What's Your State Hospital Policy R/T BPD/O?

[autumn-moon]

Just curious.....

There is always griping going on at my job in a state acute care facility that pts. with Borderline Personality D/O require so much staff and so much time to keep them safe that the patients with psychotic disorders such as Bipolar Affective D/O, Schizophrenia and Schizoaffective D/O tend to end up getting much less care and attention than they diserve, as 90% of the staffs time and energy is spent ensuring the safety of the 'Borderlines'.

Some other nurses have said that in most other states, that "Borderlines" are not allowed to languish in in-pt. care, but are forces to deal with their problems in the "real world" with out-pt. care which is specialized to deal with their particular problems, such as DBT.

I'd like to get a sense of how our state compares to the rest of the country. We spend a huge amount of money to keep these people in in-pt. care for months or years, often with 1:1 staffing, not to mention the multiple trips to the hospital when they suddenly regress and manage to hurt themselves despite staffs best efforts to prevent it.

How does your state handle this, and what are your opinions?

I personally tend to think that these pts. use the hospital as a safe haven and that it tends to reinforce their maladaptive behaviors more than it actually helps. They also say that they have picked up a lot of these behaviors from their peers while in in-pt. care.

We are in the postion, where I live, that these folks are sent to us, after a self-abusive episode, straight from the ER, and we have a policy that no one is to be turned away. Many of them are "frequent flyers" or have been in in-pt. care for months to years.

TIA for your input!

Melissa

[lovingtheunloved, ASN, RN]

Thunderwolf, I appreciate your knowledge and sharing it with me. I am so worried about her. She has been hospitalized a few times. She told me that she knows it's bad, but she said whatever they wanted to hear just so she could get out of there. It's interesting about manipulation. The facility we work at has it's share of manipulators, and I swear, she is UNmanipulatable. A resident screams and cries and throws things because she can't have a cigarette NOW, and my friend gently says, "If you continue to behave this way, you will not have a cigarette at smoking time." Some people cave really easy.

[Thunderwolf, MSN, RN]

Lovingtheunloved, be supportive to your friend/co-worker. Let her know that you are there for her and concerned about the cutting. Be honest, be supportive. Just be mindful that the cutting may reflect her stress. You may inquire about ways or opportunities that she currently has to de-stress her situation, building de-stressing activities more into her daily routine. What is her support network like, again building in supports. I wish you well.

[lovingtheunloved, ASN, RN]

Lovingtheunloved, be supportive to your friend/co-worker. Let her know that you are there for her and concerned about the cutting. Be honest, be supportive. Just be mindful that the cutting may reflect her stress. You may inquire about ways or opportunities that she currently has to de-stress her situation, building de-stressing activities more into her daily routine. What is her support network like, again building in supports. I wish you well.

She says she's "not a talker." I wish I could just MAKE her better.

[CliveUK]

She says she's "not a talker." I wish I could just MAKE her better.

Ah, these are the tensions you have to live with as a nurse. You can't "make" people better, they do that for themselves.

[Shell5]

I would like to make an comment related to SOME people's views about Borderline Personality Disorder. I have come across this even on the unit I work on. I have worked in adult and child psych many years and I view things much different. I suppose this is because I was told I had some borderline traits at one point. I happen to believe we all do.

I am 40 and have been on meds with therapy off and on since 18. I tend to be more loving, compassionate and supportive of these patients as a result. I have read and studied over years about Borderline Personality. Patients with Borderline did not ask to have their personality and life significantly altered. It did not just happen and it is not their fault. These are ingrained disorders in their personalities. Patients have maladaptive coping skills and have a hard time managing their emotions. I don't see that most of the patients are trying to dominate the ward or get all the attention. I see most of them as truly sick individuals who need a lot of attention (not all) and positive direction. Maybe they actually need someone's attention. A lot of them don't get it at home.

I don't say this out of ignorance. I say this out of my personal experience. I remember when I was younger going to a counselor who had a view that things were just more of a negative attitude or more of bad behavior but that wasn't the case. It was more than that. That view/perspective toward me caused me to feel worse about myself, not better. It was only when I came across the those that were compassionate, loving, tolerant and understanding and those I knew truly cared about me that is when I felt I could share the things in my life that had CAUSED part of the disorders in my personality.

My mother dies when I was a little girl of a drug overdose. They found her dead body laying in the street at 0400. She left me and my 2 sisters before that. Her and my father were divorced prior to that. I saw a lot of things I should have never seen growing up. This may not have effected some but it effected me. I was later emotionally abused by grandma. As a result, I felt rejected by 2 key women in my life. Then, my father picked women over my sisters and I which in my mind was a 3rd rejection, etc...........You see. If I were to tell 5 people that story 5 people would tell me how to deal with this in their view and how they think I should feel.

One never really knows what to do with someone because we don't know what is in someone's heart. Some people are more hardy than others. For whatever reason, the above, DEVASTATED me!!!!! I needed compassion not others talking about me. I needed love. Let's give our patients some compassion.

I see many of these kids/adolescents have been through a lot of TRAUMA. Unless we have walked in their shoes you can't possibly know how they feel. We have to be more compassionate with our patients. After all, we are patient advocates not adversaries.

[RochesterRN-BSN, BSN, RN]

I just started reading a really good book--writen for both patients with BPD and their families as well as for care providers. It is a much easier read then a text book...... It's called "I Hate You....Don't Leave Me." By Jerold J. Kreisman, MD and Hal Straus.........I would recommend this book. I picked it up as I work in the Psych ER and do the primary evaluations when the patients first arrive to the hospital and am a big part of the decision as to if a patient should be admitted, discharged and if so with what f/u or put into one of our EOB beds, where they can stay for up to 72 hours. We get a lot of patients who suffer form BLPD which is why I decided to read that book. I actually do enjoy working with most of them. As far as the person who posted about cutting-- self injurous behaviors are one of the syndromes defining criteria. It can be in many forms--cutting, burning, hair pulling (trictotillomania), eating disorders, and even drug/alcohol abuse and suicidal gestures--this is part of the self loathing they feel. Many times these behaviors are not done with intent to kill themselves but they go everboard and have no insight as to how these things could "accidently" kill them.

I would say being in the seat of deciding if hospitalization is helpful or not--these are all very individual cases and you can't take and put all patients with a Dx of BLPD in one pot and make a blanket statement that none of them should be hospitalized. Their safey risk has to be looked at as they do actually succeed in killing themselves.

I have worked with them inpatient as well and it was always standard of care that we all knew what patients were BLPD from report and all staff knew to be sure that all contacts were with the assigned nurse only. ---I happened to be that one nurse quite often!!! LOL---they always gave me all the BLPD patients on the unit I swear because I do like them and well they take a lot of patience.

---I would say try not to put them all in one pot --they are not all the same despite having similar characteristics. and also take some time and read this book---very helpful and only 184 pages.

[Mr Ian]

I can't not comment!

Firstly Shell5 - thankyou for sharing your perspective and I acknowledge you 100% in this.

There has always been debate on 'how to manage borderline PD' - which has always infuriated me as it should be 'how to help people with BPD'.

Having typed that - it's hard to disagree with Nurse Ratched - but I will

General rule: get 'em out as soon as possible. (This of course, means the true borderlines, not the ones who just annoy you like a person with BPD .)

Yes the person with BPD can be disruptive to the running of the unit. But it's not their fault the unit is lacks capacity.

Try putting someone with an acute heart condition (someone give me a fancy named critical heart condition please requiring 1:3 nursing on CCU) into a general stroke rehab unit and see how well the nurses cope.

MH units are a 'one size fits all' facility which is very wrong. Putting depressed people together with hypomanic people and people who hear voices and those who are suicidal. You don't see it happen in mainstream hospital wards. Why does psych have to?

BPD require specialist intervention - but we do the best job with limited tools.

My rule on my shift: borderlines assigned to me report directly to me with all needs. That way I can assure a consistent response. All staff are aware that pt is to be directed to me with even the smallest concern. Yeah, it gets a little old by the end of the day, but if there is any question in my mind that everyone is not 100% on board with the plan of care, it's the only way to avoid the problems created by the master staff splitters.

Totally agree - and I do this myself. However, on the "staff-splitting" -

How is it that patients are responsible for their own behaviour - yet staff behaviour is the patient's fault?

Patient's with BPD cannot "split staff" - staff fall apart - because they don't work cohesively.

There doesn't appear to be a single mindset (at least in practice) as to how to deal with the true borderline, unfortunately. I don't work in a state-run setting, but I have a fellow nurse friend who does and she states the inconsistencies there are problematic as they are everywhere, it would seem.

Again agreed - no single mindset .... inconsistencies... staff fall apart.

If a patient came in with a diabetic coma and the staff all treated them differently - what likely outcome?

Some staff treat with hypostat and get the crisis resolved - but other staff seem to want to do the equivalent of 'diet education' while the patient is still in crisis.

Both are useful tools for management of diabetes - but the situation calls for different interventions.

autumn-moon:

The basic theme being that they repeat a "script", when the "voices" are urging them to harm themselves, which essentially says that they are now adults and have learned better ways to cope rather than harming themselves. They also carry a list of alternate activities that we have worked up together to use during times of stress. So far it seems to be helping a lot, but it is a very, very long process. And so the very sick, but low profile pts. still don't get the time they deserve....sigh

Personally I disagree with this approach.

When they get to wanting to cut/harm - they are IN crisis. Teaching a self harmer to not cut is gong to lead to a replacement maladaptive behaviour (usually risk taking of another form - alcohol, drugs, promiscuity)

IMO, deliberate self harm is a symptom - not the problem.

Hukilau:

A novel approach one psychiatrist used was a contract that specified a borderline pt. could be in the hospital a certain number of days every three months for a maximum of three days at a time.

Novel is one way to describe it.

Do they apply the same principle to people who have heart attacks? Only 3 a year and I'm sorry you can only stay a fixed length of time?

I understand there are 'relationship' and 'dependency' issues - but plans like this are purely for operational convenience and are not in any way 'treatment' - merely containment and diverting thye problem elsewhere - like jail.

Unstable personality (thanks Wolfie ) is an abnormal pattern of behaviours and is most often brought on by childhood trauma (not met one who hasn't yet).

What always gets me about how dismissed people with BPD are -

Why do we feel so upset about hearing of a child who has been abused? Because we know that's not right - because we know that child is likely to be psychologically traumatised.

Hello? BPD?

Are they not the abused child we cried for 10 or 20 years ago.... ?

In 10 or 20 years will they not be the abused child we cried for today?

What happened to the compassion we felt for them when they were being abused or harmed?

Yes, they are difficult to manage, contain, support, treat, heal....

But, so what if they make my day "hard"? Their whole childhood was pretty messed up.

[Thunderwolf, MSN, RN]

Patient's with BPD cannot "split staff" - staff fall apart - because they don't work cohesively.

There is great truth in this statement.

:paw:

[Jules A, MSN]

What has been others experience regarding cutters?

Great question and I hope others write in also. I'm still not used to all the cutting I see. Where the heck did this come from? These aren't all psychotic kids. Its as if threatening suicide and cutting are acceptable ways of dealing with upsetting situations. Boyfriend says he "learned" to do it because girlfriend and her friends do it etc. My personal opinion is that for many, not all but many, it has become part of the teenage angst that is our society's norm today. Sort of like eating disorders were 20 years ago. For some it becomes a life threatening problem for others they seem to pass through it as a phase.

[Whispera, MSN, RN]

Since a patient with borderline personality disorder can't "split" staff, that means staff should be aware of conscious or unconscious efforts to split them, so that they continue to work together for the benefit of the potential splitter, eh?

My experience with cutters is that they cut in order to feel. They have buried their emotions so much that they are detached from them, but they are about to explode with some unknown something. So they cut to let pain happen so they can feel and react. I've never felt they do it for effect on other people. It's just an intense emotion they MUST let out.

[Mr Ian]

self harm fits many theories:

1. To "feel" the pain that is otherwise intangible - a detachment from emotions; inability to cry/grieve leaves little options to deal with emotional pain.

2. Endorphin release - much less of a theory but suggestion that the act of harming releases endorphins that give a 'high' to counteract the 'low'

3. Self hatred - for 'letting themselves' get that way.

4. Self control - in a turmoiled world - especially when others control every movement of the person or when others can cause significant emotional pain - it can be a way to demonstrate some control over their own lives.

5. Disempowering antagonists - to protect from those who they perceive as seeking to 'hurt' them; the antagonist is no longer the one responsible for the person's pain since the person themself is.