How do you use solutions from Maria?A solution focused approach to working

with individuals diagnosed with borderline personality disorder

Dr Wendy H McIntoshRGN, RMHN, Grad. Dip. MH, MN

© www.davaar.com.au

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When I’m with her I’m confusedOut of focus and bemusedAnd I never know exactly where I amUnpredictable as weatherShe’s as flighty as a featherShe’s a darling, she’s a demon, she’s a lamb

She’d outpester any pestDrive a hornet from its nestShe could throw a whirling dervish out of whirlShe is gentle, she is wildShe’s a riddle, she’s a childShe’s a headache! She’s an angel!She’s a girl!

“the more traumatised the patient has been, the more we (health professionals) are dealing simultaneously with an adult and victimised child” (Reed, 2005:35)

What are your reactions and responses to someone diagnosed with a borderline personality disorder?

Reactions:• Frustration / Anger

• Fear

• Love

• Over empathise

• Hopelessness

• Devalued

• Exiled

• Overwhelmed (Reed, 2005)

Responses:• disengage • disconnect (individual & self)• refer to them objectively• wish to rescue / save / heal(Gutheil, 2005, McIntosh 2006)

Individuals identified as “difficult” due to their:• intense unpredictable affect• unpredictable behaviours• propensity for rapid regression• staff splitting (favourite nurse / anger)• affect on staff (tension, exhaustion, burnout, high staff turnover)

Many a thing you know you’d like to tell herMany a thing she ought to understandBut how do you make her stay and listen to all you sayHow do you keep a wave upon a sand?

Term “borderline” first used by Stern in 1938 to describe a group of patients who exhibited the following:poor impulse control, difficulty with self-identity, primitive defences, multiple symptoms and transient psychotic episodes.

individuals who had BPD had a pathology which lay on a border between psychosis & neurosis(Paris, 2005)

Prevalence• 1% of community• Approx 80% of patients receiving therapy for BPD are women (gender less obvious in community samples)• 41% of individuals presenting to A&E with history of multiple suicide attempts – met criteria for BPD (Foreman, et al., 2004)

Improvement• Approx: 75% individuals gain close to normal functioning by age of 35-40• 90% will recover by age 50

Suicide• 1 in 10 will succeed in committing suicide (Paris & Zweig-Frank, 2001)

DSMIV: characterised the “dis order” as a pervasive pattern of interpersonal relationships, self-image and affects, and marked impulsively beginning in

early adulthood and present in a variety of contexts as indicated by 5 or more of the following:

Frantic efforts to avoid real or imagined abandonment

• experience intense abandonment fears and inappropriate anger even when faced with a realistic time-limited separation or when there are unavoidable changes in plans (ie nurse states that they will return with prn medication is 5 mins … get delayed because of an emergency) they may feel that this abandonment means that they are “bad”

• abandonment fears are related to an intolerance of being alone and a need to have other people with them - frantic efforts to avoid abandonment may include self-mutilation behaviours, impulsively, increased emotional distress

Pattern of unstable and intense personal relationships characterised by alternating between extremes of idealisation and devaluation

• may idealise potential care givers or lovers at the first/second meeting, demand to spend a lot of time with that person, share their most intimate details early in relationship

may quickly change from idealising to devaluing others, feeling that the other person does not care enough, does not give enough, or is not there for them

Identity disturbance: markedly and persistently unstable self-image or sense of self

– will be characterised by markedly and persistently unstable self-image or sense of self– sudden dramatic shifts in self-image characterised by shifting goals, values, and vocational aspirations– may be sudden changes in opinions and plans about career, sexual identity, values, and types of friends– may suddenly change from the role of a needy supplicant for help to a righteous avenger of past mistreatment– whilst usually having a self-image based on their being bad/evil,– individuals with this disorder may also feel that they do not exist

Recent suicidal behaviour, gestures or threats, or self-mutilating behaviour

– self-mutilation that often precedes suicide attempts (cutting, punching walls, head-banging, burning)

– phenomenon of self-mutilation typically associated with severe stress and tension reduction - which usually precede a dissociative state described as being numb or empty (self-mutilation terminates the feeling of dissociation)

Act impulsively in at least 2 areas that are potentially self-damaging

– gambling, spend money recklessly, bingeing, – substance abuse, engaging in unsafe sex, driving – recklessly, suicidal behaviours, gestures or

threats– self damaging / destructive acts usually

precipitated by threats of separation or rejection or by expectations that they assume extra responsibility

Affective instability due to marked reactivate of mood (irritability, anxiety lasting for hours)

– affective instability in patients with a BPD is displayed due to a marked reactivity in mood

– basic mood of these individuals often disrupted by periods of anger, panic or despair, rarely relieved by periods of well-being or satisfaction

– easily bored constantly seeking something to do– frequently express inappropriate anger, or have

difficulty controlling their anger, verbal outbursts, – may display sarcasm, enduring bitterness– g) chronic feeling of emptiness– h) inappropriate, intense anger or difficulty controlling anger– i) transient, stress-related paranoid ideation or

severe dissociative symptoms

Other features– deep feelings of insecurity, lack of self-esteem– difficulty with interpersonal relationships– poor frustration tolerance– depression– sensitivity to criticism and rejection– distrust– suspiciousness– fragile sense of self– may have a pattern of undermining themselves the moment a goal is about to be realised– may develop psychotic like symptoms (hallucinations, ideas of reference, body distortions)– may feel more secure with transitional objects (pets or inanimate objects)

“Psychological trauma is at the very core of understanding personality disorders”

(Karger, 2003)

Compared to other “psychiatric patients” – individuals who have experienced CPA or CSA have greater incidences of:

- suicide attempts- earlier first admissions- longer & more frequent admissions- spend more time in seclusion- receive more psychotropic medications- exhibit higher global symptom severity

(Brier et al., 1997; Pettigrew & Bucham, 1997; Read, 1998)

• Mediates arousal and therefore traumatic hyperarousal• Regulates survival behaviours & emotional expression• Influences memory processing• Signals the ANS either to rest the body or prepare for fight/flight• Responds to the extreme of traumatic threat by releasing hormones that tell the body to prepare for defensive action

Limbic System

Has three involuntary responses to threat – perceived or actual

Flight, fight, freeze

Freezing response:The limbic system can simultaneously activate the PNS causing a state called tonic immobilityWhen death is imminent, escape is impossible,or the traumatic event is prolonged…..the individual enters an altered reality, time slows down, there is no fear or pain ..... the sense of death/dying is welcome

Triangle of impact

Re experiencing

Increased arousalAvoidance

“remember this moment”

“never go this way again”

Dalenberg (in Pender, 2005) describes three distinct biological messages of complex PTSD

“be prepared”

Focal Conflict Model

Disturbing Motive Reactive Motive

Focal Conflict

Restrictive solution Enabling solution

(Whitman & Stock, 1958)

Solution Focused - Philosophy

• If it ain’t broke (in the clients mind) don’t fix it• Once you know what works, do more of it• If it doesn’t work, don’t do it again, try something different • If their going slow, go slower (Berg & Miller 1992; Perkins 1997)

Solutions & Resourceful

Solutions

S - self harm (modulate feelings)O - objectifyL - leave the (scene, feeling) U - understandT – try something I – identify the disturbanceO – opinionatedN – needy (nurturance)S – seek help

Resourceful

R – resourcefulE - effectiveS – strengthsO – organize (every one)U – usefulR – resilientC – creativeE – energyF – fightersU – unrelentlessL – life (even though have long term wish to be dead)

She climbs the tree, the world she seesShe sees through different eyesShe’s figured out that keeping safeIs very well disguisedAnd when she’s feeling lonely It’s not a nice surpriseShe may self harm to keep herself alive

She uses some creative meansTo tell her story loudI may not get on board with her, I think they’re not allowedYet the shouting and the yelling is expression of her truthShe’s fighting for her very survival

HOW DO WE USE SOULTIONS FROM MARIA

I’d like to say a word on her behalfMaria challenges me

How do we use solutions from Maria?How do we use Maria’s resourcefulness?How do we change the scripts about Maria?How do we acknowledge her resilience?

There’s many a time I know I’d like to tell herMany a time she ought to understandBut how do I make her stay and listen to all I sayHow do I keep her safe and alive?

How can I use solutions from Maria?How can I learn from Maria about her life?

So my challenge, how would you finish the song using a solution focused lens?

How can we use the solutions from Maria?

Any questions?

And now for that little extra…….

Prevalence

• Borderline personality disorder is diagnosed in 8-15% of all patients seen in mental health services

• Community prevalence approx 1.8%

• More commonly diagnosed in women (76%) than in men Why more commonly

diagnosed in women?

Outcomes

– studies completed demonstrate large variation in outcome

– studies of mortality rates related to suicide revealed figures that ranged from 7-21%

– most negative outcomes associated with parental brutality

– combination of incest and brutality assessed as most devastating -- group presenting with significant chronic psychosocial dysfunction

What lies beneath?

a) consistent and persistent failure to validate the child’s emotional experience

- child unable to learn how to accurately describe and express their emotion, to modulate distress or rely on their own responses to events

– child learnt to rely on others as to how to feel and respond to situations

– only when situation and emotional stress were critical was emotional expression tolerated - thus a pattern of anxiety related to emotional expression and extreme acting out of emotional tension could be established - person left with an overwhelming sense of emptiness a sense that there was no real “me” - resulting in a fragile, poorly defined self largely dependant on moment to moment interpersonal communication for self-definition

– b) Child Abuse: – BPD highly correlated with childhood abuse and

neglect Lego)– Herman, et al., (1989) reported 87% of patients with

BPD identified trauma histories (further the earlier the

onset of abuse in persons life the more likely the

features of self-mutilation)– Laporte & Guttman (1996) 93% of people with BPD

experienced at least one form of abuse or separation

in childhood

What if ….?• Many researchers consider BPD to be a

form of “Chronic PTSD” or “Complex PTSD”

• The physiological flight-or fight response to stress feeds upon itself – continually placing the person in alternating states of hyper arousal and numbness (Karger et al., 2003).

Let’s discuss further

What are the challenges for health professionals?

Management– short inpatient admissions (if admission required)

aim:maintain safety to provide temporary respite from situations

which are emotionally overwhelmingset firm limits to regressive behaviour

long term psychotherapy– use of medication to control symptomatology– use of structured activities– role modelling– developing affect modulation– group therapy– community support

Specific Nursing Considerations

• nurses may feel frustrated and hopeless or want to rescue and protect (issues of transference)

• generally attitude towards clients is one of negativity

• terms such as “manipulative” used indiscriminately

• Process of staff splitting

• use of agreements (developed in collaboration between team and client)

• specific times established for 1:1 interactions (staff need to be prepared to adhere to these times)

• may be need for constant observation or specialling if client assessed to be at “risk from self”

• discuss and develop hierarchy of symptom identification and options to manage same with client

• be flexible and creative in responses to clients chaos (they are expressing their story)

• use expressive mediums (journalling, art, music) to express self, tell their stories

Psycho-education and psychotherapy

• Need to adapt to local understanding of illness

• Discussion of triggering events

• Use of grounding techniques

• Normalization of illness• Reinterpretation of

events• Integration of the

memories of the trauma

• Individual/group/family activities

• Cognitive behaviour• Eye movement

desensitization and reprocessing (EMDR)

• Brief therapies– Solution Focused

Window of opportunity

References• Agar, K., & Read, J. (2002). What

happens when people disclose sexual or physical abuse to staff in a community mental health centre? International Journal of Mental Health Nursing, 70-79.

• Beck, J., & van der Kolk, B. (1987). Reports of childhood incest and current behaviour of chronic hospitalized psychotic women. American Journal of Psychiatry, 144, 1474-1476.

• Beitchman, J., Zucker, K., Hood, J., DaCosta, G., Akman, D., & Cassavia, E. (1992). A review of the long-term effects of child sexual abuse. Child Abuse & Neglect, 16, 101-118.

Boney-McCoy, S., & Finkelhor, D. (1999)Is youth victimization related to trauma symptoms and depression after controlling

for prior symptoms and family relationships. A longitudinal prospective study. Journal of Consulting and Clinical Psychology, 64,

1406-1416.

Brier, J., Woo, R., McRae, B., Foltz, J., &Sitzman, R. (1997). Lifetime victimizationhistory, demographics, and clinical status infemale psychiatric emergency room

patients.Journal of Nervous and Mental Disease,

185,95-101.

• Ellenson, G. (1985). Detecting a history of incest: A predictive syndrome. Social Casework, Nov, 525-532.

• Fleming, J., Mullern, P., Sibthorpe, B., & Banner, G. (1999). The long-term impact of childhood sexual abuse in Australian women. Child Abuse & neglect, 23, 145-149.

• Karger, A. G., Basel, C. E., Kino, T., Souvatzoglou, E., Chrousos, G. P. (2003). Hormone Research, 59, 161-179.

• Kendler, K. S., Bulik, C. M., Silberg, J., Hettema, J. M. Myers, J., & Prescott, C. A. (2000). Childhood sexual abuse and adult psychiatric and substance use disorders in women: An epidemiological and cotwin control analysis. Archives of General Psychiatry, 57, 953-959.

• Lothian, J., & Read, J. (2004). Asking about abuse during mental health assessments. Clients’ views and experiences. New Zealand Journal of Psychology.

• Mullen, P., Martin, J., Anderson, J., Romans, S., & Herbison, G. (1993). Childhood sexual abuse and mental health in adult life. British Journal of Psychiatry, 163, 721-732.

• O’Brien, L. (1998). Inpatient nursing care of patients with borderline personality disorder: A review of the literature. Australian and New Zealand Journal of Mental health Nursing, 7 172-183

• Palmer, R., Bramble, D., Metcalf, M., Oppenheimer, R., & Smith, J. (1994). Childhood sexual experiences with adults: Adult male psychiatric patients and general practice attenders. British Journal of Psychiatry, 165, 675-679.

• Pettigrew, J., & Burcham, J. (1997). Effects of childhood sexual abuse in adult female psychiatric patients. Australian and New Zealand Journal of Psychiatry, 31, 208-213.

• Read, J. (1998). Child abuse and severity of disturbance among adult psychiatric inpatients. Child Abuse & neglect, 22, 359-368.

• Read, J., Agar, K., Argyle, N., & Aderhold, V. (2003). Sexual and physical abuse during childhood and adulthood as predictors of hallucinations, delusions and thought disorder. Psychology and Psychotherapy, Theory, research and Practice, 76, 1-22.

• Read, J., Perry, B., Moskowitz, A., & Connolly, J. ( 2001). The contribution of early traumatic events to schizophrenia in some patients: A traumagenic neurodevelopmental model. Psychiatry: Interpersonal and Biological Processes, 64, 319-345.

• Read, J., & Argyle, N. (1999). Hallucinations, delusions, and thought disorder among adult psychiatric inpatients with a history of child abuse. Psychiatric Services, 51, 534-535.

Recommended Reads• Bremner, J.D. (2005). Does stress damage the brain? Understanding trauma-related disorders

from a mind-body perspective. W.W. Norton Company: New York.

• Briere, J., & Scott, C. (2006). Principles of trauma therapy. A guide to symptoms, evaluation and treatment. Sage Publications: Thousand Oaks.

• Middleton, W. (2005). Owning the past, claiming the present: perspectives on the treatment of dissociative patients. Australasian Psychiatry, 13, (1), 40-49.

• Pridmore, S., Ahmadi, Jamshid, & Evenhuis, M. (2006). Suicide for scrtinizers. Australisian Psychiatry, 14 (4), 350-364.

• Rothschild, B. (2000). The body remembers. The psychophysiology of trauma & treatment. W.W. Norton & Company: New York.

• Vermetten, E., Dorahy, M.J., & Spiegel, D. (2007). Traumatic dissociation, neurobiology and treatment. American Psychiatric Publishing Inc: Arlington, VA.