How to deal with a Borderline who tries to pick a fight?

[lishka15]

Hi everybody,

Last week I had to "guard" a Borderline patient overnight, and it didn't go well, so I was hoping for some advice from you wise and experienced psychiatric nurses. My apologies if this story is too long, but maybe it will make it easier to give some in-depth guidance if you know the details.

I work as a nursing assistant in a somatic department for the summer. This patient was supposed to stay overnight for a procedure and then go back to her treatment facility the next day.

My job was to keep her from harming herself, and I was told that she seemed calm and nice, and that she was about to fall asleep. When I got into the room, a young doctor and her nurse was trying to convince her to agree to the treatment she was there for, as she kept changing her mind. She barely answered, and had a sulking vibe. I had expected the doctor to be more firm, but both he and the nurse were very accommodating.

The trouble began after an hour, when she obviously got tired of pretending to sleep, and turned around and started looking at me as if she was trying to figure out what kind of person I was. I smiled and tried to be nice, casual and relaxed, yet not seem insecure. I am aware of borderline splitting, and didn't want to go into her "bad person" category and trigger rage or difficult behavior.

She was nice for about two minutes and seemed to accept me, but then she started asking why I had to sit in that room with her. I sensed that she was about to pick a fight, so I tried to answer as light and casually as I could, and said something like "The doctors are probably worried that you're going to hurt yourself". Obviously the wrong answer, and she started arguing, saying that "she would never do such a thing". (Although I knew that the last time she was in that hospital, she hurt herself badly.)

What should I have done differently here?

Then she suddenly asked to go to the restroom, and it dawned on me that I hadn't been informed about the rules (unlocked/open door or go in ther with her), so I asked the nurse, who told me that the door to the bathroom had to be unlocked, and that I had to stay in her room (She had a private room with an en-suite bathroom). Then she began arguing again, saying she was "unable to go to the restroom when I was right outside the door", sulked and shouted.

What should I have said?

I was really unsure about how "firm" I was allowed to be, after observing how accommodating the doctor and the nurse had been, and my mind was on high gear trying to find a strategy to de-escalate the situation.

After a while I gave up and the nurse (who obviously was in her "good people" splitting category) went in to talk to her, and she agreed to an unlocked door. But when the nurse was gone, she started the same argument again. Then she went over to her bed and put on her shoes. I asked: "What are you doing?" and she said: "I'm leaving! I can't be here when I'm not even allowed to... (some obscure angry mumbling)". So she left. The nurse went after her to make her sign the discharge papers (The treatment she was there for wasn't "life or death" enough to make her stay against her will, and she wasn't considered acute suicidal), but she wouldn't sign anytning and just left.

I felt really shaky inside after this incident, and would really like to know what I could have done differently, in order to prevent such an outcome next time I encounter a Borderline patient. I tried to ask the nurses, but they said they - as somatic nurses - aren't very good with such patients, because they don't encounter them very often at that department. A young nurse even seemed surprised that the patient had acted that way, ("because she seemed like the calm type"), as if it was something I had done wrong (As a female medical student, some of the nurses are already extra critical towards me, and I really try to be good at my job so that we can co-operate well, and this for sure didn't make them any less critical or condescending.)

Any advice...?

[Jules A, MSN]

The good news is there is often little you can do to placate a patient with borderline personality disorder who wants to act out. It sounds to me like you were appropriate and I would imagine if she had stayed longer she would have decided you were her best friend, for a while, and then rolled back to being irritable. When I encounter the inevitable power struggle like the rule that she has to be observed while using the toilet and then refused to use it because staff has to be there I will not engage in the power struggle or even entertain negotiating or discussing a topic that is not up for compromise. Stay low key and say something like "Thats cool, you are free to make your own choices but if you change your mind just give me a holler". They will sense and feed on any increase in your anxiety or frustration so keeping it as nonchalant as possible is key, in my experience.

If you have time do some reading on BPD because the more you know the better prepared you will be and you will encounter them in all aspects of life not just on the psych unit. There are a couple of old books that are geared towards lay people that I still like including Stop Walking on Egg Shells. Many of these patients know about this diagnosis and are interested in discussing it which can give you an in or not, lol, there really is no predicting how they will roll.

The big thing I try to remember is this disorder feels awful, even though they are making everyone else miserable too, they truly are in pain and often have horrific trauma backgrounds. If you learn a bit about DBT that is something I like to suggest which has been shown to be helpful and can give these patients some hope as many of them have been made to feel that they are beyond help.

[lishka15]

Thank you so much! If you don't mind, I have a few questions to what you wrote.

The good news is there is often little you can do to placate a patient with borderline personality disorder who wants to act out. It sounds to me like you were appropriate

...speaking of "appropriate" - what would not be appropriate? What am I supposed to accept, and when am I allowed to draw the line and i.e. say that I won't tolerate verbal abuse, etc? Will a firm "NO" always (usually) be counter-productive, or can they respond well to firm boundaries and resistance?

and I would imagine if she had stayed longer she would have decided you were her best friend, for a while, and then rolled back to being irritable. When I encounter the inevitable power struggle like the rule that she has to be observed while using the toilet and then refused to use it because staff has to be there I will not engage in the power struggle or even entertain negotiating or discussing a topic that is not up for compromise. Stay low key and say something like "Thats cool, you are free to make your own choices but if you change your mind just give me a holler". They will sense and feed on any increase in your anxiety or frustration so keeping it as nonchalant as possible is key, in my experience.

So what you're saying is, you don't let her bend the rules, and if she doesn't agree to them, she doesn't get to use the bathroom (her choice being: either use the bathroom with your rules, or not at all)? What if it escalates and gets physical? I mean, she was anorexic and I am pretty fit, but still... I am terrified of doing something wrong, and breaking some kind of rule I wasn't aware of, or in worst case - having someone harm or kill themselves on my watch. (Or attack me. Or report me to the health authorities with some manipulative fabrication.)

Btw - is the "toilet rules" a common rage-inducing thing with such patients?

If you have time do some reading on BPD because the more you know the better prepared you will be and you will encounter them in all aspects of life not just on the psych unit. There are a couple of old books that are geared towards lay people that I still like including Stop Walking on Egg Shells. Many of these patients know about this diagnosis and are interested in discussing it which can give you an in or not, lol, there really is no predicting how they will roll.

But how far can I go in regards to discussing their problems - I mean, I sit there as a nursing assistant, clueless medical student and am only supposed to watch her... Can I somehow sabotage the work her therapist is doing, by talking to her about her disorder? Is it appropriate to initiate a conversation about it?

The big thing I try to remember is this disorder feels awful, even though they are making everyone else miserable too, they truly are in pain and often have horrific trauma backgrounds. If you learn a bit about DBT that is something I like to suggest which has been shown to be helpful and can give these patients some hope as many of them have been made to feel that they are beyond help.

Actually, I used to (used to!) have a high functioning borderline "friend", and as her "best friend" I was the target for some crazy, surreal "damned if you do, damned if you don't" fights. So I did read up on it, but I never found an effective way to deal with her and had to end the friendship. I tried just about everything. And even though I might seem calm and strong on the outside when borderlines go off like that, I'm terrified, shaky and my heart races like crazy. It's hard to remember what you have read, when you're in full fight-or-flight mode yourself.

I will definitely never, ever become a psychiatrist, but it would be nice to get to the point where I can stay calm and feel safe even when they act out. I wish there was some disarming general comments I could learn.

[lishka15]

Hmmm.... If I were to go with the flow, I would have said something like this: (Am I "allowed" to say something like this, in a firm way - if a borderline starts arguing, or would it be counter-productive or even out of line?)

She wants to fight because she isn't allowed to be alone in her room:

"I know what happened the last time you were here (hurt herself by injecting disinfectant into her pvc), and we don't want that to happen again. You might say that it won't, and maybe next time - if you prove to the doctors this time that you are willing to cooperate and meet us half-way, you will have more freedom. But in the meantime - what we all have in common, is that we are all judged by others based on our previous actions. And if we would like to change how other people view us and what they expect from us, we have to show them over time that we have changed. That's just the way life is, for all of us".

I have a few more of these kinds of responses in my mind.... but is it appropriate, or can the nurses fault me for it?

And does it have a chance of having a positive effect?

[Jules A, MSN]

I'm going to quote you and then answer so I don't miss anything. Probably a better way to do it but I'm old and not the most computer savvy. You make a good point about what your limits as a sitter might be and I'm not exactly sure of the answer with regard to patient education on things like DBT but again it wouldn't hurt to have knowledge. Being aware of different diagnosis and presentations is helpful under stressful situations because the knowledge is in your head you just need to remain calm and access it.

"what would not be appropriate? What am I supposed to accept, and when am I allowed to draw the line and i.e. say that I won't tolerate verbal abuse, etc? Will a firm "NO" always (usually) be counter-productive, or can they respond well to firm boundaries and resistance?"

To me it sounded like you tried to remain friendly and casual with the patient which I think is a good strategy. I don't argue, they are free to feel the way they feel and are free to make their own choice in how they decide to participate or not in their treatment.

Attempts at redirecting them can sometimes be helpful, causal conversation like what do they like to do for fun, do they like animals, what is their favorite concert, anything that can distract them from their gripes is worth a try.

Pissing them off is rarely worth it in my experience and as a sitter you are in a great position to play it off like "hang in there with me cause I'm only trying to follow the rules and keep my job. I'll do whatever I can within the rules to make you as comfortable as possible". To me that can diffuse some of their insistence that you are the one causing them the discomfort.

I'm firm with rules for consistency but rarely set boundaries about how they talk to me. In my experience they can be dramatic, histrionic and often out for shock factor. Like its the first time I have heard the "F" word, lol. I could care less if they are disrespectful to me or curse unless they are verbally threatening me with physical harm and in that case as a sitter I would let the nurse know and hopefully you would be reassigned.

"...speaking of "appropriate" - what would not be appropriate? What am I supposed to accept, and when am I allowed to draw the line and i.e. say that I won't tolerate verbal abuse, etc? Will a firm "NO" always (usually) be counter-productive, or can they respond well to firm boundaries and resistance?"

Not appropriate to me would be engaging in a negative way. Arguing with them or making them feel as if they are being a pita, even if they are.

"So what you're saying is, you don't let her bend the rules, and if she doesn't agree to them, she doesn't get to use the bathroom (her choice being: either use the bathroom with your rules, or not at all)? "

This will really depend on how the unit operates. On my unit inpatient psych, which of course is our business so we have more strategies in place, we rarely bend the rules with patients with cluster B traits, especially in the cases of safety like her using the bathroom alone when you know she has a history of self harm. Absolutely not. Her choice would be use the bathroom with me there or not, no skin off my nose either way.

"What if it escalates and gets physical? I mean, she was anorexic and I am pretty fit, but still."

Not that it can't happen but if you aren't engaging or arguing with them I think it would be fairly rare for them to go right to a physical attack. Like I said with the verbal stuff if it escalates especially to the point of threatening to harm you I would call for assistance. Again the good news is you are only there as a sitter so the nurses and techs will need to take charge of the situation.

".. I am terrified of doing something wrong, and breaking some kind of rule I wasn't aware of, or in worst case - having someone harm or kill themselves on my watch. (Or attack me. Or report me to the health authorities with some manipulative fabrication.)"

You are wise to be cautious about these very ill patients however unless you are asleep there is a very minimal chance a patient is going to successfully suicide without you at least being able to call for help, right? I would definitely take some extra time to speak with the staff and find out what your strategy for the shift is because having a united staff is going to be key. Again check for the rules of the unit but I don't ever close a door with these patients because they can and do make accusations which are almost never substantiated but like you I'm not into having that even be a consideration.

"Btw - is the "toilet rules" a common rage-inducing thing with such patients?"

For eating disorder patients absolutely although for patients with borderline traits anything can be rage inducing. Don't take it personally. Remember you didn't make the rule, you are only trying to do your job.

"I will definitely never, ever become a psychiatrist, but it would be nice to get to the point where I can stay calm and feel safe even when they act out. I wish there was some disarming general comments I could learn"

So you just have to force yourself to remain calm, fake it until you make it as they say. They will sense your apprehension and use it against you if you don't. Now if you happen to come across any disarming comments please let me know because I don't know anything across the board that will always work. Try distraction, minimizing your role in the rule making process while remaining firm that the rules will need to be followed and assuring them that you will attempt to be as minimally intrusive as possible in an effort to make them comfortable is a decent strategy. Hopefully others will write in and share their tips also. Good luck!

[Jules A, MSN]

Hmmm.... If I were to go with the flow, I would have said something like this: (Am I "allowed" to say something like this, in a firm way - if a borderline starts arguing, or would it be counter-productive or even out of line?)

She wants to fight because she isn't allowed to be alone in her room:

"I know what happened the last time you were here (hurt herself by injecting disinfectant into her pvc), and we don't want that to happen again. You might say that it won't, and maybe next time - if you prove to the doctors this time that you are willing to cooperate and meet us half-way, you will have more freedom. But in the meantime - what we all have in common, is that we are all judged by others based on our previous actions. And if we would like to change how other people view us and what they expect from us, we have to show them over time that we have changed. That's just the way life is, for all of us".

I have a few more of these kinds of responses in my mind.... but is it appropriate, or can the nurses fault me for it?

And does it have a chance of having a positive effect?

Anything you say can and will be used against you, remember that. :) I usually keep things very superficial and lighthearted if possible. She knows dang right well why she can't go to the freaking bathroom by herself so I usually won't waste either of our time revisiting it and the argument that will definitely ensue. You will need to feel out what your style is and what works for you.

I'm more along the lines of: "all I was told is that you aren't allowed to be alone at all for safety reasons so unfortunately I will have to hang with you but I'll try not to pluck your last nerve. How can I make this easier for the both of us?" Obviously when she says "you can get out of my face" I'd be like "hmmm wish I could girlfriend but I need this job cause I have 4 puppy dogs at home to feed so you are stuck with me for now". At that point if she doesn't totally cuss you out you can ask if she has any children or animals, anything to pull her out of the immediate drama, avoid staff splitting and lighten things up is always my goal.

[lishka15]

(....)

Thank you very very very much, Jules!!! I really appreciate that you took the time to share your insights. (And what a relief that I actually did try some of the strategies you proposed - distracting by asking where she's from etc when she wanted to act out, + taking the "I'm just the sitter" friendly approach. I think it went out of control because she sensed my insecurity, and the break when I had to go and ask the nurse.

Next time I will definitely make sure to talk to the nurse more thoroughly beforehand (and make sure we all agree on the rules, so that I don't end up as the bad guy if I stick to it and then the nurse intrudes and gives in.) .... and I will remember to stick to the cool "it's up to you" attitude! :)

I would really appreciate any feedback and advice from others, too! Especially on how I can deal with "such patients" when I've graduated and am supposed to treat them. I.e. when a patient such as her changes her mind a hundred times about whether to accept the treatment or not, to prevent the staff from running back and forth with the equipment and medications in an already busy department. I mean, sooner or later I guess I would have to give such a patient an ultimatum after they have changed their mind for the fifth time in an hour... any tip on how to do such efficiently (maybe from the start, to prevent forseeable problems related to the disorder)

[sadiemae1123]

I think you've been given some good advice above. I would only add that you should make sure that you review your facility's policy and procedure regarding a sitter's responsibilities. That should help you feel more confident in what you are and are not allowed to do.

[lishka15]

"all I was told is that you aren't allowed to be alone at all for safety reasons so unfortunately I will have to hang with you but I'll try not to pluck your last nerve. How can I make this easier for the both of us?" Obviously when she says "you can get out of my face" I'd be like "hmmm wish I could girlfriend but I need this job cause I have 4 puppy dogs at home to feed so you are stuck with me for now". At that point if she doesn't totally cuss you out you can ask if she has any children or animals, anything to pull her out of the immediate drama, avoid staff splitting and lighten things up is always my goal.

BRILLIANT, Jules Thanks a million!!

[lishka15]

I think you've been given some good advice above. I would only add that you should make sure that you review your facility's policy and procedure regarding a sitter's responsibilities. That should help you feel more confident in what you are and are not allowed to do.

I will do that first thing tomorrow! Thank you :)

[lishka15]

Oh, and one last thing!!

Is this "having a patient storm out and not return" something that has happened to other sitters as well, or is it so unusual that I can expect to be the talk of the department for the next weeks?

[FolksBtrippin, BSN, RN]

Avoid lecturing the patient and giving life lessons. Don't bring up past behaviors, or history, diagnosis. Pretend you have no idea why you are there, you're just doing what the boss said to do.

Don't engage unless the patientv wants to talk. Then it's hobbies, pets, tv shows, whatever.

Blame everything on the rules. Patient hates that you are right outside the door? Apologize abd validate her feelings. I'm sorry I have to stand here, it must be annoying for you.

You want to avoid touchy subjects and for borderlines there are a lot of them. You might stumble on some unintentionally and then you will need to do a quick recovery, talk about something else, like pets or whatever.

But some guaranteed hot topics: the fact that the patient is on suicide watch, previous self harm behaviors, suicide attempts, the diagnosis.