PERSONALITY DISORDER/SELF ABUSE

  1. 0 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 during admission/stay. Can anyone please comment or share admission and treatment protocol.

    Thank you,



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    Barb
    Registered Practical Nurse
    Psychiatry
    Ontario CANADA
  2. Visit  BarbRPN profile page

    About BarbRPN

    From 'CANADA'; Joined Mar '01; Posts: 7.

    27 Comments so far...

  3. Visit  ck profile page
    0
    Originally posted by BarbRPN:
    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 during admission/stay. Can anyone please comment or share admission and treatment protocol.

    Thank you,

    Dialectical Behavior Therapy (DBT) is a compassionate psychosocial treatment for borderline personality disorder with proven effectiveness including: reduced suicidal behaviors, reduced substance abuse, reduced therapy dropout rates, and reduced hospitalization. I plan to go to a workshop soon by Patricia Verby MA LP that will give a comprehensive overview of DBT.

  4. Visit  BarbRPN profile page
    0
    Originally posted by ck:

    [/b]
    Dialectical Behavior Therapy (DBT) is a compassionate psychosocial treatment for borderline personality disorder with proven effectiveness including: reduced suicidal behaviors, reduced substance abuse, reduced therapy dropout rates, and reduced hospitalization. I plan to go to a workshop soon by Patricia Verby MA LP that will give a comprehensive overview of DBT.
    [/B][/QUOTE]

    CK,

    Thank you very much for responding. Ironically enough, I was just reading about Dialectical Behavior Training the night before last. I've been searching the net every night in my free time, for therapy models for this type of client. The DBT was the model that was most desirable to me and seemed the most all-encompasing for this particular client. I would love to attend such a conference but I live in a very small town and there is never any conferences within a day's trip. And despite the fact that I work in a huge facility, we are in a divestment transition between government and public governance of the facilty, so budget for such a conference is always denied. If I could afford to pay for entire conferences I would do it, but I can't. At any rate, I would be interested in learning more about this therapy, do you have any websites that you find particularly helpful? I need to present information to my team, particulary the medical part of the team. Right now we are using up nursing resources to the MAX on this one client. She is on constant observation 24/7 at an arm's length. What really gets me hot under the collar is that we are providing her with nothing more than a "paid companion". We are doing NO therapy what so ever. We are giving her no responsibility for her actions/decsisions. We aren't empowering this client AT ALL and I feel that the longer we keep her in this situation the more dependant she will become on this type of relationship. She even calls us her "body guards"! This is not therapeutic at all. The doctor is of the opinion that the nurses will be the downfall of this client because we suggest that this relationship and technique is not only NOT therapeutic but detrimental. The doctor says we are damaging the patient by suggesting this but our supervisor will not support us in any manner. (this is not unique to this situation only). I'm not even cautiously optimistic that the doctor will be ammenable to even review any info on DBT but at this point I figure there's nothing to lose. The last admission this client was on one to one, arm's length observation 24/7 for FIVE years!!!! I know this client from two other units I've worked on and aside from the obvious, I know that this current intervention DOES NOT WORK and is not therapuetic in the least.

    Thank you for your comment and if you have any good web resources, please post or email them directly.




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    Barb
    Registered Practical Nurse
    Psychiatry
    Ontario CANADA
  5. Visit  HazeK profile page
    0
    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!

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  6. Visit  nurse lala profile page
    0
    From what I understand of this process, the client needs to be marginally intelligent.
  7. Visit  BarbRPN profile page
    0
    Originally posted by Nurse Nola:
    From what I understand of this process, the client needs to be marginally intelligent.
    Hi and thanks for your input. I've been checking DBT links and it does appear that this modality is for the "outpatient" client. I still think there may be valuable therapeutic technique that can be elicited for inpatient use. Any thoughts, anyone?



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    Barb
    Registered Practical Nurse
    Psychiatry
    Ontario CANADA
  8. Visit  greg in mass profile page
    0
    DBT is used in my facility, but only a few people are trained in. The downfall with this therapy is that it is designed for clients in a out-patient setting. My facility uses it in an in-patient setting and from my opinion it is not that useful. From my understanding of a Borderline Personality Disorder client, it is better to discharge them as quickly as you can out of a in-patient setting. If not, then this type of client tends to become dependant on the system and will do anything....including hurt themselves very violently....to stay in an in-patient setting. Trust me, I've seen many Borderline clients over a 8 year span. Many of these clients that do leave tend to become repeat clients that come back to the in-patient setting.

    What also gets to be difficult is dealing with 5 or more on a unit....while you also have 20 other clients as well. Borderline clients burn out your staff and they all want so much attention....positive or negative....it does not matter. When you have more than 1 client on your unit, they tend to be buddies often, and they also compete against one another for staff's attention. If one gets more attention than the other, then you will often see the other act out purposely to harm themselves to attain attention....and this competion continues. These type of clients tend to be on close observation often. Treatment teams try and devise special plans for these clients, which only works temporarily. These clients are well aware of what they are doing, because remember it is a personality disorder they have. They tend to split staff often and tend to lie often about staff. Sometimes their lies get staff in trouble, and they have no remorse for their actions. They cannot stand being alone....and will converse with anyone...whether they like them or not just so they can have company....and will try and do anything to get on 1:1. Many other characteristics also occur, but I could go on and on. Hopefully this gives you some insight to help.

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  9. Visit  AussieRN profile page
    0
    Originally posted by BarbRPN:
    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 during admission/stay. Can anyone please comment or share admission and treatment protocol.

    Thank you,

    Hi there, I am a Nurse Unit Manager of a busy inpatient psych unit. I don't have any specific resources but in writing policies like this it is wise to remeber that despite repeated presentations, each admission is a separate entity, BPD patients can still suffer clinical depression, this is often overlooked due to their history. I do think a guidelines/management plan is definatley needed and my view is that long term inpatient treatment is not desireable. I have found these patient's seem to do well in long term psychotherapy/counselling with a person who knows how to manage them well.
    Contracting with voluntary patients can also be useful and even a condition of their admission.
    Michelle
  10. Visit  BarbRPN profile page
    0
    Thanks for your comments and you are so right about s/s of depression and other problems having potential for being overlooked due to the nature of BPD. Thanks for your insights.



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    Barb
    Registered Practical Nurse
    Psychiatry
    Ontario CANADA
  11. Visit  TopazStone profile page
    0
    I have read some research-- someone forwarded it-- about the use of Narcan for self-mutilation. They have found that the patient secretes endorphins that block the pain and Narcan allows them to feel the consequence of their action. Borderlines usually cut because they don't feel connected to themselves; the fact that they can feel the "normal" response to pain decreases these behaviors.
  12. Visit  waynesoo4 profile page
    0
    Hi
    You probably will not get a lot of response to a question like that. There is no cure its more try and discharge as soon as possible, crisis admissions only. The longer a person with this type of disorder is in hospital the more difficult it is to discharge them. Time and time again I have seen CBT used with little to no success, admittedly depending on the severity of the disorder. Medication does not seem to have much effect apart from sedation and I have even seen ECT used to no evail. Firm limits with reassurance has been noted to at times have a little effect.
    I repeat discharge once the crisis is settled is the best treatment that I am aware of
  13. Visit  YukonSean profile page
    0
    Hello Barb
    Inpatient mental health services at our small hospital (49 beds) in northwestern Canada are provided by two registered nurses,
    who work opposite one another on 12 hour days. There is no standardised admission eligibilty criteria for personality disorders or acting out behaviours. Patients must be assessed and triaged through Emerg, with an eye to suicidal ideation, threat to others, substance abuse, etc. However, the other RN and I have been working on individualised care plans for our "frequent flyers". We have many locum physicians coming through the north, and having a frequent flyer plan in place helps with continuity of care, especially if inpatient admission is countertherapeutic for these folks. You might need to do some planning with other services in your area in order to implement such plans (eg, transient shelters, detox centres, or wherever).
    Sean
  14. Visit  Aerolizing profile page
    1
    Borderlines....What a difficult population. I totally agree, with 1:1constant supervision harming borderlines. It does make them helpless and dependent. I have been a psych nurse for 10 years and I have found some little ideas that might help you. I have never heard of DBT but I will certainly look into it.

    #1. On admit, tell them what their discharge date and time will be. Your doc has to agree with this of course. Make sure it is no more than 72 hours from admit time. Tell them that you are sure they will become more suicidal at time for discharge but it is a chronic condition and that you provide a service to get them past the immediate crisis and stress they have long term outpatient resources to help them once discharged.
    #2. Benign neglect. I love this phrase. Make sure the patient has food, water, proper hygiene, med teaching, assess for side effects and keep sharps out of reach. We place them on a q1hr (five minutes at the most and use a clock) request schedule to their nurse only.
    #3. Use staff interactions as a reward. If they are able to comply with no self abusive behavior and can comply with q1hr requests, then at the end of the shift, they earn 15 minutes of 1:1 interaction with their nurse. This really works if they crave staff attention.
    #4. Focus on immediate crisis only. Repeat over and over again that everything else is for her to discuss with her outpatient therapist. Explain the reasons why like you would need time to recover from deep therapy issues since they are so emotionally exhausting.
    #5. Behavioral contracts. When a patient comes in, be ready for her. I am sure you know your frequent fliers and what their behaviors are. You can explain to them that since what we have done before is not helping you, we have to come up with something else to try to help you. I love to do this. Very simple things can be made into a contract.
    List positives like you are expected to eat breakfast, be bathed, take meds and get vs done by 10:00. Attend each group appropriate to you to benefit from treatment. Check in with only your nurse only on the hour.
    List negatives like no acting out, no going to other nurses for anything, no cutting. Keep this brief so as to focus on positives.
    What is the reward? Interactions with you as her nurse of course.
    With our frequent fliers, we kept copies of the contracts so on each admit, we were ready with new copies of old contract. Offer to have her sign it but it is totally not necessary. Have the doc and the nurse sign it and tell her it is being put into place as a part of her treatment plan weather she signs it or not.

    #6. Consistency. This is what our staff has the most trouble with and this leads our patients to act out. Put the contract in the patients room for her to have a copy of. Let it be part of the treatment team. Make sure all staff know each and every line of the contract including the secretary.

    When we first started doing contracts, our frequent fliers revolted and tested our new system. We had to work out the bugs too. We often had to put patients in locked rooms with nothing but a bare mattress on the floor, blanket, one gown, one pair of footies and undies and lock the bathroom, just until they felt they were in control enough to earn back their clothes and bed linens. If they have prn's, of course, by all means offer it to them.

    Another thing that helps is to have a contract presented from the whole treatment team. That way it is not just the evil nurses who are doing this to them.

    In my hospital, it seems to work to decrease length of stay, decrease staff burnout and it seems to give everyone a sense of control (even the patient) over a very difficult population. I hope this helps you.
    greenbeanio likes this.


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