Working with People with Borderline Personality
Disorder in Acute Psychiatric Admission Wards
Who Am I?
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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
Borderline Personality Disorder
• Instability of interpersonal relationships, selfimage 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)
Circumstances of Admission
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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
Management
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Crisis Admission
Focus on Management of Immediate Distress
Assessment of Risk
Constant Observations
Use of the Mental Health Act
Medication
1 – 1 Interaction
Challenges for Staff
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Transference
Counter-transference
Maintaining Professional Boundaries
Coercive Bondage
Splitting
Personal Stress
Staff Burnout
Challenges for Patients
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Transference
Counter-transference
Diagnostic Baggage
Perceived Rejection from Staff
Malignant Regression
Malignant Alienation
Mentalization
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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
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).
8Year Follow-Up of Patients Treated for Borderline
Personality Disorder: Mentalization-Based
Treatment Versus Treatment as Usual
Evidence
• BATEMAN, A and FONAGY, P., (2009). Randomized
Controlled Trial of Outpatient
Mentalization-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
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
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)
Clinical Supervision
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Opportunity to Process Experiences
Space to Reflect
Emotional Support
Helps Prevent Burnout
1 – 1 or Group Sessions
Particularly Valuable in Working with BPD
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)
Why Implement Change?
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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
NHS Quality Strategy
• Safe
• Person-Centred
• Effective
(The Scottish Government, 2013)
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
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
Thank You
daniel.warrender@nhs.net
References
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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-andbehavioural-conditions/are-there-any-trials-examining-the-effectiveness-of-mentalization-based-therapy-for-patients-with-borderlinepersonality-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/mentalhealth-and-behavioural-conditions/what-are-the-figures-for-amount-and-percentage-of-acute-psychiatric-hospital-admissions-which-arepeople-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
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FAGIN, L., (2004). Management of Personality Disorders in Acute In-Patient Settings. Part 1: Borderline Personality Disorders, Advances in
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GROSS, R., et al., (2002). Borderline Personality Disorder in Primary Care. Available from:
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References (continued…)
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HOLMES, J., (2008). Mentalization: a key skill for psychiatrists and their patients - in 100 words. The British Journal of Psychiatry. 193: 125.
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McGRATH, B. and DOWLING, M., (2012). Exploring Registered Psychiatric Nurses’ Responses towards Service Users with a Diagnosis of
Borderline Personality Disorder. Available from: http://www.hindawi.com/journals/nrp/2012/601918/ [Date Accessed 12th April 2012].
NES, (2011). The Matrix - Mental Health in Scotland: A Guide to Delivering Evidence Based Psychological Therapies in Scotland. Available
from: http://www.nes.scot.nhs.uk/media/425354/psychology_matrix_2011s.pdf [Date Accessed 10th April 2013].
NHS CHOICES, (2011). Psychotherapy – Availability. Available from: http://www.nhs.uk/Conditions/Psychotherapy/Pages/Availability.aspx
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NHS CHOICES, (2012). Borderline personality disorder – Treatment. Available from: http://www.nhs.uk/Conditions/Borderline-personalitydisorder/Pages/Treatment.aspx [Date Accessed 21st March 2013].
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