“Managing Challenging Behaviors Associated with Personality Disorder and Serious Mental Illness”

1. Rebecca Fromme, Ph.D. McGuire VAMC Geriatrics and Extended Care “Managing Challenging Behaviors Associated with Personality Disorder and Serious Mental Illness”

2. 64 year-old, married Vietnam veteran • 100% SC: PTSD, Impaired Vision, Diabetes, Loss of Lower Leg • Cognitively intact • Dialysis 3 days per week • Long history of poor compliance, CLC admission in 2009 for amputation and rehab of right lower limb, recent readmission for wound on other foot CLC RESIDENT “Mr. W”

3. Frequently refused dialysis, and when he did go, he only stayed for 1-2 hours (rather than full 4 hour session) • Frequently refused meds, refused blood sugar checks • Very poor food choices, would not follow diabetic diet, made it impossible to keep his blood sugars level • Refused care, then later demanded a shower “RIGHT NOW” • Verbally and physically threatening to staff, particularly nurses • Caught smoking in his room • Used foul language when he did not get immediate attention • Refused to attend PT so that he could be strengthened and fitted for prosthesis, but demanded the prosthesis anyway Defining the problem(s)

4. Extensive diabetic education from Geriatricians, Dietician, NP, Nursing Staff, RT, and OT on multiple occasions • Pleading • Encouraging • Nagging • Scolding • Escorting to cafeteria to make healthier choices • Psychiatry Consult • Increasing ALL OF THE ABOVE Initial interventions

5. Challenging behaviors continued Medical providers and staff became more concerned, frustrated, worried, guilty Staff decided to regroup, try something else….. Results of initial interventions

6. Longstanding pattern of maladaptive relationships Poor ability to understand others’ point of view Lack of empathy on how his behaviors affect others Poor recognition of his own responsibility in current circumstances Fixed way of responding to staff, regardless of the situation Emotional dysregulation Manipulative behaviors Unhappiness Socially maladaptive/Complete disregard for unit rules Personality disorder Diagnosis based on:

7. Psychology met with treatment team to inform them of results of cognitive evaluation- Behaviors not a result of cognitive impairment, inability to remember the rules, or inability to remember what he should be eating Mr. W’s food choices are conscious choices, and he has right to make them even if we don’t agree- PATIENT-CENTERED CARE Nagging, pleading, scolding only serves to trigger control issues and increases resistant behaviors Instead, praise, encourage, reinforce those times he does behave appropriately- HARM REDUCTION Do not engage in a “battle of the wills” Understand that not all situations can be “fixed”- CARING NOT CURING Practice de-escalating conflicts before they occur Intervention, part deux

8. Check yourself first– remember not to take it personally. It’s about the situation, not you Deal with the person’s emotions first. Problem solving cannot occur if the person is fuming! When hostility is rising, diffuse it early with an empathic statement Most people will DRASTICALLY de-escalate once the emotion has been recognized and they have a minute to vent Speak to the other person as if he/she IS NOT upset Inquire, don’t interrogate Set limits, if necessary. Return later when patient is calmer. De-escalating conflict

9. Positive communication Instead of: • “That’s never going to work” • “That’s not my problem” • “I don’t work that way, I have high standards” • “I don’t have time right now” Try: • “I don’t have enough info to see how this will work” • “I don’t understand how you feel I can help in this situation” • “I have concerns about doing it this way. I’d like to suggest another way that leads to the same goals” • “I’m handling several emergencies today, but if you let me know what you need I will get to it as quickly as I possibly can”

10. Summarize the patient’s chief concerns • Interrupt less • Increase empathy, attempt to name the patient’s emotional state • “You seem quite upset. Can you help me understand what’s going on for you right now?” • Offer regular, brief summaries of what you are hearing from the patient • “What I hear from you is that……. Did I get that right?” Improve listening and understanding

11. Discuss the fact that the relationship is less than ideal • Offer ways to improve care • “How do you feel about the care you are receiving from me?” • “It seems to me that we sometimes don’t work together very well.” • “You look a little confused. Would it help if I explain it again?” Improve the partnership with the patient

12. Clarify the reason for the patient seeking care • Indicate what part the patient must play in caring for his/her health • Revise expectations if they are unrealistic (both yours and the patient’s) • “What’s your understanding of what I am recommending and how does it fit with your ideas of how to solve your problems?” • “I wish I (or a medical miracle) could solve this problem for you, but the power to make the important changes is really yours.” Negotiate the process of care

13. Fewer aggressive episodes Slightly improved compliance with dialysis through compromise Reduced verbal abuse Reduced staff stress Improved patient satisfaction Mr. W