Nurses working on psychiatric inpatient units must manage difficult patient behaviors. Some of the most challenging behaviors are exhibited by patients with comorbid personality disorders, especially borderline and antisocial personality disorders. In addition to protecting other patients and the milieu, nurses must interact therapeutically with patients with personality disorders, who may be disruptive. Good communication skills in combination with dialectical behavior therapy (DBT) give nurses the tools to manage some of the more destabilizing inpatient behaviors.
Personality disorders are characterized by longstanding patterns of impairment apparent in multiple domains, including cognition (e.g., perceptual abnormalities, disruptions in the experience of self), emotion (e.g., excessive reactivity or intensity), interpersonal behavior (e.g., social isolation, high-conflict relationships), and impulse control (Matusiewicz, Hopwood, Banducci, & Lejuez, 2010). Managing any of these behaviors on an inpatient psychiatric unit is challenging, but violence (to self or others), aggression, and manipulation are usually the most problematic.
Often psychiatric unit inpatients are treated for serious mental illnesses, such as schizophrenia, bipolar disorder, and major depression. These illnesses generally respond to psychotropic medication with symptom stabilization. However, approximately one half of patients on an inpatient unit have comorbid personality disorders (Adshead & McGauley, 2010). Although medication may help decrease distressing symptoms, such as impulsive aggression and suicidal behavior (Howland, 2007), patients with severe personality disorders may continue to behave in ways that are disruptive or destructive because of their personality structure. Currently, no U.S. Food and Drug Administration–approved drug treatment exists for aggression; prescribers often use a trial-and-error method, which may complicate the clinical picture. Mauri et al. (2011) note that the effects of psychotropic drugs on aggression and violence are unclear and undifferentiated.
Overview of the “Terrible Two” Personality Disorders
The two personality disorders most likely to be seen on psychiatric inpatient units are among those in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders Cluster B personality disorders: antisocial personality disorder (ASPD) and borderline personality disorder (BPD) (American Psychiatric Association [APA], 2013; Langton, Hogue, Daffern, Mannion, & Howells, 2011). ASPD and BPD are characterized by impulsivity, manipulative behavior, irritability, and sometimes aggression.
Antisocial Personality Disorder
In forensic samples, the incidence of ASPD is estimated to be as high as 70% (APA, 2013); the percentage is less on general psychiatric units. Black, Gunter, Loveless, Allen, and Sieleni (2010) note significant comorbidity with BPD, substance use, and high suicide risk. ASPD is characterized by a pervasive pattern of disregard for, and violation of, the rights of others. Patients with ASPD may demonstrate deception, criminality, lack of remorse, and a sense of entitlement (APA, 2013). Individuals with ASPD have also been characterized by a tendency to malinger and manipulate others for their own gain (Byrne, Cherniack, & Petry, 2013; Kucharski, Falkenbach, Egan, & Duncan, 2006). Suicidal threats may be manipulative or genuine and must be carefully assessed. Often irritable and violent, these patients may blame the victim and experience frequent arrests. Lying and stealing are typical behaviors, as well as impulsivity, lack of insight, and bad judgment. Patients with ASPD may also be charming and superficially likable, which allows them to manipulate others more effectively.
Borderline Personality Disorder
The occurrence of BPD on psychiatric inpatient units is estimated to be between 20% and 40% (Aguirre, 2012; APA, 2013; van den Bosch, Sinnaeve, Hakkaart-van Roijen, & van Furth, 2014). Patients with BPD tend to disrupt the milieu and interfere with other patients' treatment. They often cause staff to disagree about patient care—a maneuver related to the ego defense mechanism called splitting (Zanarini, Frankenburg, & Fitzmaurice, 2013). Self-harm behaviors, such as cutting, burning, or scratching, are common among patients with BPD (Roth & Pressé, 2003). These behaviors necessitate watching the patient closely and may tax staffing resources. The hallmark of BPD is avoidance of abandonment, either real or imagined. Patients with BPD may lie to gain admiration or nurturance from staff and often engage in power struggles.
On inpatient units it is common to see several types of disruptive behavior exhibited by patients with ASPD and BPD. Each behavior is briefly examined.
Aggression and Violence
Aggressive and violent behaviors may be the most distressing for staff and other patients. Although patients with serious mental illness, such as schizophrenia, psychosis, and bipolar disorder, may behave violently, the combination of psychotherapy and medication may help these patients control behavior, given enough time. However, patients with personality disorders may continue to have violent outbursts as a result of their personality structure rather than acute mental illness. Abracen et al. (2014) noted that BPD and ASPD are among the personality disorders most likely to commit two or more instances of violence.
Another distressing behavior present on psychiatric inpatient units is pre-meditated versus impulsive violence. In patients with ASPD, manipulative behavior may take the form of calculated (or instrumental) violence for a perceived gain (Walsh, Swogger, & Kosson, 2009). In this case, the nurse must be aware of the patient's history and intervene by keeping other patients safe.
Manipulative tactics are common and may be used by patients who feel powerless. There is a power differential between the nurse and patient because the nurse is the ultimate decision maker. This reality, as well as past experiences that may include physical and sexual abuse or incarceration, may make patients feel especially powerless. Potter (2006, p. 148) defines manipulation as “behavior that is intended to produce a belief or action in another.” Manipulative behavior may take many forms, such as deception, angry verbalizations or actions, disruption of the treatment plan, covert aggression, devaluation, intimidation, demands, ultimatums, compliments, clinginess, exaggeration, and secretiveness.
Often the feelings evoked in nurses by patients with a personality disorder (a process known as countertransference) inform nurses that they are being manipulated. When working with manipulative patients, nurses may feel trapped or pressured to comply with their demands. To avoid acting out one's own negative feelings, it is important for nurses to realize that the patient's interpersonal manipulation is part of the pathology. Manipulation may be the only way the patient has gotten needs met in life. Unfortunately, when effective, manipulative behavior is reinforced and becomes habitual. It is also possible that the patient may not realize that being direct (i.e., asking politely and having a calm discussion with a decision maker) may accomplish the same goal as manipulation.
Splitting is a type of manipulative behavior that may be especially disruptive and is used often by patients with BPD (Leichsenring, 1999). It is a primitive defense mechanism in which patients attempt to keep “good” and “bad” separate, both in their mind and the world. From the patient's point of view, unless good and bad elements are kept apart, the bad may overwhelm and destroy the good. Patients act this out in reality by arbitrarily deciding that certain individuals or experiences are all “good” and others are all “bad”; they are splitting, or mentally keeping individuals apart by idealizing the good and devaluing the bad. These designations can reverse repeatedly. Splitting may be especially destructive if staff are not aware of what is happening and enable patients' manipulations. Patients' behaviors may incite arguments among staff members, some of whom may bend unit rules to give them what they want. A united staff that enforces unit rules and refuses to allow patients to either idealize or devalue can usually defend against this destructive type of manipulation, but may be challenging because of high turnover rates of staff and separate staffing during the weekends.
Parasuicide refers to any self-injurious behavior, which may represent a maladaptive attempt to cope with intense and overwhelming emotion. There is evidence that self-injury may become an addictive process (Roth & Pressé, 2003). It may also be a form of manipulation with the goal of eliciting concern and care for others, engaging in a power struggle, or obtaining mood altering drugs. Patients in forensic populations may engage in self-injury for secondary gain more frequently than other patients (Roth & Pressé, 2003). The behavior often involves cutting one's own skin on the extremities, but can include other behaviors. Skin may be burned with a cigarette, match, or pencil eraser. Per the current author's (L.P.) observations, patients have been known to use whatever they can find to self-injure (including the serrated cardboard edge of a tissue box); therefore, any item that may be used in this way must be controlled by staff.
Regardless of patients' motivation, self-injury is a cause for concern. Patients with BPD may have frequent episodes of self-injury due to intense emotional response to interpersonal issues or conflicts (APA, 2013). It is important to note that individuals who practice parasuicide are at just as much risk for actual suicide as those who have attempted suicide in the past (Roth & Pressé, 2003).
Given current knowledge and skills, it may be said that no treatment exists for a personality disorder—only the associated symptoms and behaviors. Success in treatment has more to do with amelioration of these behaviors and symptoms rather than the disordered personality itself (Bateman, Gunderson, & Mulder, 2015; National Collaborating Centre for Mental Health, 2009, 2010). There are interventions that nurses may perform to help symptoms and keep the psychiatric unit safe.
Dialectical Behavior Therapy and Borderline Personality Disorder
DBT is a form of cognitive-behavioral therapy (CBT) adapted by Linehan (1993) to decrease suicidal behavior by patients with BPD. DBT has been influential, as it is one of the only treatments that specifically targets this often challenging personality disorder. A longitudinal study described by Hörz, Zanarini, Frankenburg, Reich, and Fitzmaurice (2010) revealed patients with BPD used more psychiatric services (in-patient and outpatient) than those with other personality disorders. A treatment that may help stabilize chronically unstable patients is a welcome tool. DBT was originally designed to be used in an intensive outpatient treatment format, with patients receiving group and individual treatment. Since its inception, much research has been done that supports the effectiveness of DBT for BPD (Bloom, Woodward, Susmaras, & Pantalone, 2012; Linehan et al., 2006; Swenson, Sanderson, Dulit, & Linehan, 2001; van den Bosch et al., 2014).
How Does Dialectical Behavior Therapy Differ from Cognitive-Behavioral Therapy?
DBT has much in common with CBT. Both treatments require a collaborative relationship between the treatment provider and patient for meaningful work to occur. This work includes an initial assessment of patient behaviors and goal setting. Behaviors are carefully defined so progress may be measured. DBT makes use of cognitive-behavioral techniques, such as exposure, problem solving, management of negative outcomes, skills training, and cognitive modification. The difference lies in the use of a philosophy called dialectics, in which opposites are brought together in the mind to form an understanding of the whole. For example, a patient who uses splitting is encouraged to change from a worldview in which individuals and experiences are either all good or all bad to a view that recognizes good and bad. DBT therapists also use a dialectic understanding of the patient by accepting him/her as a person while fostering change. Consistent with this, DBT therapists encourage the patient's self-acceptance while also working to change his/her behavior. The DBT model includes crisis support services to deter suicide attempts and weekly phone consultations to incorporate new skills in daily life. Treatment is focused on emotion regulation, interpersonal effectiveness, distress tolerance, and mindfulness. Peer supervision for involved clinicians is also part of the treatment protocol, mainly to assist the therapeutic process and help clinicians manage countertransference, which may be negative and intense (Linehan, 1993; Maltsberger & Buie, 1974).
In addition to outpatient settings, researchers have suggested DBT as an option for BPD on inpatient units (Bloom et al., 2012; Linehan et al., 2006; van den Bosch et al., 2014). Bloom et al. (2012) compared 11 studies that examined DBT in inpatient settings and reported reductions in suicidal ideation, self-injurious behaviors, and symptoms of depression and anxiety that lasted up to 21 months after discharge. Study results were mixed for the reduction of anger and violent behaviors. To explain this disparity, the authors noted that variations of DBT used did not adhere to the original Linehan (1993) model. The authors concluded that DBT is helpful in inpatient settings, but advocate further testing. A protocol for a randomized controlled trial for short-term inpatient DBT is currently being tested (van den Bosch et al., 2014).
Although current psychological treatments of BPD (including DBT) improve outcomes on life-threatening behaviors and psychiatric symptoms, they fail to improve social functioning. Patients with BPD continue to suffer in relationships and demanding social contexts, such as work and school (Bateman et al., 2015).
News About Antisocial Personality Disorder
Current treatment options for ASPD are not as promising as those for BPD. A review of treatment techniques for patients with ASPD (Gibbon et al., 2010) concluded that although some techniques were helpful in curbing substance abuse, no studies reported significant changes in any specific antisocial behavior. A more recent review by Bateman et al. (2015) concluded that evidence for effective treatment of all personality disorders is insufficient, with the possible exception of BPD. No convincing evidence exists that the core domains of impaired interpersonal relationships, identity problems, and social dysfunction improve with treatment.
Patients with ASPD are associated with having violent behaviors. As previously stated, currently no empirically supported psychotherapeutic treatment modalities exist for this disorder (Davidson et al., 2009). However, out-patients with a history of aggression participating in a trial of CBT reported more positive beliefs about others, increased social functioning, and less alcohol use (Davidson et al., 2009). One disappointing finding about CBT was that a decrease in aggressive behavior was not statistically significant when compared to other treatment modalities (Davidson et al., 2009). A study by Maghsoodloo, Ghodousi, and Karimzadeh (2012) found that 62% of incarcerated patients with schizophrenia had a comorbid diagnosis of ASPD compared to 23% of non-incarcerated patients. In these incarcerated patients, aggression was related to impulsivity as measured by the Psychopathy Checklist-Revised (PCL-R; Maghsoodloo et al., 2012). In this situation, DBT may be useful in treating the impulsivity underlying aggressive behavior.
Strategies and Nursing Interventions
Good nursing practice may be helpful in managing disruptive behaviors and improving some psychiatric symptoms. Learning about behavior may help nurses understand patients with personality disorders; however, nurses must also learn strategies and specific interventions. Psychiatric nurses must practice therapeutic use of the self, primarily through good communication techniques.
Bateman (2012) identified five common characteristics of evidence-based treatment, paraphrased below, to guide nurses in their interventions with patients with personality disorders:
- Provide patients with a structured approach to problem solving;
- Encourage patients to practice self-control;
- Help patients connect feelings to events and actions;
- Be active, responsive, and validating with patients; and
- Discuss countertransference issues with staff members.
Therapeutic Use of Self Through Good Communication
Empathic but Firm
Nurses may use their own interpretation of a situation to help patients with personality disorders see things differently. For example, patients may try to avoid negative consequences by rationalizing their behavior or projecting their feelings onto others. Nurses must calmly and firmly enforce unit rules that relate to patients' behaviors. If patients reacted violently because they believed they were disrespected by another patient, nurses may empathize with their feelings, but patients must experience the consequences of their actions. An example of a nurse's therapeutic response:
I can understand why you feel the way you do. There's some truth in what you say, but you attacked your roommate and there are consequences to that action. Next time, let's work together to find a strategy that avoids violent behavior but still upholds your self-respect. In the end, it does not matter what the other person says or thinks about you. Violence leads to negative consequences, and I am concerned about what is in your best interest.
This response shows empathy and consideration of the patient's point of view, but also objectivity and a determination to follow the rules. The quality of empathy is therapeutic for patients and enhances trust and rapport.
Positive but Firm
Nurses may help patients with personality disorders by maintaining a positive tone during interactions, which may help patients cope with increased demands to exhibit appropriate behavior. An exception may be when a nurse must be firm when giving an important direction due to threatened safety. In most situations, keeping a positive tone dampens stress and supports coping skills neurocognitively by supporting working memory and problem solving. Negative emotions in the environment increase the demand on emotion regulation by the prefrontal cortex, which may be quickly overwhelmed by negative affect (Delaney, 2009).
Negative countertransference may cause nurses to lose the ability to empathize and, as a result, act in a nontherapeutic manner. Countertransference is loosely defined as the health care provider's emotional reaction to the patient. Often it is rooted in nurses' experiences with other important individuals from the past, especially during childhood. Nurses may or may not be aware that this dynamic is occurring. When this psychological process occurs in the patient, it is called transference. Consider a patient with a personality disorder who may lie or use intimidation to create an ostensibly logical and convincing argument designed to make a nurse grant his/her wishes. The demand could be something as trivial as more to eat or as major as discharge from the unit. The patient tries to make the nurse believe that only his/her perspective is valid and that all others (i.e., the nurse's) are incorrect. The nurse's feeling of being invalidated or devalued may stimulate negative countertransference.
Feelings of resentment or even hatred toward patients may cause nurses to avoid or shorten interactions with them. In response, patients may demand even more attention and nurses may respond by being challenging or combative. Nurses and patients are then engaged in a power struggle, as nurses take on the hostile communication style of the patients (Evans, 2011).
Conversely, nurses who try to love all of their patients and suppress negative countertransference are at risk for unconsciously acting it out (Maltsberger & Buie, 1974). The only defense against negative countertransference is for nurses to be fully aware of the negative feelings, accept them, and try to be as objective as possible when communicating with patients (i.e., focusing on the facts rather than feelings about patients). It is important to remember the nature of the disorder and that the patients' ways of interacting with society may be what led to hospitalization.
Nurses who work in forensic settings may struggle to control their own feelings. Remaining nonjudgmental when managing patients such as pedophiles, murderers, and sex offenders, or those with personality disorders, may be difficult. Nurses must be aware of an unspoken type of violence in the health care setting, in which knowledge of patients' histories makes them feel psychologically violated. Negative countertransference (e.g., fear, revulsion, disgust) may cause nurses to withdraw from patients and focus more on their own safety rather than therapeutic engagement (Jacob & Holmes, 2011).
Managing Difficult Behaviors
Managing Aggression and Violence
To prevent aggressive or violent behavior, it is helpful to know a patient's history, use a statistically validated measure to assess the risk of violence, and address agitation as soon as it is recognized.
To reduce episodes of aggression, one must be familiar with its precursors. Violence typically results when patients are generally agitated, experience restrictions (e.g., unit rules), or provoked by others. Patients who are continually violent show more signs of agitation that those who are not continually violent. In their article on agitation in the inpatient psychiatric setting, Hankin, Bronstone, and Koran (2011) discuss the behavioral antecedents of aggression and violence. Some of the more salient behaviors include explosive or unpredictable anger; intimidation; restlessness, pacing, and excessive movement; physical or verbal self-abuse; verbally demeaning or hostile behavior; uncooperative or demanding behavior; and impulsivity and impatience (Hankin et al., 2011).
Tools for assessing violence risk include the empirically supported PCL-R (Hare, 2003) and Forensic Early Signs of Aggression Inventory (Fluttert et al., 2011). Recognizing that attacks often occur among patients of the same gender, and outlining specific expectations for behavior and consequences for those violations, may help maintain calm on units. It is also worth noting that harmony among staff was more useful in preventing violence than other tactics commonly used, such as having more male nurses (Cornaggia, Beghi, Pavone, & Barale, 2011).
When patients become agitated, nurses must use de-escalation techniques, such as directing them to an environment with less stimulation (e.g., a quiet or patient room) and ensuring patient and staff safety. If nonpharmacological de-escalation techniques do not sufficiently calm patients, the protocol for pharmacological intervention should then be used as a last resort to ensure safety.
More recently, CBT has been specialized for the forensic population. It is often offense-focused and examines the topics of criminal attitudes, substance abuse, and impulsivity, which are empirically supported correlates of criminal risk (Polaschek & Daly, 2013). These cognitive-behavioral group therapies are traditionally performed by trained psychologists. Nurses able to attend these groups may benefit in working with difficult patients.
Managing Splitting and Other Manipulative Behavior
Patients using manipulative behavior treat others like objects. Manipulation is goal-oriented (i.e., designed to get the patient what he/she wants, without regard for the needs or feelings of others). Manipulators form interpersonal relationships to control or take advantage of others (Stuart, 2013). In an inpatient setting, manipulation may be used to avoid taking responsibility for behavior, obtain special favors, or avoid unpleasant tasks, among others. Sometimes manipulative behavior is not recognized until one or more of these outcomes occur. As previously stated, manipulation is common and often used by patients who feel powerless. Nurses who are knowledgeable may predict patient manipulation and use therapeutic communication combined with objective rule enforcement to manage this behavior.
A good way to avoid engaging in a power struggle with manipulative patients is to refuse to “take the bait.” When patients cannot have what they want, they may criticize nurses, calling them incompetent or insensitive. A nurse may simply respond, “Maybe I am,” without any other comment. In this way, the nurse is agreeing with the patient and it is hard to argue with an agreeing individual. Of course, the nurse must continue to enforce unit rules and behavioral expectations, but this strategy helps avoid an escalating power struggle. It does not matter what patients may say or think at the time because their critical statements are designed only to serve their own immediate interests.
Although nurses may understand the dynamics of splitting and other manipulations, the behavior may still cause disruption on the unit. Manipulation and splitting are managed by having clear unit rules as well as good communication among staff members. It is helpful to review rules frequently with patients, perhaps in a daily goals group, and give them the opportunity to comment and discuss unit issues with nurses. It is helpful to review expectations about behavior in a group setting so everyone hears the same information. Staff and patients must be clear about policies and procedures on the unit so patients who are persistent or well-liked will not be allowed to manipulate successfully. Asking patients to wait for a decision about a request until a nurse has had time to talk with other staff members is also a useful intervention. These practices may help eliminate the effect of patient deception.
DBT is the only empirically supported treatment for patients who frequently engage in parasuicidal behavior (Linehan et al., 2006; Roth & Pressé, 2003). These patients often have BPD along with other psychiatric diagnoses. Nursing interventions include establishing a system to manage parasuicide with components recommended by Roth and Pressé (2003):
- Access to sharp items is restricted.
- Patients must inform staff when the urge to self-harm is strong.
- Patients are taught healthy ways of coping with intense emotions.
- A quiet room with cameras may be used to monitor patients who feel the urge to self-harm.
- If self-harm occurs, patients cannot be left alone.
- After self-harm, patients must agree not to self-harm in the future.
- If a patient continues to self-harm while in the quiet room, restraints are necessary.
- After an incident of self-harm, patients must list the events leading to the feelings of self-harm.
Behaviors exhibited by psychiatric inpatients with BPD and ASPD may be complex and challenging to address. Currently, no treatment exists for personality disorders, but there are treatments for symptoms (e.g., aggression, impulsivity, manipulation, parasuicidal behavior). DBT has been effective in treating these difficult symptoms, especially in patients with BPD who are self-injurious. Using the relationship formed with patients, as well as good communication skills (e.g., empathy, limit-setting, cooperation with peers), nurses may aid patients' rehabilitation and maintain a peaceful and therapeutic milieu. Nurses must also be aware of countertransference to avoid being manipulated, getting into a power struggle, or withdrawing from patients. Skilled psychiatric nursing care can make a difference in the lives of patients with personality disorders.
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