Borderline Personality Disorder

Doc · Apr 15, 2001

Having worked as an Addictions Counsellor prior to Nursing I was faced with working with many patients with personality disorders, mostly antisocial, histrionic and borderline, but I also worked with patients who had a narcisistic, paranoid, depressive or dependent personality (not necessarily with the personality disorder as such, but at least with those characteristics in their personality). Approximately 1/3 of D&A cls/pts have an underlying PD.

One important consideration is not to label. It does not matter if they have had this Dx made recently or a long time ago, there may be other cause for the behaviour and it may be a temporary manifestation of a nervous breakdown, for instance. Also, many "normal" pts on a med/surg unit behave in a demanding manner and are not treated as a person with a personality disorder nor are they considered to have one. Often the functional or non-PD-related behaviour of the person with a PD is then interpreted as part of their disorder. This labelling can be a barrier to proper therapy much in the same way that known narcotic dependent people are often refused adequate pain relief.

A second consideration is that you may not be the only nurse working with this cl/pt. The attitudes of others will affect therapy. Of course, these cls/pts are known to be manipulative but remember that this should not affect the treatment goals, only the strategies used to achieve them. You might find it useful to have a discussion about BPD with your colleagues. A good way to go about it is to suggest a team meeting with a psychologist, social worker, psychiatrist and nurses. Then there is room for everybody to learn from each other's expertise and experiences in a positive environment, and it won't be coming from just one person.

I strongly recommend Marsha M. Linehan's (1993) book, Cognitive Behavioural Treatment of Borderline Personality Disorder (558 page hardback from Guilford press, which goes into the development of the disorder and the theories behind it. Linehan is the pioneer of Dialectic Behavioural Therapy and explains it very well in her book. I am sorry, but it is a complex therapy and I cannot offer any kind of summary here.

If you don't have time to read a whole book on the topic, I would at least recommend that you read the theory in Linehan's book so that you have a grounding in understanding the behaviour and what techniques will likely bring a good response. For instance, in a broad sense, the fact that many of the behaviours of BPD cls/pts stem from a lack of validation in their lives would help you to understand the importance of temporarily accepting some of the behaviours from these patients that you wouldn't accept from other cls/pts, and devising statements that confront the need for this behaviour while still validating the person's feelings/needs.

You also indicated that you had some difficulty working with more than one personality disordered cl/pt at a time. The best suggestion I can give you at this time is to treat each person individually unless you are doing groupwork, and to explain this to the cls/pts. That way you won't find yourself a victim of two or more ganging up on you.

I am also not sure of your facility's way of delegating pt assignments, but all units/facilities should have a policy on assessing (in a sense, triaging) the degree of load each pt demands. Pts/cls with a PD often pose a HEAVY load, so the rest of your assignment should consist of lighter pts. However, with a good deal of experience in dealing with these pts, you may find it increasingly easier to take on more of these kinds of pts.

Doc

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AussieRN · Apr 20, 2001

Originally posted by greg in mass:
Does Borderline Personality Disordered clients present a problem to you?

What works and does not work for you? Do you also find it hard to work with more than one at a time? If so, why?

Does anyone out there know and understand what Dialetical Behavioral Therapy is? If so, please explain what it is. If you use it, does it work?

What is the average stay of this type of client in your facility? Do they tend to be repeat clients?

\Hi Greg, I am a nurse unit manager of a busy inpatient psych facility in a teaching hospital. How these patient's are managed depends on the skills and model of the treating psychiatrist but I believe that in an acute psych facility,brief crises admissions are preferred. Behaviour, acting out, cutting etc all gradually worsen over the course of a long admission I have found. Personally I use consistent, polite and professional behaviour utilising firm boundaries and not allowing any anger or frustration (which is easy to feel sometimes!) show. I see my role as displaying appropriate behaviour, maintaining a professional boundary (it is important to perhaps be a bit more formal with these patients). This consistent behaviour is important because these patients will often think you are the best nurse in the works one minute and the worst the next! I remember my lecturer saying to me "do not allow yourself to play out the rolse the BPD patient casts you in"!These patients raise alot of issues and emotions in staff especially those who do not understand the background of this disorder.

I have not heard of that other treatment...will have to look it up!

Michelle