I have witnessed the most obscene, ornate, loud, and grandest displays from people I work with both clients and colleagues. Center-staging isn’t just about the magnitude and lengths gone through to create a circus around him or her. Instead, it is the seductive pull and mystique about enacting the behavior rooted in creating one giant emotional and behavioral maelstrom. Center-staging can create countertransference for workers and peers whom find themselves trapped in the life of their client, and a great turn of irony, front and center in the life of their client where the object of his or her madness is your playground and you must be the clients savior.
I am reminded of one client who moved into an adult home after living independently for her entire adult life. All the sudden the client’s mental status was in free-fall, and she began perseveration over her ongoing capacity to perform even the most basic of ADL’s and maintain livable conditions in her apartment. Clearly at this point, myself and our team we 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 realized we already in the seductive pull of a borderline and histrionic diagnosable client in full blown crisis.
Discovering ourselves center-stage in our client’s life, almost, working harder at introspection and self-reflection, the countertransference can and will build. Now, this client having trouble living on her own for the first time was stating she wanted to move into an adult home and receive round-the-clock care e.g. help tioleting, 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 whom has histrionic traits to self-sabotage goes deep, it can be extremely confusing for the patient experiencing the symptom, and even more beguiling, profoundly a-motivational for someone with a long history of loss and relapse. For the borderline 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, the fall-out of weeks of bad decisions, and 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 or her PTSD symptoms from the re-traumatization. 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 behavioral 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 behavior? 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 as the clinician feel in control of the situation, because clients can sense and are in touch with clinicians afraid of their clients and feeling like they’ve lost control of the intervention. Modeling self control, and providing some verbal self-assurance may be just what’s needed in the moment.