Care Interventions for Patients With BPD in the Acute Setting

1. Care Interventions for Patients With BPD in the Acute Setting

2. Aims • Look at process of malignant alienation and how it hinders therapeutic collaboration • Show how interventions based on available nursing skills delivered in a consistent fashion can promote therapeutic working • Examine the essential components of these interventions and describe some of the problems encountered

3. Main Features Of Presentation • Chronic emptiness • Repeated DSH and suicidal ideation • Feelings of abandonment • Distorted communications • Denial of helpful relationships • Projection • Splitting

4. Staffs’ Perceptions • Provocative • Unreasonable • Over dependent • Controlling • Untreatable

5. Staff Approaches • Dogmatic approach • Heal all, know all, love all-narcissistic snares • Neutral-therapeutically inert • Pragmatic approach

6. Obstacles To Therapeutic Collaboration • Staff found it difficulttoequate her projection and splitting as acknowledgement of possible inner distress. • Nursing staff did not promote a ward environment in which negative feelings of staff could be discussed in a supportive and reflective manner.

7. Malignant Alienation • “ A progressive detraction in the relationship with patient including loss of sympathy and support” which can lead to “impaired judgement in the nurse who selectively attends to the facts of the clinical situation in order to repudiate and devalue the patient.” ( Watts and Morgan 1994)

8. Plan • Appoint link nurse x4 to implement baulk of interventions.[Specialist team approach*] Attributes of link nurses “Be pragmatic rather than dogmatic” (Shaw et al 1999) “Retain the capacity to be steady, skilful and competent despite provoked anxiety and pressure to transgress” (Bateman and Fonagy 1999)

9. Plan • Develop individualised care pathway with its empathises on collaboration over three distinct phases • Immediate • Transitional • Developmental [fig 1] • The aim of this is to provide more consistent care by minimising variations in practise

11. Plan • Prepare patient for general obs over a period of six weeks. • Encourage patient to write up a security plan and incorporate it into her care pathway.[Fig2] • Bring patient off constant obs in a staged manner.

13. Plan • Encourage staff to attend regular support groups. • Ensure that all interventions are delivered in a coherent and consistent manner.

14. Security Plan • What she could do to help herself. • What she thought others could do tohelp.

15. Benefits of Regular Meetings • These have helped staff to appreciate, bear and put into perspective manifestations of projection and splitting and view its meaning as possible representation of the patients inner process. • Reflective practise has been encouraged.

16. Improvements in Therapeutic Relationship • Patient appeared better equipped with coping skills.(Distress tolerance) • Therapeutic alliance more robust. • Staff more attuned and empathically responsive to her emotional state.

17. Pharmacology • “The pharmacological treatment of BPD remains limited in scope…..By and large the results can be described as a mild degree of symptom relief.” (Paris 2005)

18. Successful Features • Link nurses have remained unchanged. (Constancy) • Care has remained co-ordinated and delivered consistently. • It is clear that limiting the people involved in care to those whose roles are clear reduces the chances of inconsistencyarising.

19. Successful Features • Patients respond better to well planned interventions as it is clear that “patients need to feel that those responsible for their care communicate frequently and effectively,get on well together and are clear about the boundaries of treatment offered”. (Bateman and Tyrer 2004)

20. Successful Features • A thorough assessment of their needs and completion of a detailed security plan gives patients a tangible feeling that that their needs are being acknowledged.

21. Key Features • Be well structured. • Devote effort to achieving adherence. • Have a clear focus. • Be therapeutically coherent to both staff and patient.

22. Key Features • Involve a clear therapeutic alliance between staff and patient. • Be relatively long term. • Be well integratedwith other services available to patient. (Bateman and Tyrer 2002)

23. Problem Areas • Keeping staff working to plan • High staff turn over can mitigate against constancy • Some staff find it difficult working with patients’ who have B.P.D. • Some staff easily fall into narcissistic snares or adopt confrontational dogmatic approaches.

24. Problem Areas • Hard work in short term • Lack of specific training • Reluctance of staff to attend support groups • Inappropriateness of • 1) nursing patients with BPD on constant obs for protracted periods of time. • 2) long term residency in acute admission wards

25. Evaluation • Look at incidence, frequency and intent of self harm. • Achievement of goals. • Progress through care pathway. [Fig 3] • Client satisfaction. • Nursing entries then and now.

27. References • Bateman,A. and Tyrer,P. (2004) Psychological treatment for personality disorder.Advances in psychological treatment. Vol. 10 378-388. • Watts,D. and Morgan,G. (1994) Malignant alienation. Dangers for patients who are hard to like.British journal of psychiatry. 164, 11-15.

28. References • Bateman,A. and Tyrer,P. (2002) Effective management of personality disorder. National institute for mental health in england. • Fonagy,P. and Bateman,A. (2006) Progress in treatment of personality disorder.British journal of psychiatry 188,1-3

29. References • Personality disorder-no longer a diagnosis of exclusion NIMHE(JAN 2003) • Personality disorder in Scotland.Demanding patients or deserving people.Delivering improved care.A discussion paper. • Integrated care pathways.Effective interventions unit.Scottish executive publications(2003)

30. References • Shaw et al(1999) Therapist competence ratings in relation to clinical outcome in cognitive therapy of depression.Journal of consulting and clinical psychology. 67, 837-846. • Paris,J.(2005) Borderline personality disorder.Canadian medical assessment journal.

31. References • Tidal model-http://www.Tidal • Prochaska,J.O., Diclemente, C.C,Norcross, J.C. (1992) In search of how people change.Applications to addictive behaviour.American psychologist.47,9,1102-1114.