On Wednesday, February 4, 2004, Dr. Robert Abernethy, III, M.D., from the MGH Department of Psychiatry, gave a talk entitled "Managing the Distressing Patient," as part of a series sponsored by the Chaplaincy Department.

Dr. Abernethy began his talk by reminding the audience that by the time a social worker or chaplain is called in, the patient has most likely already gone into distress. It is important to keep in mind that this patient is frightened, helpless, insecure, guilty, angry, ashamed, lonely, or all of the above. The labels "borderline" and "narcissistic" are the labels most commonly used for the most distressing patient.

The most common characteristics associated with a borderline label are:

• frantic efforts to avoid real or imagined abandonment
• a pattern of unstable and intense interpersonal relationships characterized by alternating between extreme idealization and devaluation
• identity disturbance - markedly and persistently unstable self image or sense of self
• impulsivity in at least two areas that are potentially self-damaging
• recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
• chronic feelings of emptiness
• inappropriate, intense anger or difficulty controlling anger

The most common characteristics associated with a narcissistic label are:

• a grandiose sense of self-importance
• is preoccupied with fantasies of unlimited success, power, brilliance, beauty, or ideal love
• believes that s/he is special and unique and can only be understood by, or should asso-ciate with, other special or high-status people
• requires excessive admiration
• has a sense of entitlement
• is interpersonally exploitive
• lacks empathy
• is often envious of others or believes that others are envious of him or her
• shows arrogant, haughty behaviors or attitudes

Dr. Abernethy stressed that there are two common pitfalls in dealing with the distressing patient:

• Taking the patient's anger and helplessness personally. (For example, "His feelings are my fault" or "His feelings are my responsibility" or "I have to do something.")
• Getting caught up in the patient's splitting - dividing people into "us" vs. "them." (For example, "My nurse on this shift is really a jerk. I wish she cared as much as you do.")

The antics of the distressing patient make her/his situation worse. The patient may be telling you that no one likes him, while over the last few days, he has been miserable to the staff. It is important to bear in mind how effective simply listening to the patient can be. Try saying something like, "I can't imagine how you feel, but please try to tell me about it so that I can understand."

Dr. Abernethy discussed twelve practical strategies for the management of borderline and narcissistic patients. He states, "Psycho-dynamic insight allows us to understand these patients and to ally with them. However, behavioral strategies allow us to help them!"

1. If you can't or don't like the patient, get consultation immediately or get out of the alliance.
2. Be frank and straightforward with these patients. Dr. Abernethy suggests you say something like "You know it is really hard for me to see you because of the way that you speak to me."
3. Avoid getting into the position of being angry with the patient. If the patient is making you angry, you aren't setting limits appropriately or you may be stuck in contertransference distortion.
4. Be a teacher to the patient. For example, Dr. Abernethy suggests that you "tell the patient what a borderline or narcissistic personality disorder means, or explain how we think someone acquires such a disorder. The patient should understand what the strategies of the therapy are, what your role is in making the therapy work, and what the patient's responsibilities are."
5. Find a person in the patient's life around which to focus therapeutic work.
6. Homework for the patient between visits fosters hopefulness and reinforces the importance of life outside as the place where change will occur.
7. If the patient begins to make phone calls between visits, carefully define the meaning of the calls and your strategy in response.
8. Suicidal ideation or action may represent many issues, including the patient reminding him/herself that there is a way out of the suffering. In this case, suicidal ideation may allow the patient to keep going. Suicidal action usually suggests a major problem in the therapeutic alliance that must be evaluated by a consultant.
9. Avoid letting the therapy gradually become a constant in the patient's life that stops promoting change.
10. Pharmacological management can present unique challenges with these patients because the patient may feel like you are saying "shut up and take a pill." Always consider the dynamic and behavioral meaning of prescribing… or not prescribing.
11. Be willing to take a break from therapy when no progress is being made.
12. A series of briefer therapies with the same or a different therapist during times of pain or crisis may serve these patients better than one long-term alliance.

Remember to collaborate with colleagues about these patients and communicate with the medical staff.

- Thanks to Dr. Robert Abernathy for his assistance with this article.