Download How do you use solutions from Maria?

How do you use solutions from Maria?
A solution focused approach to working
with individuals diagnosed with
borderline personality disorder
Dr Wendy H McIntosh
RGN, RMHN, Grad. Dip. MH, MN
© www.davaar.com.au
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When I’m with her I’m confused
Out of focus and bemused
And I never know exactly where I am
Unpredictable as weather
She’s as flighty as a feather
She’s a darling, she’s a demon, she’s a
lamb
She’d outpester any pest
Drive a hornet from its nest
She could throw a whirling dervish out of
whirl
She is gentle, she is wild
She’s a riddle, she’s a child
She’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 her
Many a thing she ought to
understand
But how do you make her stay
and listen to all you say
How 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 selfmutilation 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, headbanging, 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)
Limbic System
• Mediates
arousal
and thereforeresponses
traumatic hyperarousal
Has three
involuntary
to threat
• Regulates survival behaviours & emotional expression
perceived
or
actual
• Influences memory processing
• Signals the ANS either to rest the body or prepare for
fight/flight
• Responds to theFlight,
extreme fight,
of traumatic
threat by
freeze
releasing hormones that tell the body to prepare for
defensive action
–
Freezing response:
The limbic system can simultaneously activate
the PNS causing a state called tonic immobility
When 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
Dalenberg (in Pender, 2005)
describes three distinct
biological messages of
complex PTSD
Avoidance
“never go this way again”
Re experiencing
“remember this moment”
Increased arousal
“be prepared”
Focal Conflict Model
Reactive Motive
Disturbing 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 - objectify
L - leave the (scene, feeling)
U - understand
T – try something
I – identify the disturbance
O – opinionated
N – needy (nurturance)
S – seek help
Resourceful
R – resourceful
E - effective
S – strengths
O – organize (every one)
U – useful
R – resilient
C – creative
E – energy
F – fighters
U – unrelentless
L – life (even though have
long term wish to be dead)
HOW DO WE USE SOULTIONS FROM MARIA
She climbs the tree, the world she sees
She sees through different eyes
She’s figured out that keeping safe
Is very well disguised
And when she’s feeling lonely
It’s not a nice surprise
She may self harm to keep herself alive
She uses some creative means
To tell her story loud
I may not get on board with her, I think they’re not allowed
Yet the shouting and the yelling is expression of her truth
She’s fighting for her very survival
I’d like to say a word on her behalf
Maria 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 her
Many a time she ought to understand
But how do I make her stay and listen to all I say
How 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 Why more commonly
(76%) than in men
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 overwhelming
set 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,
14061416.
Brier, J., Woo, R., McRae, B., Foltz, J., &
Sitzman, R. (1997). Lifetime victimization
history, demographics, and clinical status in
female 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.
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Fleming, J., Mullern, P.,
Sibthorpe, B., & Banner, G.
(1999). The long-term impact of
childhood sexual abuse in
Australian women. Child Abuse
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•
Karger, A. G., Basel, C. E.,
Kino, T., Souvatzoglou, E.,
Chrousos, G. P. (2003).
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Kendler, K. S., Bulik, C. M.,
Silberg, J., Hettema, J. M.
Myers, J., & Prescott, C. A.
(2000). Childhood sexual abuse
and adult psychiatric and
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•
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,
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•
O’Brien, L. (1998). Inpatient nursing
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personality disorder: A review of the
literature. Australian and New
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Nursing, 7 172-183
•
Palmer, R., Bramble, D., Metcalf,
M., Oppenheimer, R., & Smith, J.
(1994). Childhood sexual
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psychiatric patients and general
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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
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Biological Processes, 64, 319-345.
•
Read, J., & Argyle, N. (1999).
Hallucinations, delusions, and
thought disorder among adult
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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.