[autumn-moon]

Just curious.....

There is always griping going on at my job in a state acute care facility that pts. with Borderline Personality D/O require so much staff and so much time to keep them safe that the patients with psychotic disorders such as Bipolar Affective D/O, Schizophrenia and Schizoaffective D/O tend to end up getting much less care and attention than they diserve, as 90% of the staffs time and energy is spent ensuring the safety of the 'Borderlines'.

Some other nurses have said that in most other states, that "Borderlines" are not allowed to languish in in-pt. care, but are forces to deal with their problems in the "real world" with out-pt. care which is specialized to deal with their particular problems, such as DBT.

I'd like to get a sense of how our state compares to the rest of the country. We spend a huge amount of money to keep these people in in-pt. care for months or years, often with 1:1 staffing, not to mention the multiple trips to the hospital when they suddenly regress and manage to hurt themselves despite staffs best efforts to prevent it.

How does your state handle this, and what are your opinions?
I personally tend to think that these pts. use the hospital as a safe haven and that it tends to reinforce their maladaptive behaviors more than it actually helps. They also say that they have picked up a lot of these behaviors from their peers while in in-pt. care.

We are in the postion, where I live, that these folks are sent to us, after a self-abusive episode, straight from the ER, and we have a policy that no one is to be turned away. Many of them are "frequent flyers" or have been in in-pt. care for months to years.

TIA for your input!
Melissa

[Nurse Ratched]

General rule: get 'em out as soon as possible. (This of course, means the true borderlines, not the ones who just annoy you like a person with BPD .)

My rule on my shift: borderlines assigned to me report directly to me with all needs. That way I can assure a consistent response. All staff are aware that pt is to be directed to me with even the smallest concern. Yeah, it gets a little old by the end of the day, but if there is any question in my mind that everyone is not 100% on board with the plan of care, it's the only way to avoid the problems created by the master staff splitters.

There doesn't appear to be a single mindset (at least in practice) as to how to deal with the true borderline, unfortunately. I don't work in a state-run setting, but I have a fellow nurse friend who does and she states the inconsistencies there are problematic as they are everywhere, it would seem.

[chris_at_lucas_RN]

Originally Posted by Nurse Ratched

My rule on my shift: borderlines assigned to me report directly to me with all needs. That way I can assure a consistent response. All staff are aware that pt is to be directed to me with even the smallest concern. Yeah, it gets a little old by the end of the day, but if there is any question in my mind that everyone is not 100% on board with the plan of care, it's the only way to avoid the problems created by the master staff splitters.

Absolutely brilliant! I've always liked working with borderlines (as an LMFT), but I didn't like the staff splitting they are soooooo good at, and if you deal with the staff's difficulties in managing the splitting, there's no time left to work with the patient. Which of course just supports their contention that you really are "all bad" (as opposed to the "all good" you might have started out with!).

Makes me want to do psych nursing instead of med surg.....

Back to the OP, in the acute care situations I've worked, units worked hard to keep borderlines from being admitted, and if they were, the units worked hard to get them discharged fast. I always found they were just as interested as anybody else in not feeling awful, and that some gentle patient education about "how it feels to have borderline personality disorder" seemed to help. Since they craved attention, basic behavior mod (not unlike managing a toddler's tantrums) worked pretty well, as long as they didn't manage to up the ante enough to totally disrupt the unit or hurt themselves in the process.

But most of my experience with them was as an outpatient therapist--limit setting kept the onslaught to a minimum.

[autumn-moon]

Originally Posted by chris_at_lucas

Absolutely brilliant! I've always liked working with borderlines (as an LMFT), but I didn't like the staff splitting they are soooooo good at, and if you deal with the staff's difficulties in managing the splitting, there's no time left to work with the patient. Which of course just supports their contention that you really are "all bad" (as opposed to the "all good" you might have started out with!).

Makes me want to do psych nursing instead of med surg.....

Back to the OP, in the acute care situations I've worked, units worked hard to keep borderlines from being admitted, and if they were, the units worked hard to get them discharged fast. I always found they were just as interested as anybody else in not feeling awful, and that some gentle patient education about "how it feels to have borderline personality disorder" seemed to help. Since they craved attention, basic behavior mod (not unlike managing a toddler's tantrums) worked pretty well, as long as they didn't manage to up the ante enough to totally disrupt the unit or hurt themselves in the process.

But most of my experience with them was as an outpatient therapist--limit setting kept the onslaught to a minimum.

Unfortunately, in our setting, most of the borderlines are hardcore....even the kids (with whom I don't work...I don't have the energy for that!
I actually do enjoy working with them....up to a point. I don't think we're doing them any favors keeping them in-hospital, but we're kinda stuck between a rock and a hard place....every time we get close to discharge, they become anxious, and totally up the ante by cutting, swallowing, or assaulting, etc. Since we are charged with keeping them safe, they end up with a 1:1 situation. The best approach, so far, is to institute some sort of room program which gradually allows them more social contact contingent on their safe behavior. I still think that the best situation would be court-ordered out pt. care when they are discharged from the ER, rather than in-pt. care, which only provides opportunities to learn new maladaptive behaviors and reinforces their inablility to handle stress on their own.

I've been working hard with a couple of hard core borderlines.....we are working on ways to "talk back" to their "voices"....ie: learning to disagree in an adult manner and learning other, healthier ways to handle stress and distraction techniques. The basic theme being that they repeat a "script", when the "voices" are urging them to harm themselves, which essentially says that they are now adults and have learned better ways to cope rather than harming themselves. They also carry a list of alternate activities that we have worked up together to use during times of stress. So far it seems to be helping a lot, but it is a very, very long process. And so the very sick, but low profile pts. still don't get the time they deserve....sigh.

[CliveUK]

Acute in-patient units are not appropriate for more than a very short-term crisis admission for people with BPD. However, over here in the UK, I'm sure it's the same as over there in the US: BPD patients up the ante by carrying out ever more dramatic acts of self-harm in a bid to extend their hospital stay. Some of them inevitably end up detained under mental health legislation. Experience tells me this allows them to avoid responsibility for their actions and be kept away from whatever stresses and strains are outside of hospital and which led them into hospital in the first place.

They are perhaps the most frustrating and infuriating group of patients to deal with. The havoc they can cause on acute units, well...I don't need to tell you about it I'm sure. And yes, it does gall to see them sucking attention and time away from people with mental illnesses.

Nurse Ratched offers some excellent strategies for dealing with BPD patients. But I think the best thing you can do for them is to advocate for their swift discharge.

[Hukilau]

Originally Posted by Nurse Ratched

General rule: get 'em out as soon as possible. (This of course, means the true borderlines, not the ones who just annoy you like a person with BPD .)

My rule on my shift: borderlines assigned to me report directly to me with all needs. That way I can assure a consistent response. All staff are aware that pt is to be directed to me with even the smallest concern. Yeah, it gets a little old by the end of the day, but if there is any question in my mind that everyone is not 100% on board with the plan of care, it's the only way to avoid the problems created by the master staff splitters.

There doesn't appear to be a single mindset (at least in practice) as to how to deal with the true borderline, unfortunately. I don't work in a state-run setting, but I have a fellow nurse friend who does and she states the inconsistencies there are problematic as they are everywhere, it would seem.

Yes, a primary staff contact person and an agreed upon plan of care is the key concept in an inpt unit. I have found it's also helpful if the pts outside therapist has a standing agreement that she/he won't see the pt while they are in the hospital. A novel approach one psychiatrist used was a contract that specified a borderline pt. could be in the hospital a certain number of days every three months for a maximum of three days at a time. Of course, that was back in the days when insurance companies did not ask many questions about admissions!

[Whistleblower]

Originally Posted by Hukilau

Yes, a primary staff contact person and an agreed upon plan of care is the key concept in an inpt unit. I have found it's also helpful if the pts outside therapist has a standing agreement that she/he won't see the pt while they are in the hospital. A novel approach one psychiatrist used was a contract that specified a borderline pt. could be in the hospital a certain number of days every three months for a maximum of three days at a time. Of course, that was back in the days when insurance companies did not ask many questions about admissions!

Besides limiting staff contact and providing a primary contact staff person for the Borderline; to avoid splitting; Benign Neglect is the Management of Choice for the general staff dealing with the Borderline Personality Disorder.

Forget about continuous room plans and indefinite 1:1. These treatments causes severe dependency; simply do not work; and, in some states could be judged as illegal and coercive in nature. In addition such treatments are countertherapeutic in the long run and do remove care from other patients.

These people are living a lifestyle of continual crisis and self loathing. If they are to ever change for the better then a certain dignity of risk must be taken collectively by all staff. Once the Borderline goes over the edge of sanity and reasoning and there is an immediate threat of suicide, then and only then, should a temporary 1:1 be ordered and even this must be time limited and well defined for safety reasons only.

Most certainly, DBT is, without a doubt, the best treatment for the Borderline when done by those who are trained. One distinct advantage of this treatment over 'room plans' is that it can be ongoing and done outside a hospital setting. While the Borderline is in the hospital, general staff should always be non-judgemental. General staff should encourage the Borderline to employ the Tools provided in this treatment especially whenever she is in crisis with others and/or is contemplating self harm..After a borderline anounces that she averted the crisis, praise is in order by all.

Regards,

Tom

[lovingtheunloved]

Maybe this is a silly question, but is every cutter a Borderline?

[Thunderwolf]

In my experience, unless there is an active psychotic process going on, my cutters have usually been BPD, or tendencies thereof. Fairly easy to differentiate. The "voices" of a BPD are usually internal, usually someone that has been a past threat, causing harm. Some have proposed that BPD is a similar process to PTSD, but has impacted the person developmentally ...therefore, the personality disorder. Most truly psychotic folks do not present this as the "cause" of their disorder. In fact, it is often absent. In this case, "voices" are usually external and can be bizarre in their requests or demands of the individual, even if a voice is someone they know. Again, usually a psychotic individual presents with other symptoms of psychosis...such as delusions or paranoia. However, there is nothing preventing a person experiencing both disorders. This is the reason that accurate health/family/social histories are important . Look at the whole picture, the person's presentation, and cluster of symptoms. A good spot check on a mental health unit is that persons of PD find each other like magnets, where a person with psychosis often does not, usually isolating from others due to their symptoms (unless mania is present). BPD as a name came from the old school of Freudian psych where a person "Bordered" between Neurosis and Psychosis. There has been talk in the past that a renaming of the diagnosis is in order, which I agree. One such possible rename was "unstable" personality disorder in order to better catch the nature of the disorder. Instability or unstable is a better term than borderline. Personally, I think "chaotic" is a better term. Now what's interesting is this Goth/Punk culture which lets kids be Borderlinish as a means to fit in. Many out grow it, thank goodness. What does cutting do for most who do it who are not psychotic? Many clearly state that it allows them to "feel" their pain or to reduce their experience of it. This is really not too surprising since there is usually a release of body endorphins, the body's own pain killers. The problem is that some folks can become addicted to this sort of behavior, sort of like dare devils living for the rush. Again, not all cutters are the same, but they do share some common traits...internal anquish, anger, emptiness, loneliness, and feeling misunderstood by self and others. I agree, inpatient stays should be kept extremely brief in order to not foster dependency (reinforcing the behavior with the reward of a hospital stay). The cut should be stiched up in ER, and unless genuine suicidality is present, referred back to or to a therapist. What has been others experience regarding cutters?

[Whistleblower]

Originally Posted by Thunderwolf

In my experience, unless there is an active psychotic process going on, my cutters have usually been BPD, or tendencies thereof. Fairly easy to differentiate. The "voices" of a BPD are usually internal, usually someone that has been a past threat, causing harm. Some have proposed that BPD is a similar process to PTSD, but has impacted the person developmentally ...therefore, the personality disorder. Most truly psychotic folks do not present this as the "cause" of their disorder. In fact, it is often absent. In this case, "voices" are usually external and can be bizarre in their requests or demands of the individual, even if a voice is someone they know. Again, usually a psychotic individual presents with other symptoms of psychosis...such as delusions or paranoia. However, there is nothing preventing a person experiencing both disorders. This is the reason that accurate health/family/social histories are important . Look at the whole picture, the person's presentation, and cluster of symptoms. A good spot check on a mental health unit is that persons of PD find each other like magnets, where a person with psychosis often does not, usually isolating from others due to their symptoms (unless mania is present). BPD as a name came from the old school of Freudian psych where a person "Bordered" between Neurosis and Psychosis. There has been talk in the past that a renaming of the diagnosis is in order, which I agree. One such possible rename was "unstable" personality disorder in order to better catch the nature of the disorder. Instability or unstable is a better term than borderline. Personally, I think "chaotic" is a better term. Now what's interesting is this Goth/Punk culture which lets kids be Borderlinish as a means to fit in. Many out grow it, thank goodness. What does cutting do for most who do it who are not psychotic? Many clearly state that it allows them to "feel" their pain or to reduce their experience of it. This is really not too surprising since there is usually a release of body endorphins, the body's own pain killers. The problem is that some folks can become addicted to this sort of behavior, sort of like dare devils living for the rush. Again, not all cutters are the same, but they do share some common traits...internal anquish, anger, emptiness, loneliness, and feeling misunderstood by self and others. I agree, inpatient stays should be kept extremely brief in order to not foster dependency (reinforcing the behavior with the reward of a hospital stay). The cut should be stiched up in ER, and unless genuine suicidality is present, referred back to or to a therapist. What has been others experience regarding cutters?

Well done!

I especially agree that a sort of perverse pleasure-release of endorphins- take place during the cutting episodes. Surprisingly, when patients are able to label their sick behavior of cutting as an addiction a recovery process can usually take place.

Placing patients in restraints and or seclusion for extended periods of time - weeks and months at a time to stop this behavior- does not help these patients and tends to make things worse for all concern.

Regards,

Tom