Rebecca Fromme, Ph.D.
McGuire VAMC
Geriatrics and Extended Care
“MANAGING CHALLENGING BEHAVIORS ASSOCIATED
WITH PERSONALITY DISORDER AND SERIOUS
MENTAL ILLNESS”
CLC RESIDENT “MR. W”
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
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DEFINING THE PROBLEM(S)
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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
INITIAL INTERVENTIONS
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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
RESULTS OF INITIAL INTERVENTIONS
Challenging behaviors continued
 Medical providers and staff became more
concerned, frustrated, worried, guilty
 Staff decided to regroup, try something else…..
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PERSONALITY DISORDER DIAGNOSIS BASED ON:
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Longstanding pattern of maladaptive relationships
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Poor ability to understand others’ point of view
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Lack of empathy on how his behaviors affect others
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Poor recognition of his own responsibility in current circumstances
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Fixed way of responding to staff, regardless of the situation
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Emotional dysregulation
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Manipulative behaviors
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Unhappiness
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Socially maladaptive/Complete disregard for unit rules
INTERVENTION, PART DEUX
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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
DE-ESCALATING CONFLICT
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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.
POSITIVE COMMUNICATION
Instead of:
Try:
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“That’s never going to work”
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“That’s not my problem”
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“I don’t work that way, I have high
standards”
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“I don’t have time right now”
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“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”
IMPROVE LISTENING AND UNDERSTANDING
Summarize the patient’s chief concerns
 Interrupt less
 Increase empathy, attempt to name the
patient’s emotional state
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“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
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“What I hear from you is that……. Did I get that right?”
IMPROVE THE PARTNERSHIP WITH THE PATIENT
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Discuss the fact that the relationship is less than ideal
Offer ways to improve care
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“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?”
NEGOTIATE THE PROCESS OF CARE
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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)
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“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.”
MR. W
Fewer aggressive episodes
 Slightly improved compliance with dialysis
through compromise
 Reduced verbal abuse
 Reduced staff stress
 Improved patient satisfaction
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