for people, so that when I'm sitting with somebody who's been trying all kinds of things to improve their life and has now become demoralized and despairing of really getting help, I have to carry the hope for the two of us for a while. I have to have confidence that this works, and that's where I got it from, my own experience in psychotherapy.

My life is radically different from what it would have been if I hadn't had good psychotherapy.

Question: What do therapists need to know after diagnosis?

The DSM (Diagnostic and Statistical Manual) describes differences in personality based on traits. You have a paranoid personality, you were suspicious and distrustful, for example. Those are traits. That's not wrong but it misses the fact that it's the theme that organizes the paranoid person. The theme of paranoia is trust versus distrust and paranoid people can be pathologically over trusting, not just pathologically under trusting. There are a lot of paranoid people that feel that their cult leader or their idealized political leader is perfect. That's being pathologically over trusting.

In obsessive people they have the trait of neatness but that misses the theme of control, dis- control, neatness, messiness. The most of obsessive compulsive people I've ever worked with have a terrible mess somewhere but they coexist with all these efforts to be neat.

People with hysterical psychologies are sometimes very seductive and sometimes very prudish, so the trait of seductiveness misses the dynamic of a theme about sexuality, gender, and power.

Schizoid people are famous for the trait of withdrawal, but they will sometimes have moments of exquisite connection with people from which they then flee. So even the way we try to describe people based on the traits in our taxonomies, this is the internal experience of what it's like to see the world a certain way, to see the world as defined by who do you trust, or not, or as defined by whether you’re in control, or not, or as defined by gender and power, or as defined by closeness and distance. And you know, there are other themes for the other personalities and we don't go near that in our descriptions but for therapists, you have to have a feel for that.

There are other ways of thinking about individual differences that take those internal experiences more into consideration. I know you've done a lot of work with people with borderline. Psychologists really describe borderline psychology very well as without a feeling for the terrible preoccupation with whether you're connected or disconnected, and the terrible anxiety if you feel rejected, and the terrible feeling of being controlled if you feel too connected.

Those are internal experiences that are important to understand, and also you want to understand the way the persons with borderline psychology behave. You know, they will complain for years about their horrible partner, and you help them separate from the partner and then they get free and they go into abandonment terror. So if you don't understand that, you're working toward a goal that you don't fully understand. You don't know what to make of it when that doesn't help the person and you decide, okay, this kind of person isn't amenable to treatment so now I'll throw them out of treatment. You really need to understand what their internal experience is like, to understand what the nature of treatment is.

Question: Has modern diagnostic methods minimised the importance of personality in treatment?

Up until about 1980, when the Diagnostic and Statistical Manual of the American Psychiatric Association made a major paradigm change, it was personality that preoccupied most clinical writing - individual differences, like whether you were more hysterical, obsessional, paranoid, ,narcissistic, schizoid  - there were many different sort of organizations of personality on which there was a fairly large clinical literature and in some cases a significant empirical literature, and those literature's were very helpful to therapists because an anxiety disorder in a person with hysterical psychology looks different in response to a different kind of therapeutic style than an anxiety disorder in an obsessional person, for example. But in DSM 3 and since then personality disorders were first of all kind of an afterthought, they were literally relegated to the back of the book because that manual was more interested in describing specific syndromes, especially depressive and anxiety syndromes, but also eating disorders addictions and other problems, and the personality in which those occurred were somewhat minimized.

Question: What would you have liked to have known at the start of your career?

I guess I would love to have known how powerful the emotional experience is, really getting inside another person's sense of the world. I don't think people who were not therapist have any sense of how exhausting it is to let yourself feel all the toxic emotions that come at you from people who suffer a lot. I would probably try to prepare myself for that and also give myself some advice to be sure that I had places in life that were free of that. You can't be in that space all the time. You have to have friends completely outside the psychotherapy network or some hobby or interest that nourishes. There's an awful lot of exhaustion from doing the work.

I would certainly encourage myself as a young person to get a lot of group supervision to take advantage of listening to other people's struggles with their patients, and I would I would put much less emphasis on theoretical orientation and more on experience. You can learn from people of any theoretical orientation. We're all looking at the same suffering animal, we have different languages for what we are describing, but experienced therapists tend to work rather more similarly than new therapists – very different theoretical orientations. So the more interaction you have in the people who influence you, the more you can learn from different orientations, the better.