Psychiatric nurses' knowledge, experience and attitudes towards clients with borderline personality disorder

There is evidence in the literature to suggest that mental health care staffs' attitudes towards clients with borderline personality disorder (BPD) are less than favourable. This study reports on a survey of psychiatric nurses' knowledge, experience and attitudes towards care received by clients with a diagnosis of BPD. The questionnaire was sent to all clinical nurses (n = 157) working in a psychiatric service in Dublin, Ireland and received a response rate of 41.4% (n = 65). The results indicate that the majority of nurses have regular contact with clients with BPD and nurses on inpatient units reported more frequent contact than nurses in the community. Eighty per cent of nurses view clients with BPD as more difficult to care for than other clients and 81% believe that the care they receive is inadequate. Lack of services was cited as the most important factor contributing to the inadequate care and the development of a specialist service is reported as the most important resource to improve care.     

Attitudes, knowledge and experience of nurses working in psychiatric hospitals in Greece, regarding borderline personality disorder: a comparative study

The objectives of this study is to determine the knowledge, attitudes and experience of psychiatric nurses regarding clients with Borderline Personality Disorder (BPD) and to compare nurses working in Psychiatric Hospitals with those in Psychiatric Clinics of General Hospitals. The study was performed in two public Psychiatric Hospitals and the Psychiatric Clinics of two public General Hospitals in the area of Greater Athens. The 23-item questionnaire of Cleary et al. was used in this study. It was sent to all nurses ( n  = 127) in 15 psychiatric wards. The staff have good enough knowledge regarding the diagnosis and treatment of the BPD patients. In Psychiatric Hospitals (A) the staff comes in contact with BPD patients less frequently than in the Psychiatric Clinics in General Hospitals (B). In the diagnostic question of 'the unstable mood with rapid shifts' most of the nurses who responded correctly belong to group A than to group B. In group A, nurses believe that not informing the patients of their disorder is the reason for their inadequate treatment, while in group B it is not reported as a reason. In group A, the staff consider that it is within their role to assess BPD patients, far more than in group B. Our hypothesis that nurses in psychiatric hospitals had less knowledge and experience as well as negative attitudes towards BPD patients was not confirmed, although the contact frequency with BPD patients was found statistically low.     

Experience,knowledge and attitudes of mental health staff regarding clients with a borderline personality disorder

A survey of mental health staff experience, knowledge and attitudes regarding the management of clients with a diagnosis of borderline personality disorder (BPD) aimed to obtain baseline data to provide direction for developing planned education and determining staff willingness to participate in such training. A 23-item questionnaire was developed and posted to mental health staff in a public Area Mental Health Service in New South Wales ( n = 516). A total of 229 staff completed the questionnaire. Most staff (85%) reported having contact with clients who have a diagnosis of BPD at least once a month or more frequently, with 32% of respondents reporting daily contact. Eighty per cent of respondents found dealing with clients who have a BPD to be moderate to very difficult; 84% of staff felt that dealing with this client group was more difficult than dealing with other client groups. Most staff (82%) believed that, as mental health professionals, they had a role in the assessment, management and referral of clients with BPD, as well as in educating and providing information. Staff readily identified resources which would be helpful to them when working with such clients. It was encouraging to see that the majority of staff (95%) indicated their willingness to gain further education and training in the management of these clients. Although many staff believed they were knowledgeable about and confident in managing these clients, most staff also indicated difficulties posed by these clients and perceived a need for further education and training in this area .     

Health-related quality of life in women patients with borderline personality disorder

OBJECTIVES: The aims of the study were to: (i) test the reliability of a health-related quality of life (HRQOL) instrument [Swedish Health-Related Quality of Life Survey (SWED-QUAL)] on women patients with borderline personality disorder (BPD); (ii) compare their HRQOL to a normal population group comparable in age; and (iii) test for subgroup differences in HRQOL considering psychiatric DSM axis-I comorbidity. METHOD: The study was conducted in connection to a randomized, controlled trial of psychotherapy for women BPD patients. Seventy-five women with BPD diagnosis were administered the SWED-QUAL. Statistic reliability was evaluated with inter-item correlations, total-item correlations and internal consistency criterions. The BPD patients' SWED-QUAL results were compared with data extracted from a published study and subgroup differences due to axis-I comorbidity were analysed. RESULTS AND CONCLUSIONS: SWED-QUAL could be considered as an instrument with acceptable reliability when assessing HRQOL in BPD patients. The BPD patients suffered significant impairments in HRQOL overall health dimensions compared to normal population. There were no subgroup differences due to axis-I comorbidity, which indicate that BPD in itself might be a predictor of substantial HRQOL impairment.     

Staff and client perspectives of the Open Borders programme for people with borderline personality disorder

In recent years, there has been a move away from the medical model of care for people with borderline personality disorder, as hospital admission comes with a number of risks and potential adverse consequences. Although long‐term outpatient‐based therapy is successful, this may not be an option for those whose condition is in need of stabilisation. Brief admission for crisis intervention has been successful and is now widely used; however, research that examines both the staff and clients’ perceptions of a dedicated programme is lacking. Open Borders is a residential recovery‐oriented programme that provides brief admission, respite, and phone coaching for people with borderline personality disorder who are heavy users of the public mental health system. In this paper, the authors report the perspectives of clients and staff of the Open Borders programme obtained through semi‐structured interviews. Thematic analysis of client and staff perspectives identified four common themes: ‘Benefits of the programme’, ‘Enhanced client outcomes’, ‘Impact of the physical environment’, and ‘Ways of enhancing service delivery’. In addition, analysis of the staff perspectives included the theme ‘Emotional impact on staff’. Benefits of the programme included the small supportive team approach, flexibility of the staff to spend time with the clients to tailor care, and the relaxed, welcoming environment. Enhanced client outcomes included a reduction in self‐harming and hospitalization and an increase in self‐efficacy. These results support the move away from the medical model and the empowerment of clients to self‐manage their symptoms while fostering hope and self‐determination.     

Improving services for people with personality disorders: Views of experienced clinicians

People with personality disorders are frequent users of both inpatient and outpatient psychiatric services, representing a significantly large proportion of all mental health clients. Despite this, most services find it a challenge to offer the most appropriate and effective treatment models for people with personality disorders. This paper is a report of a study of clinician opinions about how organizations can improve the delivery of services to people with personality disorders. Data was collected from experienced clinicians attending a personality disorders clinical and scientific meeting who were asked to work together in groups and present solutions for how organizations can improve the services provided to people with personality disorders. Qualitative data was collected and thematically and semantically analyzed using Nvivo and Leximancer. The Nvivo analysis revealed five main areas in which clinicians believe organizations can improve services for people with personality disorders. These focused on: (i) more training and education for health professionals and carers; (ii) better support through supervision and leadership; (iii) adoption of a more consistent evidence‐based approach to client management and treatment; (iv) clearer guidelines and protocols; and (v) changed attitudes about personality disorder to decrease stigma. The Leximancer analysis of responses indicated the identified themes were not distinct; rather they were interconnected and related to one another, semantically. In summary, clinicians across a large and diverse geographical area developed a consensus that mainstream management of personality disorder is largely poor and inadequate. The findings lend support to an integrative and collaborative whole‐service approach that enhances evidence‐based practice in the community.     

Art psychotherapy in a consumer diagnosed with borderline personality disorder: A case study

This case study reviews 11 sessions of art psychotherapy with a consumer diagnosed with having borderline personality disorder. A consumer who reported difficulty in communicating her lived trauma verbally and engaged in self‐harming behaviour was offered individual art therapy sessions following a consultation between an art therapy student and clinical nurse consultant in an attempt to understand her experiences and to collaboratively engage her. Notes were taken after each session by the art therapy student, reflecting conversations with this consumer while they were engaged in art making, which were subsequently explored within formal clinical supervision sessions with a mental health nurse consultant. An art portfolio is reproduced. It illustrates the expressive power of image creation. The key features of the images were that of lived trauma, the externalization of thoughts and feelings, and intense emotional expression. The results of this chronological art portfolio case study indicated therapeutic benefits from the intervention for this consumer. Further investigations of this type of intervention are warranted within the mental health setting.     

Exploring therapeutic engagement with individuals with a diagnosis of personality disorder in acute psychiatric inpatient settings: A nursing team perspective

Individuals with a diagnosis of personality disorder (PD) face negative attitudes and are often deemed harder to care for than individuals with other diagnoses. To improve care and engagement with services, it is essential to understand the ways general psychiatric nursing staff approach this client group. This research aims to examine the ways inpatient psychiatric nursing staff therapeutically engage with individuals with a diagnosis of PD. Focus groups were conducted with Registered Mental Health Nurses (n = 7) and Health Care Assistants (formally known as nursing assistants; n = 12) who care for individuals with a diagnosis of PD in a general psychiatric inpatient setting. A thematic analysis indicated six themes: the right frame of mind, knowing the service user, knowing when to engage, service user input, a unified approach, and structured admissions. The findings highlight what non‐PD specialist inpatient nursing staff do in order to engage therapeutically with this group of service users and areas that require improvement. Supporting good practice could improve staff confidence when caring for this client group, lower stigma around the diagnosis, and promote a more positive experience of care for individuals with a diagnosis of PD who are using general inpatient mental health services.     

Women in special hospitals: understanding the presenting behaviour of women diagnosed with borderline personality disorder

This paper critically examines the development of the concept of borderline personality disorder (BPD) in terms of the assumed centrality of abnormal early environments and abusive relationships. It is suggested that if BPD is conceptualized as an expression of past experiences in adult life, information regarding early histories can assist in 'making sense' of later behaviour. The aim of this review therefore is to explore how histories of women diagnosed as BPD, within a High Secure Psychiatric Hospital, may facilitate an interpretation of the 'adaptive' nature of presenting 'symptomology'. Case note material is utilized to gain insight into specific aspects of childhood experiences that have been documented, and are thus deemed significant. These findings support the perception that the role of the early environment and associated relationships are significant within written accounts of women diagnosed as having BPD. By exploring the links between trauma and BPD, this article suggests that an understanding of the effects of trauma and the importance of relationships can offer a way forward for self-reflection and future care.     

The effects of exogenous analgesia in a patient with borderline personality disorder (BPD) and severe self-injurious behaviour.

In order to analyse the effects of potent exogenous analgesia with opioids in borderline personality disorder (BPD), we present a case report in which the application of morphine abolished the perception of pain during self-injury and intensified self-injurious activities. On the basis of our observations, we concluded that the use of potent analgesics might aggravate psychopathology in BPD.     

The emotional pain and distress of borderline personality disorder: a review of the literature

This paper presents a synthesis of content and assessment of the methodological rigour of published literature related to concepts of emotional pain and distress in women with a diagnosis of borderline personality disorder (BPD). In the past two decades, there has been an increase in research about the prevalence of BPD, interventions, and relative effectiveness of various forms of treatment. However, there are few studies regarding emotional pain and distress in women with BPD. Emotional pain has been reported as an adaptive response to repetitive traumatic experiences in childhood. Searches of the EBSCO host, OVID MEDLINE, CINAHL, and PsycINFO databases were carried out using the following search words: borderline personality disorder, emotional pain, distress, self, suffering, women, for the period 1996-2006. Fifteen papers were assessed for methodological rigour, followed by the analysis of the concepts of emotional pain and distress. Three themes emerged from the literature, the emotionally abused and neglected child; struggling with emotions leading to self-injury; and social problems related to difficulties regulating emotions. A high prevalence of reported childhood abuse was revealed. Emotional pain was described as intense for women suffering from BPD. A further synthesis of research findings is recommended to provide information on the effectiveness of interventions.     

Cluster A personality disorders: considering the 'odd-eccentric' in psychiatric nursing

Psychiatric nurses are familiar with the concept of personality disorder because of their contact with persons with the most common personality disorder in clinical settings - borderline type, who frequently engage mental health services. Perhaps it is this familiarity that has focused research and clinical attention on borderline personality disorder compared with the other personality disorders. The significance of cluster A personality disorders for nursing is multifaceted because of their severity, prevalence, inaccurate diagnosis, poor response to treatment, and similarities to axis I diagnoses. Despite this, literature reviews have established that relatively few studies have focused on the treatment of the cluster A personality disorders - paranoid, schizotypal, and schizoid - resulting in a dearth of evidence-based interventions for this group of clients. A discussion of these disorders in the context of personality disorder and their individual characteristics demonstrates the distinctive and challenging engagement techniques required by psychiatric nurses to provide effective treatment and care. It is also strongly indicated that the discipline of psychiatric nursing has not yet begun to address the care of persons with cluster A personality disorders.     

Struggling to recover by changing suicidal behaviour: narratives from women with borderline personality disorder

Borderline personality disorder (BPD) is described as the most lethal of psychiatric disorders, with suicide rates of 3-9.5%, a rate almost 50 times higher than that of the general population. The struggle to recover by changing suicidal behaviour is not well described in relation to people with BPD. The most common reason given for suicide attempts was to escape or obtain relief from situations of extreme distress. The aim of this study was to explore how a recovery process facilitated changes in suicidal behaviour in a sample of women with BPD. An exploratory design was used. Data were collected by means of in-depth interviews (n = 13), and a thematic analysis was employed. The findings revealed two themes: 'struggling to assume responsibility for self and others' and 'struggling to stay alive by enhancing self-development'. The first theme comprised three subthemes: 'the desire to recover by searching for strength', 'the struggle to be understood as the person you are', and 'recovering by refusing to be violated'. The second theme comprised one subtheme: 'recovering by feeling safe and trusted'. The main finding of this study suggests that women with BPD who exhibit suicidal behaviour can change when they feel confirmed, safe, and trusted.