Violent Borderlines - page 2

What is a therapeutic response, in a acute setting, to a violent, attention seeking borderline?... Read More

  1. by   rn/writer
    Just because the diagnosis/label didn't exist, that doesn't mean that the condition didn't exist.

    In psych, there is always the temptation to pigeonhole patients and stop seeing them as individuals. This is rarely helpful. Even within a particular diagnosis there are countless variations on a theme.

    One of the most effective ways of dealing with any kind of psych patient is to ask them what they need. The answers--which can range from the astute and insightful to the obtuse and ridiculous--can reveal much about the patient's state of mind. And it has the side benefit of calming some who gain a small measure of relief from believing that someone is willing to listen to them.

    It has helped me greatly to change my definition of borderline patients from obnoxious, dramatic, selfish control freaks to oversized frightened children who routinely act on impulse because they have never developed emotionally beyond the preschool level and do not possess the maturity or life skills to act as the adults they appear to be.

    This definition allows a practitioner to stop trying to connect with the acting-out patient on an adult level without first making contact with the scared kid who rules the roost. You do have to offer adult-worthy respect, but you accomplish this by meeting the "child" where he or she is at the moment and then helping them move to a higher functioning level.

    In the case of someone threatening violence, you do have to establish that such behavior won't be tolerated and will have consequences, and you absolutely must follow through on enforcing any limits that have been set. It's great if you can do this matter-of-factly without attaching condemnation. "Well, Jake, I really hope we can get you some relief without going through a big confrontation. Seems like you usually feel pretty bad after one of those. And a take-down delays getting your needs met. Can you think of anything that would help you to take a break right now?"

    Again, actual violence has to be stopped in its tracks. But taking the power struggle out of an intense but still non-violent interaction can help both the patient and the staff member to disengage.

    Borderline patients can be frustrating to the ultimate power, but thinking of them as people hamstrung by arrested development has allowed me to depersonalize the conflicts. Their behavior and reasoning is soooo very like a three-year-old. Self-centered, easily frightened, impulsive, heavily sensory, greatly influenced by physical needs, etc. Like young children, they often trust the wrong people (who promise what they want) and back away from the right people (who offer what they need). Borderline folks are often either out of touch with their physical needs (not aware that they haven't eaten or slept recently) or they are obsessed with them ( I want food NOW!). They benefit from having someone who isn't mad at them help them to find some kind of balance between their drives and their reasoning.

    The prognosis for borderline patients is sometimes grim because progress is directly proportional to the level of trust they can develop, and that is hard to build when they're always ticking people off. Where trust can be established, a patient can learn from mistakes and start to grow emotionally. The kinds of things that help are the very same things that make up good parenting--setting and enforcing limits without condemnation, allowing the person to make mistakes with the understanding that it's okay to look at the results and see what worked and what didn't, a sense of humor, the ability to move on after problems, and many other similar behaviors.

    The trick to doing all of this is to address the child in an adult fashion. Not easy, but worth the effort. It rarely goes amiss to ask, "What do you need, and how can I help you to get it?"
  2. by   showbizrn

    take a deep breath.
    before the violent episode
    set the ground rules.

    contract the client
    yes, a wriiten contract
    that states the client
    will refrain from violence
    at periods of stress,
    rage, crisis, tension, etc.

    and seek out staff,
    utlilize pre-approved
    physical outlets (i.e. punching a pillow, etc).

    contract will also state
    the consequences of combative behavior
    privilege reductions (i.e., room restriction, off-unit privileges, etc)
    level of care reductions
    po meds
    im meds
    physical restaints (last resort).

    much success!!!
  3. by   Whispera
    written contract if the person can read or write (due to education level and ability to do it related to illness)....

    I think sometimes that word choice can be quite important. For instance, calling someone a borderline is labelling. In the best of all perfect worlds, I'd prefer to say someone is a person who has borderline personality disorder. Or, in the case of a violent person, I'd prefer to say that a person has a possibility of becoming violent, and leave the diagnosis label out of it, since other people can become violent too...
  4. by   Thunderwolf
    For the sake of posterity and continuity, here is a link to what I previously had written on the care of a person with BPD on the unit.

    Borderline Personality Disorder on the Behavioral Unit
    Last edit by Thunderwolf on May 2, '09
  5. by   aloevera
    truthfully, if a pt. punches the wall, threatens staff...we will do a take down, administer meds and watch them closely....they will be put on LOS (line of sight at all times) if they are a threat to themselves or anyone else..(pt. or staff)
    that is not the time to "talk" to the pt. when they have escalated to the point of violence it is time to calm them later when they are mellowed out..........
  6. by   MADHAT6
    Determine the secondary gain from these violent attention seeking behaviors and assist the client to find other ways of fulfilling that need,is the client deliberately provoking to acheive the type of destabilized environment she is used to,or to recreate the comfortably hostile environment she grew up with,is she replaying old patterns,trying to acheive control by disruption,these are some questions i would ask in order to assist the client to regain control opf her behavior,there is a great book "Mind over Mood" you might find helpful,good luck dealing with these clients,it is difficult and you are wise to seek advice,but you will find once you identify the behaviors associated with this personality,that many people share their traits...i still have to seek advice after 20 years
  7. by   aloevera
    I wish we had the time to search for reasons and cause of behavior but with usually 30 pt. ++ we a re lucky to get 10 min. with a pt. per shift......just enough info to chart on....period.....
  8. by   Smitty08
    Seems to me the most violent pts I ever dealt with were not even the BPD pts. Sure there were plenty of threats, hystrionics and tantrums - even self mutilation (usually dramatic and superficial). My most violent pts were psychotic, paranoid, in "DT's" - that type. Got a mouthful of fist once from someone who thought I was a KGB agent! I even worked once on a strictly BPD unit (26 BPD pts - what was I thinking? ) Even there, not too much violence despite industrial strength drama always going on. After gaining my footing with those pts, I usually could work with them effectively in the future. I certainly don't consider them most violent...
  9. by   aloevera
    agree with above post...Smitty08...borderlines are too busy being manipulative to get's rarely get escalated to the point of violence....
    violence I see are from schizo c PF, psychotic d/o...etc.
  10. by   Smitty08
    Oh and yes, probably there are some nice exceptions and some very violent BPD individuals. I always liked the example of that movie "Fatal Attraction", which I thought depicted a really out of control, but high functioning BPD person very nicely. But that's Hollywood. Bunny soup anyone?
  11. by   Orca
    A calm demeanor often works wonders. These patients often escalate in reaction to the responses of others, who sometimes escalate right along with them. Listening can also be very helpful. With some patients, including those who are irrational, just having someone listen to them is therapeutic. It isn't even important that you believe them in many instances. The fact that you heard the patient out can help to reduce his or her tension level.
  12. by   Leahr
    sounds like you are unhappy with the profession.
  13. by   aloevera
    we have meds to control bi-polar, schizo, and many others.....sad thing is, there is not a whole lot we can do with borderlines,.......we must not feed in to their manipulations....that is the utmost thing to keep in mind....