working with people with borderline personality disorder in acute psychiatric admission wards
TRANSCRIPT
Working with People with Borderline Personality Disorder in Acute Psychiatric Admission Wards
Who Am I?
• Dan Warrender• Staff Nurse• Acute Psychiatric Admission Ward• Early Clinical Career Fellow 2012• MSc Nursing at the University of Aberdeen• Focus on Borderline Personality Disorder• e-mail: [email protected]
Borderline Personality Disorder• Instability of interpersonal relationships, self-
image and mood• Impulsive behaviour• Rapid fluctuation between confidence and
despair• Fear of abandonment and rejection• Tendency towards suicidal thinking and self-harm• Frequent users of psychiatric and acute inpatient
services(NICE, 2009)
Circumstances of Admission
• Self-Harm and Suicidal Thinking• Chaotic Behaviour• Referral from Accident and Emergency• Place of Safety• Use of the Mental Health Act• Comorbidity• Medication Review• Re-evaluation of Treatment Plan
Management
• Crisis Admission• Focus on Management of Immediate Distress• Assessment of Risk• Constant Observations• Use of the Mental Health Act• Medication• 1 – 1 Interaction
Challenges for Staff
• Transference• Counter-transference• Maintaining Professional Boundaries• Coercive Bondage• Splitting• Personal Stress• Staff Burnout
Challenges for Patients
• Transference• Counter-transference • Diagnostic Baggage• Perceived Rejection from Staff• Malignant Regression• Malignant Alienation
Mentalization• A Psychological Therapy• Roots in Attachment Theory• Thinking about thinking• Making sense of ourselves and each-other• Regulation of emotional expression• Learn to ‘step back’ from your thoughts, examine
them to see if they are valid• Individual or group sessions with other BPD patients• Cost-effective
Evidence
• BATEMAN, A. and FONAGY, P., (1999). Effectiveness of Partial Hospitalization in the Treatment of Borderline Personality Disorder: A Randomized Controlled Trial
• BATEMAN, A. and FONAGY, P., (2008). 8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual
Evidence
• BATEMAN, A and FONAGY, P., (2009). Randomized Controlled Trial of OutpatientMentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder
• BALES, D., et al., (2012). Treatment Outcome of 18-Month, Day Hospital Mentalization-Based Treatment (MBT) in Patients with Severe Borderline Personality Disorder in the Netherlands
Challenges for Mentalization
• Staff leaving clinical areas to attend training• Facilitating MBT sessions during high levels of
clinical activity• BPD patients usually present for ‘crisis
admissions’ - variable ability to engage• Evidence base for MBT at an early stage (NICE,
2009)• MBT untested for brief stays in acute admission
environment – research necessary
The Importance of Mentalization
“We will misinterpret people if we misunderstand their motives, become distrusting if we assume that people are malevolent, and be unable to love and feel love if we cannot find ourselves in someone else’s mind” (Bateman, Brown and Pedder, 2010, p.84)
Clinical Supervision
• Opportunity to Process Experiences• Space to Reflect• Emotional Support• Helps Prevent Burnout• 1 – 1 or Group Sessions• Particularly Valuable in Working with BPD
The Integrated Care Pathways
• tolerate intense anger, aggression and hate.• promote reflection.• understand the dynamics and monitor relationships
between service users and staff.• monitor counter transference feelings, strong
feelings that can be unconsciously evoked in staff, to understand the service user’s communications and difficulties.
• Use a consistent approach.(NHS Quality Improvement Scotland, 2007)
Why Implement Change?• High Prevalence of BPD• High Frequency of Crises• Frequent Users of Psychiatric Inpatient Care• Patterns of brief and numerous, or lengthy
admissions • Economic impact of frequent readmissions• ‘Crisis Admission’ lacks structure and focus. • Mentalization and Clinical Supervision, could
help nurses responses to BPD
NHS Quality Strategy
• Safe• Person-Centred• Effective
(The Scottish Government, 2013)
Summary
• No evidence that BPD crisis admissions are beneficial
• BPD patients still frequent users of inpatient services
• Staff nurses should be trained in mentalization and make use of clinical supervision
• Make the most of the opportunity to help and support the patient with BPD
Thesis
• Mentalization as part of a structured crisis admission
• Use of Constant Observations• Promote Clinical Supervision in Staff• Early Discharge Planning• Measure to Assess Impact
References• APA, (1994). Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV). Washington, DC: APA.• BALES, D., et al., (2012). Treatment outcome of 18-month, day hospital mentalization-based treatment (MBT) in patients with severe
borderline personality disorder in the Netherlands. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22643090 [Date Accessed 12th April 2013].
• BATEMAN, A. and FONAGY, P., (1999). Effectiveness of Partial Hospitalization in the Treatment of Borderline Personality Disorder: A Randomized Controlled Trial. Available from: http://ajp.psychiatryonline.org/article.aspx?articleID=173741 [Date Accessed 10th April 2013].
• BATEMAN, A., BROWN., D. and PEDDER, J., (2010). Introduction to Psychotherapy: An Outline of Psychodynamic Principles and Practice. 4th Edition. Hove: Routledge.
• BATEMAN, A. and FONAGY, P., (2008). 8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual. Available from: http://psychiatryonline.org/data/Journals/AJP/3860/08aj0631.PDF [Date Accessed 10th April 2013].
• BATEMAN, A and FONAGY, P., (2009). Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder, The American Journal of Psychiatry, 166 (12), pp. 1355-1364. Available: http://www.ap.psychiatryonline.org/article.aspx?articleid=101399&RelatedWidgetArticles=true [Date Accessed 29th May 2013].
• BORSHMANN, R., et al., (2012). Crisis Interventions for People with Borderline Personality Disorder (Review), Cochrane Database of Systematic Reviews 2012, 6. Available: http://www.ncbi.nlm.nih.gov/pubmed/22696385 [Date Accessed 29th April 2013].
• CLEAR, (2013a). Clinical Enquiry and Response Service: Are there any trials examining the effectiveness of mentalization based therapy for patients with borderline personality disorder? Available from: http://www.knowledge.scot.nhs.uk/clear/answers/mental-health-and-behavioural-conditions/are-there-any-trials-examining-the-effectiveness-of-mentalization-based-therapy-for-patients-with-borderline-personality-disorder.aspx [Date Accessed 16th April 2013].
• CLEAR, (2013b). Clinical Enquiry and Response Service: What are the figures for amount and percentage of acute psychiatric hospital admissions which are people with borderline personality disorder? Available from: http://www.knowledge.scot.nhs.uk/clear/answers/mental-health-and-behavioural-conditions/what-are-the-figures-for-amount-and-percentage-of-acute-psychiatric-hospital-admissions-which-are-people-with-borderline-personality-disorder.aspx [Date Accessed 16th April 2013].
• DASGUPTA, P., (2004). Admission patterns of patients with personality disorder. Available from: http://pb.rcpsych.org/content/28/9/321.full [Date Accessed 15th April 2013].
• FAGIN, L., (2004). Management of Personality Disorders in Acute In-Patient Settings. Part 1: Borderline Personality Disorders, Advances in Psychiatric Treatment, 10, pp. 93–99. Available from: http://apt.rcpsych.org/content/10/2/93.full [Date Accessed 29th December 2012].
• GROSS, R., et al., (2002). Borderline Personality Disorder in Primary Care. Available from: http://archinte.jamanetwork.com/article.aspx?articleID=210746 Date Accessed 11th April 2013].
References (continued…)• HOLMES, J., (2008). Mentalization: a key skill for psychiatrists and their patients - in 100 words. The British Journal of Psychiatry. 193: 125.
Available from: http://bjp.rcpsych.org/content/193/2/125.short [Date Accessed 28th March 2013].• McGRATH, B. and DOWLING, M., (2012). Exploring Registered Psychiatric Nurses’ Responses towards Service Users with a Diagnosis of
Borderline Personality Disorder. Available from: http://www.hindawi.com/journals/nrp/2012/601918/ [Date Accessed 12th April 2012].• NES, (2011). The Matrix - Mental Health in Scotland: A Guide to Delivering Evidence Based Psychological Therapies in Scotland. Available
from: http://www.nes.scot.nhs.uk/media/425354/psychology_matrix_2011s.pdf [Date Accessed 10th April 2013].• NHS CHOICES, (2011). Psychotherapy – Availability. Available from: http://www.nhs.uk/Conditions/Psychotherapy/Pages/Availability.aspx
[Date Accessed 12th April].• NHS CHOICES, (2012). Borderline personality disorder – Treatment. Available from:
http://www.nhs.uk/Conditions/Borderline-personality-disorder/Pages/Treatment.aspx [Date Accessed 21st March 2013].• NICE, (2009). Borderline personality disorder: treatment and management. NICE clinical guideline 78. Available from:
http://www.nice.org.uk/CG78 [Date Accessed 21st March 2013].• MORAN, P., et al, (2000). The prevalence of personality disorder among UK primary care attenders. Acta Psychiatr Scand: 102: 52-57. Available
from: http://onlinelibrary.wiley.com/doi/10.1034/j.1600-0447.2000.102001052.x/pdf [Date Accessed 11th April 2013].• PARIS, J., (2004). Is Hospitalization useful for suicidal patients with borderline personality disorder. Available from:
http://ectweb.pbworks.com/f/JPersonality%20disorder.pdf [Date Accessed 10th April 2013].• PARIS, J., (2008). Treatment of Borderline Personality Disorder: A Guide to Evidence Based Practice. New York: The Guilford Press• RENDU, A. et al., (2002). Economic impact of personality disorders in UK primary care attenders. British Journal of Psychiatry, 181, 62^66.
Available from: http://bjp.rcpsych.org/content/181/1/62.full.pdf [Date Accessed 11th April 2013].• WATTS, D. and MORGAN, G., (1994). Malignant Alienation: Dangers for Patients Who are Hard to Like. British Journal of Psychiatry, 164, pp.
11-15.• WORLD HEALTH ORGANISATION, (1992). The ICD-10: Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic
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