Managing Borderline Personality Disorder

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Copyright © by Carlo Lazzari, 2015


Managing Borderline Personality Disorder

This presentation is linked to a App and represents a toolkit provided to healthcare professionals to deal with the management and treatment of patients with borderline personality disorder BPD into psychiatric wards.


Managing Borderline Personality Disorder

You will find us on the App:

BPD App:Google Play And iTunes

A combined management plan for improving an integrated care in mental health wards dealing with inpatients with borderline personality disorder

Definition of Borderline Maladaptive BehavioursBMB are defined as a pattern of challenging, self-harming, and threatening behaviours of BPD inpatients impairing the therapeutic alliance with staff, reducing patient’s compliance with ward’s regulations, boycotting care plans and discharges, and leading to disrupt power balances into mental-health wards, together with frequent complaints by part of BPD patients and staff.

Classification of BMB

• Attack to the health system: escalation of complains towards staff and requests of investigation by part of Committees for Quality Control with the intent of reducing staff’s reactivity and having the ward closed.

• Needing IM: escalation of challenging and self-harming behaviours to access intramuscular medication as a way of procured self-harm or ‘ward wound’ to claim to be ‘worse’ than any other patients.


• Multiple self-referrals to Accident and Emergency departments to deal with crises and facilitate hospital admission.

• Aiming to take leadership into a psychiatric ward with the intent to create a niche of power and to direct other patients or staff’s decisions.

• Splitting members of staff to have control and power over the ward.

Classification of BMB• Communal and synchronic self-

harming and challenging behaviours together with other BPD patients to reduce staff’s resources and intervention impact.

• Following a leader who directs ways of self-harm, time, location, ect. In other BPD patients.

• Group suicide pacts.• Sun downing: deterioration of mood

and escalation of challenging behaviours as sun downing due to dropping of mood, anxiety, boredom, less attention from staff and lack of activities.


• Claiming bipolarity and accentuation of mood swings to get access to Lithium therapy as a way of having the provision of a substance that is more lethal if taken overdose.

• ‘Calling the Police’ as a preferential channel for dealing with crises, having rapid access to boundaries and support while creating a ‘catastrophic scenario’ to access the desired care via rapid referrals by an unquestionable source.


• Boycotting discharge plans with the intention to prolong hospital stay. BMB increase in intensity before discharges as a way of reducing the likelihood of this ‘undesirable’ event for BPD. Staying in hospital for an unlimited time is often the only welcome solution to being discharged back to community.

Consequences of BMB on staff

BMB lead to resentment and dispersion of resourceful staff members. BMB also reduce the power of intervention by the staff that feels vulnerable to patients’ resentments and complaints to the commissions for quality control (CQC in UK). Furthermore, high levels of conflicts within staff are found in wards where BPD patients are treated.

Consequences of BMB on staff dealing with BMB

• Feelings of powerless• Fear from attacks, challenging

behaviours or complaints by part of BPD patients

• Feelings of discouragement and abandonment from top management

• Feelings of retaliation from patients

• Reduction of commitment and empathy in interacting with BPD patients

• Frequent transfers to other wards and sick leaves.

Integrated care and multiple management strategies to deal with BMB

• Integrated care• Utilisation of different

management theories


Scientific Management Approach (SM)Emphasizes a scientifically determined management practice as a way to improve efficiency, based on standard methods for accomplishing each job (Daft & Marcic, 2008).

Scientific Management Approach (SM)

In order to manage effectively BMB healthcare providers need to know the scientific basis of their behaviour before planning an integrated care. Theoretical models, surveys, and auditing are important in order to collect the necessary evidence needed to implement changes into the organization.


Human Relations Approach (HR)McGregor’s stated that the most significant cause of job satisfaction is a sense of realisation and achievement (Henderson, 1996). The HR approach maintains that organisational vision and human needs are reciprocal and compatible (Grobler, Wärnich, et al., 2006).

Human Relations Approach (HR)

Management should aim to consider staff’s reasons of concerns, and to promote a shared feeling of responsibility and belongings. A state of mind of power and self-realization is achieved by promoting staff’s autonomy in their decisions and an individualised support when crises arise. Proper medication of BPD patients with reduction of their challenging and maladaptive behaviours increases staff’s confidence in the own power to limit undesired conducts in their problematic patients.


Contingency Theory Approach (CA)This approach reflects on all characteristics of current scenario and acts on these phases (McNamara, 2015). It is an effort to determine through exploration which managerial methods are suitable in specific circumstances (Kreitner, 2009).

Contingency Theory Approach (CA)

Decisions on best plans are taken according to the presenting scenario. Although standardized care plans and medication-behavioural approaches are taken, each care plan and management is tailored for each BPD patient, staff’s conditions, ward safety, etc. The expected outcome is the right intervention at the right time with no delayed response in patient’s management from staff.


System Theory Approach (SA)System management entails recurrent, although at times demanding, communication with many teams within the same organisation with direct customer-user interactions (Baldwin, Hoffman, & Miller, 2004). It looks at company people, groups and teams as integrated sets.

System Theory Approach (SA)

One of the transmission belts for an integrated care and systemic management is the reinforcement of interprofessional teams. Here, team communication and coordination have been found as vital for collaboration in multidisciplinary teams (Tsakitzidis et al., 2016).

System Theory Approach (SA)

BPD patients need an active co-participation of many care workers. Hospital staff, home treatment teams, care coordinators and community mental health nurses create unified systems. There is a constant interaction between these systems and subsystem and no integrated care to BPD patients can be imagined without amalgamating cooperating systems into a combined care plane.


Chaos Theory Approach (CT)The idea of Chaos Management theory is that events can rarely be managed (McNamara, 2015) while empowerment will come from manager’s self-reflection (Gold & Evans, 1998).

Chaos Theory Approach (CT)

Not every aspect in the management of BPD patients can be controlled. It might be the case that due to the complexity of treating these patients, their recurrent relapses, the lack of a cooperative support network in the community, the national health system, globally speaking, is unprepared to deal with BMB and borderline patients.

Assessment Instruments

BMB-Staff Self-Assessment (BMB-SAS)

On a Scale from 1 (nil) to 5 (totally) how much do you feel the following aspects apply to you when dealing with inpatients with diagnosis of borderline personality disorder?

Assessment Instrument: Scientific Management and Human ResourcesBMB-Staff Self-Assessment (BMB-SSAS): Expressive Scale

On a scale from 1 (totally disagree) to 7 (totally agree) how much do you feel the following aspects apply to you when dealing with inpatients with diagnosis of borderline personality disorder?

• Feelings of powerless• Fear of being attacked by BPD patients• Fear of complains from BPD patients• Feeling of retaliation from BPD patients• Desire to be transferred to another or calmer ward• Desire that the patient should be discharged soon• Desire that the patient should not readmitted again in our ward• Desire for a more effective management plan and an integrated

care• Second thought about having made the right professional choice• Feeling abandoned by top management in the care of borderline

patients• Frustration about frequent readmissions of borderline patients• Frustration about the escalation of BPD behaviours and suicidal

attempts before discharge• Frustration about the fact that they aim to be under Section of the

Mental Health Act to delay discharge• Frustration about the lack of collaboration within key care orkers

Assessment Instrument: Borderline Maladaptive BehavioursBMB-Staff Assessment Scale (BMB-SAS): BMB Scale

On a Scale from 1 (Never seen) to 5 (Always seen) how much do you feel the following maladaptive behaviours of borderline patients present in your ward?

• Multiple self-referrals to Accident and Emergency departments to deal with crises and to facilitate hospital admission.

• Aiming to take leadership into a psychiatric ward with the intent to create a niche of power and to (re) direct other patients’ or staff’s decisions.

• Splitting members of staff to have control and power over the ward

• (Etc.)

Assessment Instrument: Human Relations ManagementBMB-Staff Self-Assessment (BMB-SAS): Self-Actualisation Scale

On a Scale from 1 (totally disagree) to 7 (totally agree) how much do you feel the following are attended when you are dealing with inpatients with diagnosis of borderline personality disorder?

• My needs of feeling protected are not attended• My needs of self-actualisation are not attended• My needs of safety are not attended• My needs of understanding are not attended• My needs of learning how to deal with BMB are not

attended• My needs of having a respite are not attended

Assessment Instrument: System Theory ManagementBMB-Staff Self-Assessment (BMB-SIS): Self-integration Scale

On a Scale from 1 (totally disagree) to 7 (totally agree) how much do you feel supported by other healthcare providers in the care provision of care to the patients with borderline personality disorder?

• I feel supported by the whole interprofessional team in my ward• I feel supported by medics in my team• I feel supported by nurses in my team• I feel supported by the top management• I feel that there is a supportive team in the whole trust to deal with

BPD patients• I feel that there is a social network system helping staff to deal with

BPD patients

Assessment Instrument: Contingency Theory ManagementBMB-Staff Contingency Plan Assessment (BMB-CPA): Self-integration Scale

On a Scale from 1 (totally disagree) to 7 (totally agree) what is your opinion about contingency plan to deal with BPD into psychiatric wards?

• I believe that there is a clear plan how to manage BPD into psychiatric wards

• I believe that the trust where I work has clear plans how to deal with crises linked to admissions of patients with borderline personality disorder

• I am confident that when a crisis arise in my ward the whole team as a clear plan on how to deal with BMB

• I believe that top management has a contingency plan for the whole trust on how to deal with the emergent crisis of BPD patients.

ConclusionIn this learning unit, you have found instruments to deal in a successful way with patients with diagnosis of borderline personality disorder. The toolkit is designed in order to provide guidelines at an individual, group and organizational level. This social network will provide other learning units to support your daily practice in the healthcare.

Thank you for participating to these learning units.

Managing Borderline Personality Disorder

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