alternate ways of treating borderline personality disorder

[squeakykitty]

Borderline personality disorder is in every culture, but it may manifest differenty in different cultures.

Being shipped to Africa won't help maladaptive ways of coping, it won't give borderline pts. insight into their own self-defeating ways of coping, and it won't give insight into their own behaviors.

Perhaps the OPs idea of shipping them to Africa could be frustration with borderline pts. not getting better, the staff can't "fix" them, and they're not "fixing" themselves. As far as an enabling environment, I'd think enabling would happen when people get sucked into the chaos, allowing themselves to be manipulated, or feeding into the power struggles, instead of setting caring, firm, consistent boundaries.

As DidiRN suggested, maybe a specific inpatient unit with trained staff may help. There, borderline pts. would more likely to have those limits set and less enabling when all of the staff (even dietary, housekeeping, maintenence) is on the same page on how to interact with the borderline pt.

[deeDawntee, RN]

ok i am a person who has healed from and still manage my diagnosis of borderline personality disorder. i'm telling you what heals is relationship. relationships heal. when i was hospitalized what helped me were the staff who were "nice" to me. unconditional positive regard. let me tell you, those nurses were few and far between. (the ot and other educational and counseling staff were far better at dealing with us then nursing). but you are correct, the hospital is not the time where drastic healing can take place...you can only provide safety. (and be nice)

i never officially did a full dbt class, but know it has been helpful to

a lot of people. what i did was got myself into full-time long-term therapy and have experienced the security of having someone "in my corner". i have learned to handle stressors much differently but it has been long and hard.

what can you do as a nurse? keep believing and communicating that healing is possible!! can you change the culture? no. i had both an inherited mental health vulnerabilty and suffered some ugly abuse.

what we need is to experience what it means to be loved. we need relationships that heal. sending us to the rainforest, is pretty absurd...let me tell you, although i like your creativity!!!

[purplekath]

I think most of us working in the area would agree that it is a disorder that can always use more ideas in its treatment. I think it is totally necessary to try and get a handle on the worldview of the patient, both as a person with a diagnosis and as an individual. This itself is a difficult enough thing to try to piece together ... let alone to try and find ways to help that person make changes.

My theory is that most of us grow up with a pretty decent foundation - a strong floor beneath our feet. Our parents and others give us that. Sure, all parents muck things up and all of us come out with the occasional hole in our foundation, but we can still stand up most of the time and live our lives.

Borderlines on the other hands have foundations that have TOO MANY holes... the floor beneath their feet resembles swiss cheese and they find it impossible to use this foundation to support them. That is why the world is a chaotic and terrifying place. ANY stressor threatens to throw them into one of the many holes in their foundation. They didn't have the luxury of a firm foundation from their parents...they must learn to build their own.

Most "treatments" for bpd involve trying to fix those holes, however if we as professionals attempt to do that for the person, we are doomed to fail. There are too many, and besides, we can't even SEE them, let alone fix them. Therefore, the key has to lie in helping that person to mend the holes in their own foundations. We give them the tools to do it. But of course, they are terrified. They want to cling to anyone and anything in their world that will stop them falling in. They do not want to venture to the edge of these chasms. They will do almost anything to avoid it -- get angry, avoid, self destruct, manipulate....we've all seen the behaviours.

In order to get well (and yes...some DO get well), EVERY person in their world must stand back and insist that the borderline use their tools and get to work on one hole at a time. Getting to that stage is a long and difficult process, but one of the biggest joys in my life is when I see that person stand with pride and say in effect, "look what I did! I fixed that one! And I did it by myself!"

As practictioners it is our job to:

* give the tools and teach how to use them. DBT, life skills, how to cope with stress, how to cope with trama, how to learn to love yourself, to love and care for others.

* to REFUSE to allow that person to "manipulate" to avoid doing this scary thing.... and I use the term "manipulate" in an understanding way. It is a coping mechanism, just like most of the behaviours we see with BPD.

* Understand the behaviours for what they are - hole avoidance :-) And explain that to the person in a calm and appropriate way, eg: "you smashed your room up because you we afraid to do the work we talked about. I know you're scared, and I understand why you did it. But you still need to do the work. Clean up the mess you made - I am going on a lunch break, and will come and talk to you when you are ready to use your tools. I know you can do it" (smile, squeeze hand, leave room etc)

* be a cheer squad from the sideline - give messages, "I know you are terrified, but I have seen others do it, and I have seen (insert individual strengths) you be strong even though you are scared".

* Reinforce as each "hole" is fixed the achievement they have made and how much easier it is to walk around without fear with each new piece of foundation.

* Don't give up your patient and let them know that. It may take years and many admissions and setbacks while they learn to build their own foundation. With each new admission, remind them of the progress they made last time and remind them that they are here to work some more.... let them know you are looking forward to watching their achievements this time.

Then get to work yourself. Anticipate and cut off the behaviours that avoid the work. Instruct your collegues that your patient is to be directed to you for everything that shift, and make sure she knows that will always be the case. Make regular "appointments" with her (approx 10 mins an hour or two) - snippets of your time and support. Find a system of positive and negative reinforcement that works for that particular person to encourage her to keep working. Eg: a guarantee of safety means some leave to the coffee shop with you. Breaking the fire alarm and absconding into traffic and laying on the road = her time with you is delayed for one hour. Threatening to kill self or harm you = appointment ends immediately. Talking about the feelings surrounding her suicidal ideation or rage = verbal reinforcement and appointment continues.

A few ideas :-)

[vwdeano]

Finding effective treatment for those with a Dx of BPD is one of the most challenging and daunting tasks as a nurse in psyhiatry. I follow the lines of trust and maintaining the present time when they are discussing the past. Right now is the moment we are dealing with so lets spend our time on right new. There is no way of stopping some mental processes once they start, developing a strategy that allows you the ability to be flexible in approach while maintaining a trust that they can count on you. Listening is a great way to engage them and show you care, reasoning will not always get the result that you want,. but it is showing respect and time spent.

[spaniel]

Rats.. the forum was updating so I lost my reply. I've read many of the posts on borderline/alternative methods,etc. This really has been thought provoking. I also believe relationships heal. I also believe that DBT is a very strong,workable method. If I recall,it may have been Miranda (and others) reminding us that BPD is indeed a spectrum in terms of expression and severity.

One area of "alternative' treatment I believe can lie in the therapeutic work with animals. Please do not think I'm advocating this for those whose impulse control is severe. I do think there is a major issue in attachment and with the bleak inner landscape of many folks with BPD, "feeling" an attachment is not easy. Frankly I believe this is one of the fundamental problems.

I'm not naive enough to think that funding would be easy to obtain. But there are a few tx centers that work extensively with animals. .. but not your run of the mill state hospital or inpt/or outpt. center. In fact, there are a few prison projects that hook up the offender with a particular dog. This person is "charge' person in terms of the dogs physical care.

Again, I'm giving away my age here... but some "old" psych state hospitals in Pa. had farms. Laregely, these were shut down in around 1972. Oftimes, the critters became the "raison d'etre" for long term pts.

I'm not suggesting this in lieu of a more comprehensive tx-but I do believe their is true value in the human-animal bond. I've seen it again and again with BPDs who've yet to establish mutual human relationships.

[canoehead, BSN, RN]

Also approximately 10% of borderline patients do commit suicide.

I'm not a psych nurse.

Aren't 10-14% of the general population killed by suicide? If so, doesn't that make the risk of suicide in borderlines equal to the general population and therefore a moot point? If you know that, then a suicide threat by a borderline becomes less effective as manipulation, and will change the focus of treatment to something more productive.

hsieh's idea of sending everyone to a third world country may not be as easy or as effective as first thought. The core ideas might be really good though. You take away the number of choices a person has, and make the options so clear that the "correct" choice is self evident, and consequences around incorrect choices are swift and decisive (but not lethal). The patient group builds a supportive community amongst themselves and their clinician, and experiences the power of good choices and the consequences of bad. No rescuing. How can that environment be built in today's world?

Just throwing it out. I have to add that the discussion about why ideas are good or bad has really helped me understand the disorder. Thanks to everyone who spelled it out so well. It's been a great thread.

[rn/writer, RN]

According to this article--

http://www.health.state.ny.us/nysdoh/consumer/patient/chap1.htm

--suicide is attempted by 2.9% of the general population and completed by 1%.

Suicide in the General Population

Overall, 2.9 percent of the adult population attempts

suicide,(3) and the suicide rate in the general population over a

lifetime of 70 years is approximately one percent.(4) Studies of

suicide attempters suggest that one percent to two percent complete

suicide within a year after the initial attempt, with another one

percent committing suicide in each following year.(5) Suicide is

especially prevalent among the young and the elderly. It is the

third leading cause of death for individuals 15 to 24 years of age.

Over the last 30 years, the suicide rate in this age group has

increased dramatically.(6) Among younger people who attempt suicide,

between 0.1 percent and 10 percent will eventually commit suicide.

Yet it is the elderly who have the highest rates of suicide --

overall suicide rates for individuals over 65 were approximately 22

per 100,000 in 1986.(7)

Note that the rate of 10% mentioned who commit suicide is 10% of young people who attempt suicide, not 10% of the general population.

The rate is still too high, but if it were 10-14% of the general population, then if you knew 500 people, you could expect to know of 50-70 people who had killed themselves. Thank goodness that's not the reality.

---------

If you think of borderline patients as arrested toddlers (driven by their many fears, unable to put things into healthy perspective, acutely and painfully self-centered, highly impulsive, etc.) several things mentioned in this thread make wonderful senes.

As deeDawntee said, relationships--good ones--help to build trust. Trust helps to lessen fear. This allows a borderline patient room to grow and develop those abilities and skills so noticeably lacking. In one sense, borderline patients have to "grow out of" their maladaptive thinking, not by aging chronologically, but by aging developmentally and catching up to their chronological ages. This will not happen in environments that are punitive. Consequences administered with caring help borderline patients to move forward. Both parts have to be present. The consequences teach the necessary lessons. The caring makes the learning bearable.

The idea of caring for animals is an excellent one if done with regard for the safety of the pets. Some borderline folks take far better care of animals than they ever would of themselves (without improvement). But think about it. Even a small child can care about a pet. This is one of the ways we teach kids about life. A living creature for whom they have affection is a real attention-getter. Children need guidance and help in actually providing good care for an animal, but that connection can be highly motivating and a blessing to all involved.

One important consideration with borderline folks is that you are dealing with a frightened child, but that child lives inside a grown up body. It's a real trick sometimes to speak to both parts of the personality at once--giving due regard to the adult while connecting with that fragile child. It can be especially challenging when the behavior has been aggressive, irrational, and destructive. A practitioner can end up feeling cross-eyed at times. But it helps to constantly remember the lost child who needs to be "brought up" into a new state of health.

This is one of the most difficult psych populations to work with. It can also be among the most rewarding.

[Multicollinearity, BSN, RN]

I'm not a psych nurse.

Aren't 10-14% of the general population killed by suicide? If so, doesn't that make the risk of suicide in borderlines equal to the general population and therefore a moot point? If you know that, then a suicide threat by a borderline becomes less effective as manipulation, and will change the focus of treatment to something more productive.

hsieh's idea of sending everyone to a third world country may not be as easy or as effective as first thought. The core ideas might be really good though. You take away the number of choices a person has, and make the options so clear that the "correct" choice is self evident, and consequences around incorrect choices are swift and decisive (but not lethal). The patient group builds a supportive community amongst themselves and their clinician, and experiences the power of good choices and the consequences of bad. No rescuing. How can that environment be built in today's world?

Just throwing it out. I have to add that the discussion about why ideas are good or bad has really helped me understand the disorder. Thanks to everyone who spelled it out so well. It's been a great thread.

I posted that number about those with BPD and suicide over a year ago. I can't find the citation now. I do believe it's safe to say that borderlines have a higher suicide rate. I don't think they need "no rescuing" as you talked about above. I think they need firm boundaries and to learn how to manage their feelings of terror at being abandoned. I think it's about developing relationships and modulating fear.

______________________________________________________

Some thoughts in general.

I mentioned in this thread that my own mother has BPD. She continues to do quite well which is a change from the trajectory of most of her life. I believe her considerable improvement is due to those around her establishing firm boundaries and her feeling totally safe that nobody would abandon her.

The problem that I saw in this thread was many failing to distinguish between the pathology specific to BPD and someone who's just a massive pain in the rear. Wishing to treat those with BPD with generalized tactics of dealing with someone who's just a pain in the rear fails to address the quite specific pathology going on.

So while a boot camp scenario (similar to a 3rd world country) may work on a pain in the rear teen, borderlines have different challenges.

[Multicollinearity, BSN, RN]

I just found a source for suicide rates in BPD:

http://www.psychiatrictimes.com/p010737.html

"Borderline personality disorder (BPD) is associated with serious morbidity. Nearly 10% of patients eventually commit suicide, and between 60% and 80% engage in seriously damaging self-injury at some point."