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...?

[annabanana2]

And, I mean... consider what it must be like for her. She's a grown woman and she has to have a medical student sit outside the bathroom and observe her peeing? Come on. That's nobody's idea of a good time. Of course she's going to be grumpy. I would be too!

Folks who have BPD are constantly terrified that everyone they love is going to leave them, and imminently. They have such anger and are completely bewildered at it. They're confused about other people's behaviour and feelings about them and desperately want to be loved but haven't the foggiest idea how to go about getting that. They hurt themselves for many reasons, but often it's because it's the only thing they can figure out that will solve whatever problem they're having at that time. They literally don't know how to manage their (often extreme) emotions like you and I do. It's awful! Can you imagine?

I try to remember these things when I'm working with folks with BPD who are sitting on my last nerve. They aren't aliens or anything, they're just human beings who are trying to figure out how to navigate feelings and interactions with other people. And at the end of the shift, I get to go home, and they don't.

[CVICU-Nurse1.5]

Just got to be careful about how you interact. Safety first

[wingding]

When I have to do a turn on a 1:1 with pt. I am flat, matter of fact, quiet & do not interact much. If the pt. wants to know why I have to be there, chances are they already know, so I reiterate exactly why I am there. If there was no behavior before you were posted to be a sitter, I would had just said it was policy to keep her safe, I was there for her - in the most soothing tone I could. Borderline likes to get conversations going & elicit friendship & then favors (control issues) --- do not bite - keep it professional. Bathroom??? I am there, walking? I need exercise too -- I am there, sleeping? I keep you safe --- I am your shadow, until you have had XX amount of days without self harm behavior (or whatever treatment plan says). Last one was one that flooded our floor/hospital by triggering sprinkler system which earned her a sitter.

[nickfitz1969]

I would suggest that you stop viewing people as a diagnosis and treat them like human beings. Yes, some people express their emotions in challenging ways, but to be supportive and listen to what the individual is saying, putting trust in them and them trusting you are key to working with patients with these behaviours. And, rather than state that you are "guarding" them, maybe reframe it and say that you were "supporting" or "promoting a safe environment". Finally, what is a somatic nurse?