PERSONALITY DISORDER/SELF ABUSE - page 2

Would anyone who has any insights or good resources on the internet, please respond. My facility has no policy on admission and treatment of borderline personality disordered clients who are... Read More

  1. by   eht
    .....internationally reconisied culture of psychiatric consumers of mental health services.
    Here in our service, at the very most these people can recieve a 24-48 hr admission with clear expectations of behaviours and expected outcomes if those behaviours are not met. The idea of some self responsibliity is encouraged and reinforced. The main factor that plays 95% of the equation is the consistancy of the inpatient staff.
    treatment stratagies that have played some part are the ones already highlighted..DBT...CBT.
    psychopharmacutically, modecate in small doses has had some success in one of our 'frequent flyers' when treatment is formally indicated, meaning under the mental health act or its equivelent in your country, otherwise consumers refuse this treatment and therefore relapse.
    Once that this avenue has been reached a harder line is taken with regards to the amount of admissions allowed in a monthly-6monthly basis. stricter 'gate keeping' strategies by the crisis intervention / psychiatric emergency response team.
    up shot................these are the most challenging group and staff require strong support from managers, clinical directors, and psychiatrists......with the odd bit of clinical supervision!
    good luck strategising
  2. by   canoehead
    Aerolizing

    Sounds like there's not much point to them even being in the hospital with your treatment plan- which is probably the idea.
  3. by   Aerolizing
    Canoehead,
    Bingo. In order for people with BPD to get better, they need long term (outpt) therapy with a committment from the patient to want to change.
    Keeping them inpt for long periods of time teaches them all sorts of bad habits like dependence and often our patients would swap symptoms and have some sort of competition to see who could be the sickest and get the most staff attn.
    I have no problems setting limits with them as I have learned the hard way that borderlines can suck your will to live and create massive chaos within the staff while they just sit back and watch.
    I am not aware of any publication that advocates long LOS for this population.
  4. by   victoreia
    Originally posted by Aerolizing
    Canoehead,
    Bingo. In order for people with BPD to get better, they need long term (outpt) therapy with a committment from the patient to want to change.
    Keeping them inpt for long periods of time teaches them all sorts of bad habits like dependence and often our patients would swap symptoms and have some sort of competition to see who could be the sickest and get the most staff attn.
    I have no problems setting limits with them as I have learned the hard way that borderlines can suck your will to live and create massive chaos within the staff while they just sit back and watch.
    I am not aware of any publication that advocates long LOS for this population.
    I totally agree. Borderlines will suck you dry and reek havic if they are inpatient too long. I worked in a MICA unit and many of our clients were borderline. I learned to spot them the minute they came through the door. Unfotunately the MICA unit is a 28 day inpatient stay. We get them to sign a contract that they will seek out staff if they feel self abusive and/or suicidal. Does this help? sometimes... we also try not to focus on the self abusive behavior but rather redirect them. Ever have 13 female borderlines together for 28 days. Not Pretty!!
  5. by   Dana Evans
    There are many good books out there now to read. "I hate you, don't leave me", "A look in the Mirror: Borderline Personality Disorder" (both of these I do not remember the author. "The Search for the Real Self: Unmasking the perosnality disorders of our age" James Masterson. "Stop Walking on Eggshells: Taking your life back when someone you care about has borderline personality disorder" by Paul Mason and Randi Kreger.

    DBT research and literature created by Marsha Linehan and Mr. Mastersons thoughts are innovative and helpful for the borderline. In patient does promote dependence and further negative acting out of intense inner emotional chaos. Because trauma and PTSD is not unusual EMDR (Eye movement desensitation reprosessing) and trauma work is important. It's important to understand the concept of splitting, dissociation and lack of self integration (extreme cases of what was formerly multiple personality disorder and less severe cases of inability to integrate good and bad self awareness).

    Treat outside the box!
  6. by   barneyridge
    Topaz, I am interested in finding the article you mentioned about narcan and self mutilators. Can you give me the reference source. We have a difficult case cutting fingers off joint by joint. Looking for ideas. Anyone else welcome to comment. Thanks ->
  7. by   canoehead
    I'm not a psych nurse, but was wondering...

    If someone harms themself and gets increased monitering, the challenge is can they do it again...seems like there might be a snowball effect. What if you started with q15min checks, and decreased interaction for cutting? Or ignored the behavior?

    I'm assuming when I say this that they cut at home and have survived many years- and they won't die of scarring. But if they go a day without cutting they get an hr of therapy?? Good reason to hold out for a day IMHO.

    As someone advances in obs to 1-1, are they confined to their room, entertainment taken away, no TV, monotonous meals. Boredom seems to be the worst experience for the borderline.
  8. by   barneyridge
    canoehead
    while it would sometimes be fruitful to be that tough the problem is with legal aspects and inpatient status. We are not allowed to let someone go without being looked in on. The point of contracting up front is that they promise to not self harm and if they do the unit can dismiss them to a more intenive treatment regime like one of the state hospitals, who have the legal authority to medicate for safety without the patient's agreement
  9. by   TopazStone
    Barneyridge,

    Sorry I can't cite the resource-- someone had forwarded the info to me ages ago. The docs at the crisis center I worked at were not receptive to trying this.

    I had to rely on the old tried and true . . . when our fave BPD came in from the ER, pulled out her stitches and proceded to dig in her fatty tissue, I said "Oh dear, now this wound can't be sutured again." I refused to say anything more. Just cleaned the wound, slapped some gauze on it and went to document. No one came in to comment on her behaviors, we just did safety checks without extra conversation. She wanted to go home the next morning!
  10. by   YukonSean
    Hello Canoe Head
    As other subscribers have stated, contracting on admission is negotiated between patient and clinician in order to define not only inpatient rights, but also responsibilities and expectations of conduct while on ward. We all recognise that there is a vast difference between acting-out behaviours, e.g., self-mutilation with burning cigarettes or razor blades, vs. genuine suicide gestures or attempts. This said, the admission contract needs to clearly state what the consequences for unacceptable behaviour will be. For example, here we have one frequent flyer who self-inflicts burns with oven cleaner. The patient knows that while admitted, any slashing, burning, overdosing on smuggled OTC drugs, or whatever, will result in immediate discharge. This one aspect in the care plan is not on the table for debate.
    One of the major nooses around the necks of care providers is that old belief in some sort of vicarious liability. I often hear police officers, residential counsellors, etc., wanting some sort of "guarantee" that a patient will not go out and complete a suicide, after being refused admission. The only hope in this case is to educate the community service providers that some patients are chronically at risk for self-harm. Threats (to act-out) do not equal absolute danger, just as promises (not to) can easily be broken (if they were stated truthfully in the first place). Agencies are worried about being left open to legal responsibility. I suppose that this is a very real concern in the United States, where one can sue anybody for anything at anytime. On the other hand, adults are owed the right to self-determination, i.e., they cannot be detained forever because there is a suspicion that they might maim themselves.
    In terms of legislation, you must find out what is contained within the Mental Health Act in your particular jurisdiction. Barneyridge is describing what sounds like Community Treatment Orders, which are not universal. In Canada, only one region out of 13 provinces and territories has these orders, although another is working on them. Most (if not all) of the current literature points to assertive management, which minimises the positive reinforcement of the hospital experience for patients with borderline personality disorder.
    I have a copy of, I hate you: Don't leave me (Kriesman & Strauss, 1991; ISBN = 0895866595), but I have not read the others cited by Dana E. My strongest recommendation to you would be, Relationship management of the borderline patient: From understanding to treatment (Dawson & MacMillan, 1993; ISBN = 0876307144).
  11. by   jamistlc
    Originally posted by HazeK
    I went to my favorite search engine: Dogpile.com....and entered "cutting" and then "self-mutilation"....large reponse to each inquiry ranging from professional sites to sites BY cutters FOR cutters...interesting insights!

    ------------------
    Not all Borderlines do the self mutilation thing (cutting). I know several who are productive members of society and functional as well as intelligent. As far I understand the modality ,it has no set standard for psychotropic medications, only symptomatic (SSRI's for depression). Didactic teaching/therapy sessions are the only therapy that is effective and these were out patient services. It is also worth noting that this illness usually resolves it's self much like attention defict disorder does, by the person developing other traits to compensate for the defect of character/persona. It is a long term process often requiring 20 or more years to get to that point.
  12. by   Caro
    My hospital has used Narcan for self mutilating patients with varying results.
    It seems to work best for those patients who are motivated to stop their behaviour.
  13. by   Heidi
    I have seen the use of modecate depot and CBT have positive outcomes.

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