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 repeatedly readmitted and self-abuse... Read More

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    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

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    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!
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    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).
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    Originally posted by HazeK
    I went to my favorite search engine: 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.
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    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.
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    I have seen the use of modecate depot and CBT have positive outcomes.
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    I work in a state hospital; we are the last stop for many of our patients. They have been through the local mental health centers and hospital psychiatric units before coming to us.

    My unit houses up to 25 patients and now 9 of them have been diagnosed with BPD.

    We use an adapted DBT program. We have had good success, considering the clients we are treating. Most of our clients do not return after completing the program. We do get some repeaters, but thier stays out of the hospital increase in legnth.

    We have a 6 month inpatient program. The program is led by our Nurse Clinical Specialist and one other person (generally a psychologist, currently our unit director) and contains 5-6 BPD patients. The group meets for 1 hour twice a week. They also attend a 1 hour Women's issue group twice a week and receive 1 hour of individual therapy with one of the group leaders weekly.

    As the dayshift nurse for the unit I have found the most important factor in successful treatment is Consistency. This is what our staff has the most trouble with and this leads our patients to act out. Consistancy between staff and between shifts is essential. If everyone is not consistant the Borderlines will split the staff and systematically suck all the life from everyone.

    We have recently begun to use behavioral contracts. Before they can earn any privileges I have the patient write a contract. In it they have to outline thier responsibilities and expected conduct while on ward, as well as what they expect to gain from treatment. Then together we discuss and include the rewards and consequences for behaviors. Once the contract is completed and signed by the patient I present it to the Tx team where we all sign it, give a copy back to the pt. and place a copy in the chart.

    Staff interactions can be a great a reward. If they are able to comply with no self abusive behavior and the rules of 1:1 supervision, they earn a set amount of 1:1 interaction with the nurse or staff member of thier choice. This really works if they crave staff attention.

    Because patients with BPD can be so devious we have had to adapt our 1:1 policy for the self abusive/suicidal patients. They sit at a certain table in the dayroom. No other patients are allowed to sit with them ( to prevent giving them an item to hurt themself). They sit with thier hands on the table where they can be seen at all times. Every hour they are taken to the restroom and given a drink. This may seem cruel to some, but it does work because they are not getting the attention they are craving.
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    Please check the notes on the 3rd page--BPD. There is alot of good advice from nursing experiences in that listing.

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