Borderlines.......

Sorry, I don't have any advice, but my mother is borderline and I'm looking forward to the replies.

Kris - do you have specific instances that are occuring you want answers on? ie., can't chart b/c....or pt takes so much of your time...? I have experience c borderlines, but it'd be easier to answer a more specific q.

I have a lot of experience with borderlines. In order to deal with their need to consume of lot of your attention and time as a floor nurse with 8 patients this works: First accept that the borderline will get your attention one way or another. The borderline has that awful fear of abandonment and an agonizing empty feeling. At the beginning of your shift sit with this patient and give your undivided attention. Do your initial assessment and then make "appointments" with her every 2 hours or whatever you think is appropriate. If something comes up and you can't make an appointment go to her and say I have an emergency I'll be 15 minutes late. If she wants attention in between do not comply, stick with the appointment schedule. If the appointment time rolls around and she is in a meeting with the therapist approach her afterwards and say you were tied up at our appointment time, do you still need to talk? This really, really works.

Also borderlines are great staff-splitters. This requires a lot of staff education and good communication to combat.

Get DBT training. It really works for those unfortunate souls with BPD. Just the attitude adjustment that comes with the training will yield a completely different reaction to you from the patient.

DBT centers around the realization that folks with BPD have had horrific lives for the most part, are truly in emotional pain, and have terrible coping skills. Just treating the patient like they have pain and not like the leper of the unit will open doors for you. The goal is to decrease/stop inappropriate and harmful behavior, train the patient in coping skills, a gain emotional mindfulness.

Do you have any websites or books to recommend on DBT?

Dialectacal Behavior Therapy by Marsha Leinahan, PhD. Or just Google DBT, as I'm not sure of the spelling of her last name. But she has done RESEARCH, ie: Evidence Based Practice(! ) that DBT works better than traditional (non)treatment.

And SoxfanRN is right. It is as much about us learning a better way to interact than a way to "fix" them.

And I do not think any patient can split staff. Only staff can split staff. Patients try, but we do not have to follow along. Communication is the antidote to attempts to split.

Sanctuary is right on. DBT was pioneered by Marcia Linehan in the mid 90s. It is a form of CBT and is well validated by research. You can get her books from Amazon, Borders, etc. I found taking an actual class by clinicians using it in practice to be a better learning modality. Just my opinion, though.

If you get the chance, try to watch some video of Marcia Linehan working. It's amazing how she handles the patients. She says things that I would never have thought to say as a clinician, but it works. I saw some videos when I trained.

Hey thanks for the tips Jaildon! Will definately institute this on my very next shift. This week I found myself in our HDU with 6 BPD's at once and felt like I was tearing my hair out in frustration. Seems like when you have so many in a confined space they are almost in a sort of competition of "who can get the most attention" and they are constantly upping the anti.

What works for me has always been a less formal way of doing what you suggested. Also, rewarding positive behaviour and "punishing" (wrong word I know) negative behaviour. For a Borderline, we all the know the most negative thing they can have happen is to be ignored. So my plan is to approach them when they are quiet and settled to talk, and completely ignore acting out behaviour. Not always easy!

Last week for example, I had a girl laying on her back beating the doors with her feet, stark naked, screeching like a banshee. I knew I could seclude her if I had to but decided to take my other 5 patients into the courtyard, lock the door (to keep them safe), made them all cups of tea and we all sat in the sun talking about our favorite birds and flowers, braiding our hair etc. After about 10 minutes, the screecher had her clothes back on and was knocking on the locked door asking to join us. I just said, "of course you can honey, come and have a cup of tea with us". Didn't mention the behaviour at all, and neither did she. No need for seclusion.

Another thing I am starting to do is to admit Borderlines into HDU and discharge from there, never allowing them to hit LDU at all where they tend to wreak the most havoc. When they start wanting to escape, I will offer to open the doors for them. But let them know that they can stay as long as they need to. They are often puzzled by this. It is not overt rejection (which would escalate the behaviour), but it takes away the rewards involved in attempting to abscond.

Voucher systems can work well too. The patient is given a number of "vouchers" which allow them access to a 72 hour admission. They decide when they really need to use them, and know that when they run out, they run out. Alternatives if they escalate to intense suicidal or anti-social/illegal behaviour are acute HDUs or police custody. These systems don't always work if there is a lot of bed pressure. You need to be able to honour your contract, but if you can do that they are a good system.

What're HDU and LDU?

Hey thanks for the tips Jaildon! Will definately institute this on my very next shift. This week I found myself in our HDU with 6 BPD's at once and felt like I was tearing my hair out in frustration. Seems like when you have so many in a confined space they are almost in a sort of competition of "who can get the most attention" and they are constantly upping the anti.

What works for me has always been a less formal way of doing what you suggested. Also, rewarding positive behaviour and "punishing" (wrong word I know) negative behaviour. For a Borderline, we all the know the most negative thing they can have happen is to be ignored. So my plan is to approach them when they are quiet and settled to talk, and completely ignore acting out behaviour. Not always easy!

Last week for example, I had a girl laying on her back beating the doors with her feet, stark naked, screeching like a banshee. I knew I could seclude her if I had to but decided to take my other 5 patients into the courtyard, lock the door (to keep them safe), made them all cups of tea and we all sat in the sun talking about our favorite birds and flowers, braiding our hair etc. After about 10 minutes, the screecher had her clothes back on and was knocking on the locked door asking to join us. I just said, "of course you can honey, come and have a cup of tea with us". Didn't mention the behaviour at all, and neither did she. No need for seclusion.

Another thing I am starting to do is to admit Borderlines into HDU and discharge from there, never allowing them to hit LDU at all where they tend to wreak the most havoc. When they start wanting to escape, I will offer to open the doors for them. But let them know that they can stay as long as they need to. They are often puzzled by this. It is not overt rejection (which would escalate the behaviour), but it takes away the rewards involved in attempting to abscond.

Voucher systems can work well too. The patient is given a number of "vouchers" which allow them access to a 72 hour admission. They decide when they really need to use them, and know that when they run out, they run out. Alternatives if they escalate to intense suicidal or anti-social/illegal behaviour are acute HDUs or police custody. These systems don't always work if there is a lot of bed pressure. You need to be able to honour your contract, but if you can do that they are a good system.

Neat ideas, work well with the DBT core concepts. Love the tea story. Did the same thing once when we could still smoke in the hospita. Took all the others out for an "emergency smoke break." Worked just the same. And the Voucher System... Priceless.

Sorry...high dependency unit, low dependency unit.

Purplekath - dependency unit? Is that like a drug dependency or ...?