Working with People with Borderline Personality Disorder in Acute Psychiatric Admission Wards

1. Working with People with Borderline Personality Disorder in Acute Psychiatric Admission Wards

2. 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: daniel.warrender@nhs.net

3. 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)

4. 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

5. Management • Crisis Admission • Focus on Management of Immediate Distress • Assessment of Risk • Constant Observations • Use of the Mental Health Act • Medication • 1 – 1 Interaction

6. Challenges for Staff • Transference • Counter-transference • Maintaining Professional Boundaries • Coercive Bondage • Splitting • Personal Stress • Staff Burnout

7. Challenges for Patients • Transference • Counter-transference • Diagnostic Baggage • Perceived Rejection from Staff • Malignant Regression • Malignant Alienation

8. 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

9. 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

10. 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

11. 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

12. 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)

13. 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

14. 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)

15. 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

16. NHS Quality Strategy • Safe • Person-Centred • Effective (The Scottish Government, 2013)

17. 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

18. 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

19. Thank You daniel.warrender@nhs.net

20. 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].

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