1. Breaking Barriers, Building Bonds
Overcoming barriers to therapeutic relationships with those with Borderline Personality Disorder in a community setting
Student ID: 24675113
Module Code: NPMH2029
People with Borderline Personality Disorder (BPD) have long been associated with negativity , including from mental health practitioners, often connected to misinterpretation of
behaviours, and difficulties with relationships [1,2]. Guidelines state that the most effective treatment of BPD occurs in outpatient settings, with community mental health teams identified
as responsible for routine assessment, treatment and management [3]. Therapeutic relationships form an integral part of healthcare [4], and will therefore be most vital in these settings,
but potentially challenging to achieve [2,3,5]. Exploration of the theory and evidence underlying the therapeutic relationship and barriers that might be faced, may bring focus to
improvements for better nursing care and skill in this area.
The Therapeutic Relationship
The collaborative nature of the relationship, the
affective bond, and the ability to agree on treatment
goals are the main features of an ideal therapeutic
relationship[4]. It has been suggested that it should
develop from a level of “friendliness” on towards a point
of “therapeutic leverage” where positive outcomes can be
achieved through guidance of the practitioner [6].
Sustainability and improvement of the relationship over
time has been strongly linked with better recovery
outcomes [7]. If outcomes are achieved “collaboratively”,
and with “active service user participation” as guidance
recommends [3,5] this can further strengthen the
relationship [8], and can form part of a ‘positive spiral’ in
an individual’s recovery as illustrated in the “Personality
Disorder Capabilities Framework”[5].
The Barriers
References
1. Sansone R and Sansone L (2013) Responses of Mental Health Clinicians to Patients with Borderline Personality Disorder.
Innovations In Clinical Neuroscience 10(5-6):39-42
2. Aspinall D (2012) Psychological interventions in the personality disorders IN: Smith G (ed) Psychological Interventions in Mental
Health Nursing. Maidenhead: Open University Press 65-77
3. National Institute for Health and Clinical Excellence (2009) Borderline Personality Disorder: The NICE Guideline on Treatment and
Management. The British Psychological Society and The Royal College of Psychiatrists. Available from:
http://www.nice.org.uk/nicemedia/live/12125/43045/43045.pdf [Accessed 5December 2013]
4. Haugh S and Paul S (eds) (2008) The Therapeutic Relationship: Perspectives and Themes. Ross-on-Wye: PCCS Books
5. National Institute for Mental Health in England (2003) Breaking the Cycle of Rejection: The Personality Disorder Capabilities
Framework. Department of Health. Available from:
http://www.spn.org.uk/fileadmin/SPN_uploads/Documents/Papers/personalitydisorders.pdf [Accessed 5 December 2013]
6. Gardner A (2010) Therapeutic friendliness and the development of therapeutic leverage by mental health nurses in community
rehabilitation settings. Contemporary Nurse: A Journal For The Australian Nursing Profession 34(2):140-148
7. Johansson H and Jansson J (2010) Therapeutic alliance and outcome in routine psychiatric out-patient treatment: patient factors
and outcome. Psychology & Psychotherapy: Theory, Research & Practice 83(Part 2):193-206
8. Hicks A, Deane F, and Crowe T (2012) Change in working alliance and recovery in severe mental illness: An exploratory study.
Journal of Mental Health 21(2):127-134
9. Shattell M, Starr S, and Thomas S (2007) 'Take my hand, help me out': mental health service recipients' experience of the
therapeutic relationship. International Journal of Mental Health Nursing 16(4):274-284
10. Kondrat D and Early T (2010) An Exploration of the Working Alliance in Mental Health Case Management. Social Work Research
34(4):201-211
11. Daros A, Zakzanis K, and Ruocco A (2013) Facial emotion recognition in borderline personality disorder. Psychological Medicine
43(9):1953-1963
12. Miano A, Fertuck E, Arntz A, and Stanley B (2013) REJECTION SENSITIVITY IS A MEDIATOR BETWEEN BORDERLINE PERSONALITY
DISORDER FEATURES AND FACIAL TRUST APPRAISAL. Journal of Personality Disorders 27(4):442-456
13. Woollaston K and Hixenbaugh P (2008) ‘Destructive Whirlwind’: nurses’ perceptions of patients diagnosed with borderline
personality disorder. Journal of Psychiatric and Mental Health Nursing 15(9):703-709
14. Thompson A, Powis J, and Carradice A (2008) Community psychiatric nurses' experience of working with people who engage in
deliberate self-harm. International Journal of Mental Health Nursing 17(3):153-161
15. Rogers B and Dunne E (2013) A Qualitative Study on the Use of the Care Programme Approach with Individuals with Borderline
Personality Disorder. Journal of Psychosocial Nursing & Mental Health Services 51(10):38-45
Stigma
The Nature of BPD
The Practitioner
Stigma is associated with the quality of therapeutic
relationship in mental health service users [10]. Service users
report encountering stigmas such as a mental illness
diagnosis, education, poverty, race, ethnicity and
homosexuality, including from healthcare staff [9].
• BPD is such that a person may have impairments in the
ability to sustain relationships, and have emotional
instability [3].
• Studies have found that people with BPD features can be
inaccurate when identifying facial expressions, especially
neutral examples [11,12].
• Further to this, a link has been found to the lack of
trustworthiness of faces [12], and raised rejection sensitivity
has also been suggested, potentially being a mediator of
perceived trustworthiness [12].
• Nurses may feel disheartened if it seems service users are
not getting better with their help [13].
• The feeling of being manipulated is also a consistent
theme [13].
• “Splitting” of staff teams based on which nurses appear to
be favoured by the service user within the team can disrupt
team dynamics [3, 13,14].
• Threats to harm themselves or others can be a cause of
distress for nurses [13].
These feelings in nurses can mean they respond to future
service users with more negativity, anger, social distance and
are less helpful [1]. It has also been found that people with
BPD can be regarded with less empathy than people with
other mental illnesses [1], which creates an unjust inequality
within mental health care. A perceived lack of understanding
of people with BPD by practitioners can aggravate the
relationship, and contribute to being seen as “unhelpful” [15].
Recommendations for Practice
1. EDUCATION & TRAINING of whole healthcare teams is
recommended [3,5,14] to reduce stigma and anxiety,
preferably delivered by specialist personality disorder
teams [3,5]. Teaching could focus on helping staff learn to
manage their interactions and own emotions [2,3,5,13].
2. REFLECTION could increase empathy and
understanding that emotions felt towards a person with
BPD are what that person encounters daily [3,5].
Supervision and general support from the team are
suggested as ways to facilitate reflection [2,5,13].
3. GET TO KNOW THE PERSON FIRST - Service users
have found value in someone appreciating them as a
person and not a diagnosis [9] and nurses have also
reported this as a positive way to start the relationship[6].
What do service users want?
Friendliness and empathy - “When a person
comes to me as a person. Instead of ‘I’m your
nurse’”
Time - “He actually took the time to sit down
and talk with me about the things I was going
through and dealing with”
Problem solving - “Get to the root of the
problem and solve it”
Honesty - “Don’t gloss it over” [9]
Conclusion & Future Research
Therapeutic relationships within the community setting
are vital for recovery of BPD. Teaching of nurses can
increase understanding of BPD, and of their own personal
barriers. Creating focus on the person behind the
diagnosis could help develop more empathetic,
collaborative and recovery-focused care.
Future research could investigate: 1) What service users
and practitioners think would be valuable teaching, 2) If
the strength of the therapeutic relationship links to the
level of agreement over the needs of the service user.