I was just following orders…

“I was just following orders.” The Nuremberg defense, just following orders, Due Obedience, or by the German phrase Befehl ist Befehl (“an order is an

Center-staging, displays, and untoward behavior

During this writer’s brief tenure in mental health, it brought with it the opportunity to observe the most obscene, ornate, loud, and grandest ‘displays’ from clients and colleagues.

Center-staging is not just about the magnitude, energy, and investment in thought gone through by patients to create a figurative and literal circus around them. Instead, both worker and client’s seductive pull and mystique experienced when enacting these outrageous behaviors—rooted in creating one giant emotional and behavioral maelstrom.

Center-staging can create countertransference for workers and peers in the mental health field who find themselves trapped in their client’s very life. This shift in the power dynamic, perhaps even put into play to do just that, becomes a remarkable turn of fate for everyone involved. This turn brings with it irony and inserts it deep into the relationship and work process. When the worker finds him or herself front and center in the life of the client. Becoming the object of their desire and madness, all emotions, and even feelings of safety become subsumed into the client’s new playground.

This writer recalls one client who moved into an adult home. After living independently for her entire adult life, our ACT (Assertive Community Treatment team) serving team signed off on the client’s incessant requests to reduce her living standard and give up her independence. All of a sudden, the client’s mental status was in free-fall.

She began persevering over her ongoing capacity to perform even the most basic of ADLs and maintain livable conditions in her apartment within the adult home already partially maintained by the staff’s home. It was as if our client relinquished all ability to function within her new environment with even fewer responsibilities than before and zero added stress.

At this point, our team was scrambling to figure out how someone could have decompensated so quickly and lost all hope to reconstitute in the process? As our team began to answer these questions, we realized our staff was bound up within the seductive energy of diagnosed borderline and histrionic patient in a full-blown crisis.

Discovering ourselves center-stage in our client’s life, almost, working harder at introspection and self-reflection is a dark and dangerous place. The countertransference can and will build slowly, then faster and faster as the energy implodes all within its reach. This particular ACT client was having trouble living on her own independently in the community and stated she wanted to move into an adult home to receive round-the-clock care, e.g., help toileting, meal preparation, transportation to doctor visits in the surrounding community. The home also had an in-house case manager assigned to each of the residents.

The impulse of the borderline patient who has histrionic traits to self-sabotage goes deep. It can be too 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 a borderline patient now ready to lose all control for “one last” opportunity for attention, sympathy, and guilt, watch out and be ready. This patient decided our team was not helping her because we let “this” happen. The fall-out of weeks of bad decisions and maladaptive reasoning put into action. The next week we visited, we learned the patient had admitted herself to the local ER and threw her body, lunging at a medication tray to collapse on the floor. The ER staff, all too familiar with this behavior, discharged the patient back to her adult home hours later.

Patients with PTSD diagnoses who are also chronically homeless are also tricky clinically to treat. These folks become very symptomatic, lose everything repeatedly, and then experience a spike in their PTSD symptoms from the re-traumatization. For a person treating the displays and emotional outbursts, it can be tough to separate the extreme nature of some client’s self-destruction during a break, episode, or short lousy turn in their path to recovery.

Some clients can be very, very loud, and so agitated that it becomes not only dangerous to be close for both parties, but may become a physical risk to everyone involved. The potential legal risk if one party needs to press charges on the person who 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 does a therapist treat chaos and inconsolable behavior? The trick is…well, there is no one specific clinical therapy per se but rather the application of trauma centered skills and techniques applied with clinical precision. In cases like these, listening, some re-direction, and disputing irrational cognitive distortions as they surface in the dialogue is the best a person will do unless unlocking the mystery of a 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 feels heard and listened to when they were in crisis. Since there is no solution for solving, try to be less problem-focused. Shift the thinking from reparative to creative and less crisis-driven work. Since the issues are far too deep and too complicated, there is no long-term solution aside from being too reactive and triggering the client to feel out-of-control. Hopefully, the clinician feels in control of the situation, because clients can sense and are in touch with clinicians afraid of their clients and feeling like they have lost control of the intervention. Modeling self-control, and providing some verbal self-assurance may be just what is needed at the moment.

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