Theory and learning for psychiatric personnel providing care to patients with borderline personality disorder

1. Social Network for
Mental Healthcare
Providers:
Copyright © by Carlo
Lazzari, 2015

2. Social Network for Mental Healthcare Providers:
Managing Borderline Personality Disorder
This presentation is linked to a App and represents a toolkit
provided to healthcare professionals to deal with the
management and treatment of patients with borderline
personality disorder BPD into psychiatric wards.

3. Social Network for Mental Healthcare Providers:
Managing Borderline Personality Disorder
You will find us on the App:
BPDApp:
Google Play
And iTunes

4. A combined
management plan for
improving an integrated
care in mental health
wards dealing with
inpatients with
borderline personality

5. Definition of Borderline Maladaptive
Behaviours
BMB are defined as a pattern of
challenging, self-harming, and threatening
behaviours of BPD inpatients impairing the
therapeutic alliance with staff, reducing
patient’s compliance with ward’s
regulations, boycotting care plans and
discharges, and leading to disrupt power
balances into mental-health wards,
together with frequent complaints by part
of BPD patients and staff.

6. Classification of BMB
• Attack to the health system: escalation
of complains towards staff and requests
of investigation by part of Committees
for Quality Control with the intent of
reducing staff’s reactivity and having the
ward closed.
• Needing IM: escalation of challenging
and self-harming behaviours to access
intramuscular medication as a way of
procured self-harm or ‘ward wound’ to
claim to be ‘worse’ than any other
patients.

7. Classification of BMB
• Multiple self-referrals to Accident and
Emergency departments to deal with
crises and facilitate hospital admission.
• Aiming to take leadership into a
psychiatric ward with the intent to
create a niche of power and to direct
other patients or staff’s decisions.
• Splitting members of staff to have
control and power over the ward.

8. Classification of BMB
• Communal and synchronic self-harming and
challenging behaviours together with other
BPD patients to reduce staff’s resources and
intervention impact.
• Following a leader who directs ways of self-
harm, time, location, ect. In other BPD
patients.
• Group suicide pacts.
• Sun downing: deterioration of mood and
escalation of challenging behaviours as sun
downing due to dropping of mood, anxiety,
boredom, less attention from staff and lack of
activities.

9. Classification of BMB
• Claiming bipolarity and accentuation of
mood swings to get access to Lithium
therapy as a way of having the provision
of a substance that is more lethal if
taken overdose.
• ‘Calling the Police’ as a preferential
channel for dealing with crises, having
rapid access to boundaries and support
while creating a ‘catastrophic scenario’
to access the desired care via rapid
referrals by an unquestionable source.

10. Classification of BMB
• Boycotting discharge plans with the
intention to prolong hospital stay. BMB
increase in intensity before discharges as
a way of reducing the likelihood of this
‘undesirable’ event for BPD. Staying in
hospital for an unlimited time is often
the only welcome solution to being
discharged back to community.

11. Consequences of BMB on staff
BMB lead to resentment and dispersion of
resourceful staff members. BMB also
reduce the power of intervention by the
staff that feels vulnerable to patients’
resentments and complaints to the
commissions for quality control (CQC in
UK). Furthermore, high levels of conflicts
within staff are found in wards where BPD
patients are treated.

12. Consequences of BMB on staff dealing with
BMB
• Feelings of powerless
• Fear from attacks, challenging
behaviours or complaints by part of BPD
patients
• Feelings of discouragement and
abandonment from top management
• Feelings of retaliation from patients
• Reduction of commitment and empathy
in interacting with BPD patients
• Frequent transfers to other wards and
sick leaves.

13. Integrated care and multiple management
strategies to deal with BMB
• Integrated care
• Utilisation of different management
theories

14. Integrated care and multiple management
strategies to deal with BMB
Scientific Management Approach (SM)
Emphasizes a scientifically determined
management practice as a way to improve
efficiency, based on standard methods for
accomplishing each job (Daft & Marcic,
2008).

15. Scientific Management Approach (SM)
In order to manage effectively BMB
healthcare providers need to know the
scientific basis of their behaviour before
planning an integrated care.Theoretical
models, surveys, and auditing are
important in order to collect the necessary
evidence needed to implement changes
into the organization.

16. Integrated care and multiple management
strategies to deal with BMB
Human Relations Approach (HR)
McGregor’s stated that the most significant
cause of job satisfaction is a sense of
realisation and achievement (Henderson,
1996).The HR approach maintains that
organisational vision and human needs are
reciprocal and compatible (Grobler,
Wärnich, et al., 2006).

17. Human Relations Approach (HR)
Management should aim to consider staff’s
reasons of concerns, and to promote a
shared feeling of responsibility and
belongings. A state of mind of power and
self-realization is achieved by promoting
staff’s autonomy in their decisions and an
individualised support when crises arise.
Proper medication of BPD patients with
reduction of their challenging and
maladaptive behaviours increases staff’s
confidence in the own power to limit
undesired conducts in their problematic
patients.

18. Integrated care and multiple management
strategies to deal with BMB
Contingency Theory Approach (CA)
This approach reflects on all characteristics
of current scenario and acts on these
phases (McNamara, 2015). It is an effort to
determine through exploration which
managerial methods are suitable in specific
circumstances (Kreitner, 2009).

19. Contingency Theory Approach (CA)
Decisions on best plans are taken according
to the presenting scenario. Although
standardized care plans and medication-
behavioural approaches are taken, each
care plan and management is tailored for
each BPD patient, staff’s conditions, ward
safety, etc.The expected outcome is the
right intervention at the right time with no
delayed response in patient’s management
from staff.

20. Integrated care and multiple management
strategies to deal with BMB
SystemTheory Approach (SA)
System management entails recurrent,
although at times demanding,
communication with many teams within
the same organisation with direct
customer-user interactions (Baldwin,
Hoffman, & Miller, 2004). It looks at
company people, groups and teams as
integrated sets.

21. SystemTheory Approach (SA)
One of the transmission belts for an
integrated care and systemic management
is the reinforcement of interprofessional
teams. Here, team communication and
coordination have been found as vital for
collaboration in multidisciplinary teams
(Tsakitzidis et al., 2016).

22. SystemTheory Approach (SA)
BPD patients need an active co-
participation of many care workers.
Hospital staff, home treatment teams, care
coordinators and community mental health
nurses create unified systems.There is a
constant interaction between these
systems and subsystem and no integrated
care to BPD patients can be imagined
without amalgamating cooperating
systems into a combined care plane.

23. Integrated care and multiple management
strategies to deal with BMB
ChaosTheory Approach (CT)
The idea of Chaos Management theory is
that events can rarely be managed
(McNamara, 2015) while empowerment will
come from manager’s self-reflection (Gold
& Evans, 1998).

24. ChaosTheory Approach (CT)
Not every aspect in the management of
BPD patients can be controlled. It might be
the case that due to the complexity of
treating these patients, their recurrent
relapses, the lack of a cooperative support
network in the community, the national
health system, globally speaking, is
unprepared to deal with BMB and
borderline patients.

25. Assessment Instruments
BMB-Staff Self-Assessment (BMB-SAS)
On a Scale from 1 (nil) to 5 (totally) how
much do you feel the following aspects
apply to you when dealing with inpatients
with diagnosis of borderline personality
disorder?

26. Assessment Instrument: Scientific
Management and Human Resources
BMB-Staff Self-Assessment (BMB-SSAS): Expressive Scale
On a scale from 1 (totally disagree) to 7 (totally agree) how much do you feel the
following aspects apply to you when dealing with inpatients with diagnosis of borderline
personality disorder?
• Feelings of powerless
• Fear of being attacked by BPD patients
• Fear of complains from BPD patients
• Feeling of retaliation from BPD patients
• Desire to be transferred to another or calmer ward
• Desire that the patient should be discharged soon
• Desire that the patient should not readmitted again in our ward
• Desire for a more effective management plan and an integrated care
• Second thought about having made the right professional choice
• Feeling abandoned by top management in the care of borderline patients
• Frustration about frequent readmissions of borderline patients
• Frustration about the escalation of BPD behaviours and suicidal attempts before
discharge
• Frustration about the fact that they aim to be under Section of the Mental Health
Act to delay discharge
• Frustration about the lack of collaboration within key care orkers

27. Assessment Instrument:
Borderline Maladaptive
Behaviours
BMB-Staff Assessment Scale (BMB-SAS): BMB Scale
On a Scale from 1 (Never seen) to 5 (Always seen) how much do you
feel the following maladaptive behaviours of borderline patients
present in your ward?
• Multiple self-referrals to Accident and Emergency departments
to deal with crises and to facilitate hospital admission.
• Aiming to take leadership into a psychiatric ward with the
intent to create a niche of power and to (re) direct other
patients’ or staff’s decisions.
• Splitting members of staff to have control and power over the
ward
• (Etc.)

28. Assessment Instrument:
Human Relations
Management
BMB-Staff Self-Assessment (BMB-SAS): Self-Actualisation Scale
On a Scale from 1 (totally disagree) to 7 (totally agree) how much do
you feel the following are attended when you are dealing with
inpatients with diagnosis of borderline personality disorder?
• My needs of feeling protected are not attended
• My needs of self-actualisation are not attended
• My needs of safety are not attended
• My needs of understanding are not attended
• My needs of learning how to deal with BMB are not attended
• My needs of having a respite are not attended

29. Assessment Instrument: System
Theory Management
BMB-Staff Self-Assessment (BMB-SIS): Self-integration Scale
On a Scale from 1 (totally disagree) to 7 (totally agree) how much do you feel supported
by other healthcare providers in the care provision of care to the patients with
borderline personality disorder?
• I feel supported by the whole interprofessional team in my ward
• I feel supported by medics in my team
• I feel supported by nurses in my team
• I feel supported by the top management
• I feel that there is a supportive team in the whole trust to deal with BPD patients
• I feel that there is a social network system helping staff to deal with BPD patients

30. Assessment Instrument:
ContingencyTheory
Management
BMB-Staff Contingency Plan Assessment (BMB-CPA): Self-integration Scale
On a Scale from 1 (totally disagree) to 7 (totally agree) what is your opinion
about contingency plan to deal with BPD into psychiatric wards?
• I believe that there is a clear plan how to manage BPD into psychiatric
wards
• I believe that the trust where I work has clear plans how to deal with
crises linked to admissions of patients with borderline personality
disorder
• I am confident that when a crisis arise in my ward the whole team as a
clear plan on how to deal with BMB
• I believe that top management has a contingency plan for the whole trust
on how to deal with the emergent crisis of BPD patients.

31. Conclusion
In this learning unit, you have found
instruments to deal in a successful
way with patients with diagnosis of
borderline personality disorder.The
toolkit is designed in order to provide
guidelines at an individual, group and
organizational level.This social
network will provide other learning
units to support your daily practice in
the healthcare.

32. Thank you for participating to these
learning units.