Care Interventions for Patients With BPD in the Acute Setting.

Care Interventions for Patients With BPD in the Acute Setting

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

Main Features Of Presentation- Chronic emptiness

- Repeated DSH and suicidal ideation

- Feelings of abandonment

- Distorted communications

- Denial of helpful relationships

- Projection

- Splitting

Staffs’ Perceptions

Provocative Unreasonable Over dependent Controlling Untreatable

Staff Approaches

Dogmatic approach Heal all, know all, love all-narcissistic snares Neutral-therapeutically inert Pragmatic approach

Obstacles To Therapeutic Collaboration

Staff found it difficult to equate 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.

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)

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)

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

FIG 1 IMMEDIATE CARE TRANSITIONAL CARE DEVELOPMENTAL CARE

NURSING

INPUT

THERAPEUTIC

ALLIANCE

CLIENTS

PERSPECTIVE

CONSTANT OBS GENERAL OBS DISCHARGE PLANNING

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.

FIG 2 IMMEDIATE CARE TRANSITIONAL CARE DEVELOPMENTAL CARE

NURSING

INPUT

THERAPEUTIC

ALLIANCE

CLIENTS

PERSPECTIVE

CONSTANT OBS GENERAL OBS DISCHARGE PLANNING

ADHERE TO AGREED INTERVENTION STRATEGY.PROMOTE SELF EFFICACY.CONTINUE WITH MOTIVATIONAL TECHNIQUES.REFER TO SOCIAL WORK AND OCCUPATIONAL THERAPY.

FOCUS ON MAINTENANCE OF CHANGE.LOOK TO INVOLVE EXTERNAL SUPPORTS. EXPLORE DISCHARGE ISSUES/OPTIONS.

MAINTAIN A SAFE ENVIROMENT.RISK MANAGEMENT.OFFER REGULAR SUPPORTIVE INTERVENTIONS BY IDENTIFIED LINK NURSES.USE MOTIVATIONAL INTERVIEWING TO FOSTER CONDITIONS OF CHANGE.MAIN FOCUS ON CONSISTENCY IN ALL INTERVENTIONS INTERACTIONS.

WHAT DO I NEED TO MAKE ME FEEL SAFE?WHAT HAS WORKED TO MAKE ME FEEL SAFE IN THE PAST?WHAT CAN OTHERS DO TO MAKE ME SAFE?WHAT CAN I DO TO MAKE MYSELF FEEL SAFE?INCORPORATE ABOVE INTO SECURITY PLAN

HAVE I HAD ANY SETBACKS? WHAT HAVE I LEARNED FROM THESE?WHAT INPUT HAVE I FOUND TO BE MOST BENIFICIAL?WHAT HAVE I ACHIEVED SO FAR?FEEDBACK MY FEELINGS TO LINK NURSES.

RE-DEFINE MY NEEDS. WHAT ARE MY LONG TERM NEEDS.HOW CAN I CONSOLIDATE THE CHANGES THAT I HAVE MADE.

COLLABORATE AND AGREE ON CARE PLAN AND ITS CONTENTSINCORPORATE ELEMENTS OF SECURITY PLAN INTO CARE PLAN

REVIEW CARE PLAN/SECURITY PLAN.SET MEDIUM TERM GOALS

SET LONG TERM GOALS.EVOLVE SECURITY PLAN INTO MAINTENANCE OF CHANGE MANAGEMENT PLAN.EXAMINE DISCHARGE ISSUES/ POSSIBILITIES

Plan

Encourage staff to attend regular support groups.

Ensure that all interventions are delivered in a coherent and consistent manner.

Security Plan

What she could do to help herself.

What she thought others could do to help.

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.

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.

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)

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 inconsistency arising.

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)

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.

Key Features

Be well structured. Devote effort to achieving adherence. Have a clear focus. Be therapeutically coherent to both staff and

patient.

Key Features

Involve a clear therapeutic alliance between staff and patient.

Be relatively long term. Be well integrated with other services available

to patient.

(Bateman and Tyrer 2002)

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.

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

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.

FIG 3 IMMEDIATE CARE TRANSITIONAL CARE DEVELOPMENTAL CARE

NURSING

INPUT

THERAPEUTIC

ALLIANCE

CLIENTS

PERSPECTIVE

CONSTANT OBS GENERAL OBS DISCHARGE PLANNINGPRECONTEMPLATION CONTEMPLATION PREPARATION ACTION MAINTENANCE

DOOR OPENED PATIENT BECAME INFORMAL

ADHERE TO AGREED INTERVENTION STRATEGY.PROMOTE SELF EFFICACY.CONTINUE WITH MOTIVATIONAL TECHNIQUES.REFER TO SOCIAL WORK AND OCCUPATIONAL THERAPY.

FOCUS ON MAINTENANCE OF CHANGE.LOOK TO INVOLVE EXTERNAL SUPPORTS. EXPLORE DISCHARGE ISSUES/OPTIONS.

MAINTAIN A SAFE ENVIROMENT.RISK MANAGEMENT.OFFER REGULAR SUPPORTIVE INTERVENTIONS BY IDENTIFIED LINK NURSES.USE MOTIVATIONAL INTERVIEWING TO FOSTER CONDITIONS OF CHANGE.MAIN FOCUS ON CONSISTENCY IN ALL INTERVENTIONS INTERACTIONS.

WHAT DO I NEED TO MAKE ME FEEL SAFE?WHAT HAS WORKED TO MAKE ME FEEL SAFE IN THE PAST?WHAT CAN OTHERS DO TO MAKE ME SAFE?WHAT CAN I DO TO MAKE MYSELF FEEL SAFE?INCORPORATE ABOVE INTO SECURITY PLAN

HAVE I HAD ANY SETBACKS? WHAT HAVE I LEARNED FROM THESE?WHAT INPUT HAVE I FOUND TO BE MOST BENIFICIAL?WHAT HAVE I ACHIEVED SO FAR?FEEDBACK MY FEELINGS TO LINK NURSES.

RE-DEFINE MY NEEDS. WHAT ARE MY LONG TERM NEEDS.HOW CAN I CONSOLIDATE THE CHANGES THAT I HAVE MADE.

COLLABORATE AND AGREE ON CARE PLAN AND ITS CONTENTSINCORPORATE ELEMENTS OF SECURITY PLAN INTO CARE PLAN

REVIEW CARE PLAN/SECURITY PLAN.SET MEDIUM TERM GOALS

SET LONG TERM GOALS.EVOLVE SECURITY PLAN INTO MAINTENANCE OF CHANGE MANAGEMENT PLAN.EXAMINE DISCHARGE ISSUES/ POSSIBILITIES

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.

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

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)

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.

References

Tidal model-http://www.TidalProchaska,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.