How to deal with a Borderline who tries to pick a fight?

[lishka15]

Hi everybody,

Last week I had to "guard" a Borderline patient overnight, and it didn't go well, so I was hoping for some advice from you wise and experienced psychiatric nurses. My apologies if this story is too long, but maybe it will make it easier to give some in-depth guidance if you know the details.

I work as a nursing assistant in a somatic department for the summer. This patient was supposed to stay overnight for a procedure and then go back to her treatment facility the next day.

My job was to keep her from harming herself, and I was told that she seemed calm and nice, and that she was about to fall asleep. When I got into the room, a young doctor and her nurse was trying to convince her to agree to the treatment she was there for, as she kept changing her mind. She barely answered, and had a sulking vibe. I had expected the doctor to be more firm, but both he and the nurse were very accommodating.

The trouble began after an hour, when she obviously got tired of pretending to sleep, and turned around and started looking at me as if she was trying to figure out what kind of person I was. I smiled and tried to be nice, casual and relaxed, yet not seem insecure. I am aware of borderline splitting, and didn't want to go into her "bad person" category and trigger rage or difficult behavior.

She was nice for about two minutes and seemed to accept me, but then she started asking why I had to sit in that room with her. I sensed that she was about to pick a fight, so I tried to answer as light and casually as I could, and said something like "The doctors are probably worried that you're going to hurt yourself". Obviously the wrong answer, and she started arguing, saying that "she would never do such a thing". (Although I knew that the last time she was in that hospital, she hurt herself badly.)

What should I have done differently here?

Then she suddenly asked to go to the restroom, and it dawned on me that I hadn't been informed about the rules (unlocked/open door or go in ther with her), so I asked the nurse, who told me that the door to the bathroom had to be unlocked, and that I had to stay in her room (She had a private room with an en-suite bathroom). Then she began arguing again, saying she was "unable to go to the restroom when I was right outside the door", sulked and shouted.

What should I have said?

I was really unsure about how "firm" I was allowed to be, after observing how accommodating the doctor and the nurse had been, and my mind was on high gear trying to find a strategy to de-escalate the situation.

After a while I gave up and the nurse (who obviously was in her "good people" splitting category) went in to talk to her, and she agreed to an unlocked door. But when the nurse was gone, she started the same argument again. Then she went over to her bed and put on her shoes. I asked: "What are you doing?" and she said: "I'm leaving! I can't be here when I'm not even allowed to... (some obscure angry mumbling)". So she left. The nurse went after her to make her sign the discharge papers (The treatment she was there for wasn't "life or death" enough to make her stay against her will, and she wasn't considered acute suicidal), but she wouldn't sign anytning and just left.

I felt really shaky inside after this incident, and would really like to know what I could have done differently, in order to prevent such an outcome next time I encounter a Borderline patient. I tried to ask the nurses, but they said they - as somatic nurses - aren't very good with such patients, because they don't encounter them very often at that department. A young nurse even seemed surprised that the patient had acted that way, ("because she seemed like the calm type"), as if it was something I had done wrong (As a female medical student, some of the nurses are already extra critical towards me, and I really try to be good at my job so that we can co-operate well, and this for sure didn't make them any less critical or condescending.)

Any advice...?

[defying.gravity]

I felt really shaky inside after this incident, and would really like to know what I could have done differently, in order to prevent such an outcome next time I encounter a Borderline patient. I tried to ask the nurses, but they said they - as somatic nurses - aren't very good with such patients, because they don't encounter them very often at that department. A young nurse even seemed surprised that the patient had acted that way, ("because she seemed like the calm type"), as if it was something I had done wrong (As a female medical student, some of the nurses are already extra critical towards me, and I really try to be good at my job so that we can co-operate well, and this for sure didn't make them any less critical or condescending.)

Any advice...?

Since you are a med student and will most likely will encounter patients with personality disorders in your career, you might want to read a little about the emotional regulation difficulties these patients have and methods of helping keep the lines of communication open and fluid without compromising the integrity of the reason you are there, which is to help her comply with the medical intervention she was prescribed.

Historically, the borderline diagnosis has been treated with stigma, it might help you to keep that in mind and be mindful of how you think about patients with this diagnosis. Patients with this diagnosis tend to be hypervigilant and extremely sensitive to real and perceived criticism, they way you think about them will show in subtle mannerisms and often these patients are experts at picking up those subtle mannerisms. They are not necessarily good at reacting to them in their own best interest, but often very good at reading them. If you ever play poker with someone who has a borderline diagnosis, you will find it to be a challenge to hide your tells.

It helps to try to be compassionate with the emotional pain they have without letting your boundaries be manipulated. Splitting can happen, yes, which is why it is very important to take a team approach with this patient. The team being on the same page helps the patient contain the emotional dysregulation, creates an emotional environment that is steady and controlled. Something these patients tend to really have a hard time with.

Current therapeutic treatment that has reasonable treatment success for these patients is Dialectical Behavior Therapy. If you aren't familiar with that therapy, you can learn a little about it for insight into the condition that someone who has borderline experiences.

I'm not sure what your specialty will be in your career, or how much investment you wanted to make into understanding that diagnosis, but that's a little insight that I have into your question.