Managing Personality Disorder in the Dialysis Unit. Paul Gasser MS/LMFT, LCSW St. Joseph s Hospital Melissa Fry MSW, NSWC-C Mile Bluff Medical Center

Transcription

1 Managing Personality Disorder in the Dialysis Unit Paul Gasser MS/LMFT, LCSW St. Joseph s Hospital Melissa Fry MSW, NSWC-C Mile Bluff Medical Center

2 Hashmi, A. and Moss, A. (2008) indicate that dialysis units have had to contend with ever increasing numbers of difficult and/or disruptive patients. These patients present a wide range of behaviors ranging from harm only themselves to those that psychological and physically endanger staff.

3 The disruptive or difficult patient is defined as someone who is verbally or physically abusive, non-compliant to medical direction, abuses licit and illicit drugs, and violates personal and professional boundaries (e.g. coming late to appointments, demanding excessive amounts of attention, etc.).

4 These behaviors can often impede the ability of the dialysis staff to care for the patient in question and for other patients on the unit. Patients such as this place staff at risk in variety of ways: a. physically, b. emotionally, c. legally. This will be a patient that is most likely to file a complaints against staff.

5 More examples: Non-adherence to dialysis prescription (e.g. missing sessions or signing off sessions early) Non-adherence to diet Non-adherence to medications Improper care of dialysis access Proscribed behavior in dialysis unit (e.g. eating on dialysis unit)

6 Behavior harmful to the efficient operation of the dialysis unit Late arrival for scheduled treatment Requiring unscheduled extra treatments for dyspnea trigger by non-adherence to fluid restriction. Filing unsubstantiated complaints to Sate Health Department Filing a grievance against the dialysis unit Verbal abuse, threats or intimidation

7 Valid Reasons for Problem Behaviors Limited cognitive ability Limited financial resources to eat appropriately Limited transportation Limited understanding of the severity of their medical condition. Psychosocial stress due to change in lifestyle (e.g. marital issues, financial, etc.) Lack of motivation due to: depression, bi-polar, anxiety disorder, or a character flaw.

8 Red flags To Watch For That Would Suggest a Character Flaw 1. This person lies, when the truth would sound better. 2. The more you get to know this person, the more you don t like them. 3. This person is always creating some type of drama. 4. This person doesn t take responsibility for their actions. It is always some else s fault.

9 Let s get more specific about people with these types of character flaws. Often these individuals will demonstrate additional characteristics that are common for the diagnosis of a personality disorder.

10 General symptoms of Personality Disorders Personality disorder symptoms include: Frequent mood swings Stormy relationships Social isolation Angry outbursts Suspicion and mistrust of others

11 General symptoms of Personality Disorders Difficulty making friends A need for instant gratification Poor impulse control Possible alcohol or substance abuse

12 Specific types of personality disorders The specific types of personality disorders are grouped into three clusters based on similar characteristics and symptoms. Many people with one diagnosed personality disorder also have signs and symptoms of at least one additional personality disorder.

13 Specific types of personality disorders Cluster A personality disorders: These are personality disorders characterized by odd, eccentric thinking or behavior and include: Paranoid personality disorder Schizoid personality disorder Schizotypal personality disorder

14 Specific types of personality disorders Cluster B personality disorders: These are personality disorders characterized by dramatic, overly emotional thinking or behavior and include: Antisocial (formerly called sociopathic) Borderline personality disorder Histrionic personality disorder Narcissistic personality disorder

15 Specific types of personality disorders Cluster C personality disorders: These are personality disorders characterized by anxious, fearful thinking or behavior and include: Avoidant personality disorder Dependent personality disorder Obsessive-compulsive personality

16 Causes Personality is the combination of thoughts, emotions and behaviors that makes a person unique. It's the way they view things, understand and relate to the outside world, as well as how they see themselves. Personality forms during childhood, shaped through an interaction of two factors:

17 Signs and symptoms of borderline personality disorders may include: Impulsive and risky behavior, such as risky driving, unsafe sex, gambling sprees or illegal drug use Awareness of destructive behavior, including selfinjury, but sometimes feeling unable to change it Wide mood swings Short but intense episodes of anxiety or depression

18 Signs and symptoms of borderline personality disorder may include: Inappropriate anger and antagonistic behavior, sometimes escalating into physical fights Difficulty controlling emotions or impulses Suicidal behavior Feeling misunderstood, neglected, alone, empty or hopeless Fear of being alone Feelings of self-hate and self-loathing

19 Narcissistic personality disorder Narcissistic personality disorder is a condition in which people have an inflated sense of selfimportance and an extreme preoccupation with themselves.

20 Symptoms A person with narcissistic personality disorder may: React to criticism with rage, shame, or humiliation Take advantage of other people to achieve his or her own goals Have excessive feelings of self-importance Have obsessive self-interest Pursue mainly selfish goals

21 Symptoms Exaggerate achievements and talents Be preoccupied with fantasies of success, power, beauty, intelligence, or ideal love Have unreasonable expectations of favorable treatment Need constant attention and admiration Disregard the feelings of others, and have little ability to feel empathy

22 Narcissistic Personality Disorder Although some features of narcissistic personality disorder may seem like having confidence or strong self-esteem, it's not the same. Narcissistic personality disorder crosses the border of healthy confidence and self-esteem into thinking so highly of themselves that they put themselves on a pedestal. In contrast, people who have healthy confidence and self-esteem don't value themselves more than they value others.

23 Narcissistic Personality Disorder Individuals with a narcissistic personality disorder, may come across as conceited, boastful or pretentious. They often monopolize conversations. They may belittle or look down on people they perceive as inferior. They may have a sense of entitlement. And when they don't receive the special treatment to which they feel entitled, may become very impatient or angry.

24 Narcissistic Personality Disorder They may insist on having "the best" of everything the best car, athletic club, medical care or social circles, for instance. But underneath all this behavior often lies a fragile self-esteem. They have trouble handling anything that may be perceived as criticism. They may have a sense of secret shame and humiliation. And in order to make themselves feel better, they may react with rage or contempt and efforts to belittle the other person to make themselves appear better.

25 Narcissistic Personality Disorder By definition, a narcissistic personality disorder causes problems in many areas in their life, such as relationships, work, school or their financial affairs. They may be generally unhappy and confused by a mix of seemingly contradictory emotions. Others may not enjoy being around them, and they may find their relationships unfulfilling.

26 Dependent Personality Disorder Individuals with Dependent Personality Disorder have great difficulty making everyday decisions (such as what shirt to wear or whether to carry an umbrella) without an excessive amount of advice and reassurance from others. These individuals tend to be passive and allow other people (often a single other person) to take the initiative and assume responsibility for most major areas of their lives.

27 Dependent Personality Disorder Adults with this disorder typically depend on a parent or spouse to decide where they should live, what kind of job they should have and which neighbors to befriend. This need for others to assume responsibility goes beyond age-appropriate and situation-appropriate requests for assistance from others (such as the specific needs of children, elderly persons and handicapped persons).

28 Dependent Personality Disorder Because they fear losing support or approval, individuals with dependent personality disorder often have difficulty expressing disagreement with other people, especially those on whom they are dependent. These individuals feel so unable to function alone that they will agree with things that they feel are wrong rather than risk losing the help of those to whom they look for guidance.

29 Dependent Personality Disorder Individuals with this disorder have difficulty initiating projects or doing things independently. They may go to extreme lengths to obtain nurturance and support from others. Individuals with this disorder feel uncomfortable or helpless when alone, because of their exaggerated fears of being unable to care for themselves.

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32 The Borderline and Narcissistic Personality Disorder will emotionally wear you out by their insults and accusations. You can be accused as the source of all their pains, heartbreaks, anger, frustrations and hardships.

33 Borderlines and Narcissistic individuals have a problem with regulating their emotions. They feel real pain and fear of abandonment. These patients in addition to have physical issues is also mentally ill. This is one of the reasons you hesitate to give up on this person. It is important that you don t become trapped in believing that there is no other person in this world who can help these patients.

34 Dependent Personality Disorders The dependent and submissive behaviors of the Dependent Personality Disordered individual s are designed to elicit care giving and arise from a selfperception of being unable to function adequately without the help of others.

35 Ethical Situations Individuals with personality disorders will want and expect special treatment. This should be your first sign that an ethical situation is about to occur.

36 Patient Behavior Non-adherence, causing no harm to others Non-adherence, harms and inconveniences others. Verbally abusive Physical abusive

37 Key Ethical principles Respect for autonomy Beneficence

38 Respect for Autonomy As indicated in the handout, dialysis staff should continue to provide dialysis to a nonadherent patient who continues to request dialysis and does not interfere with the operation of the dialysis unit.

39 Respect for Autonomy Patients with a personality disorder might complicate the decision to change their dialysis schedule and engage in a control battle with staff by making the decision to harm themselves by not following their prescribed diet or medication. Hashmi and Moss, (2008) point out that even though such behaviors can be stressful to healthcare providers, it should not be a reason for discharged.

40 Respect for Autonomy However, Schwartz, M., and Batson, H., (2000) point out that when the actions of this type of patient become harmful to other patients, respect for autonomy of the disruptive patient is overridden by competing moral obligations to other patients.

41 Beneficence The principle of beneficence requires healthcare professionals to promote the wellbeing of all patients. The wellbeing of a patient with a personality disorder needs to be considered as long as the patient is not abusive, per Baskin, S. (1994).

42 Rules of Rescue Do rescue when: Life and limb are in danger. Rescue when there is no chance that this patient could help themselves out of the problem that has developed (e.g. cognitive limitations, financial, psychosocial stress beyond their control, etc.). Rescue if it isn t expected Rescue if this is a sin of omission vs. commission (e.g. They didn t understand.).

43 Rules of Rescue Don t rescue if: There is a chance that this patient could solve the problem them self. Don t rescue is they expect to be rescued, particularly if they demand to be rescued. Rescue if you feel you have to, but remember that short-term gain always creates long term pain for both you and patient with this 51/49% is violated. Don t rescue if there is abuse, or there is harm to other patients.

44 Please note: There is copyright materials in this handout from Love and Logic and Mayo Healthcare. As a result, I would ask that you not reproduce any of the information for distribution. Thank you in advance!

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47 What are boundaries violations and why is it so difficult to maintain these limits with difficult people? Boundary violations: Deliberate, destructive in relationships Violate the fiduciary nature of the patient-health care provider relationship, patient expects competency, and integrity Providing benefits for the professional prior to any benefit to the patient

48 What are boundaries violations and why is it so difficult to maintain these limits with difficult people? Boundary violations: Deliberate, destructive in relationships Violate the fiduciary nature of the patient-health care provider relationship, patient expects competency, and integrity Providing benefits for the professional prior to any benefit to the patient

49 Boundary crossings: Inadvertent, unintended Neutral in regard to any benefits Creates ethical quandaries which can be resolved

50 When problems come up Everyone needs to walk the talk by developing new skills!

51 Strategies for setting appropriate boundaries with difficult people Once you recognize a boundary violation it is important to develop a plan for dealing with it. The first step in developing a plan of action is to identify how you typical handle critical conversations with difficult people.

52 Identify how you typical handle critical conversations with difficult people We can avoid them and become silent. (e.g. No Talk Rule ) We can face them and handle them poorly. (e.g. Become too emotional, or say the wrong things.) We can face them and handle them well.

53 Suggestions for avoiding Ethical Situations 1. Self-esteem Self-Check You cannot survive a relationship with a personality disorder if your self-esteem is damaged or weak. You need to learn to take care of yourself by setting good professional boundaries.

54 Suggestions for avoiding Ethical Situations 2. The Four Don'ts There are four things you should not do or say to a Borderline individual. The first is don't defend yourself. The second is don't explain. The third is don't justify. The fourth is don't counter attack. The patient with a personality disorder may misconstrue the abovementioned statements and actions.

55 3. Practice SET Communication Method (Support, Empathy, Time) S stands for Support. It is very important to have a support network of others around you. When in doubt, always consult with another person. E stands for Empathy and hands the problem when a patient needs to own the problem. T stands for time. This technique allows you time to think about how you are going to handle situation after emotional outbursts or accusations.

56 4. Learn to be appropriately assertive and avoid becoming a victim. 1. Help them to make sure you have the correct understanding of what is being said, (e.g. Is your first impression of what you heard correct?). 2. Try to interpret what that person is really saying. 3. Do not respond and defend. (Remember: You will only end up looking foolish. Doing this will actually be fuel for the bully to continue the teasing.) 4. Use strategies that will empower and make you a poor target.

57 5. Setting and Maintaining Boundaries Rule #1: Sets firm behavioral limits in a caring way. They model taking good care of themselves, and setting good boundaries. This means that staff will avoid: getting angry lecturing/reasoning making threats that can not be followed through giving repeated warnings Rule #2: Hand problems back to individuals that they should be responsible for.

58 Rule #1: Sets firm behavioral limits in a caring way. They model taking good care of themselves, and setting good boundaries. This means that staff will avoid: getting angry lecturing/reasoning making threats that can not be followed through giving repeated warnings

59 Key to consider: To accomplish these two rules it will be first important to neutralize arguing and their non-compliance to what you have asked them to do.

60 Neutralizing Arguing Step One: Go Brain Dead Never attempt to reason with a person that wants to argue. Reasoning and logic will not work in these situations because the patient is playing by a different set of rules than you are. He/she is not interested in facts and logic. He/she is interested in getting their way and seeing you give into them.

61 Neutralizing Arguing Step Two: Choose a Detachment State Consider using: I bet if feels that way sometimes. This sounds like an argument. Let s talk about this at a later time.

62 Neutralizing Arguing Step Three: Do Not Attempt To Think Become a broken record, saying the same antidote for each new argument that comes up with. Keep your voice soft. Allow any frustration to be that of the individual, not of you.

63 Neutralizing Arguing Step Four: If the person continues to argue consider using Enforceable Statements For some very strong-willed or manipulative individuals, it is effective to say, I ll talk when your voice is as calm as mine. Or Please call me back when you are not swearing.

64 5b. Using the Power of Empathy To Hand Problems Back Rule #2: Hand problems back to individuals that they should be responsible for. People who re successful with this skill make it easier by using just one empathetic statement that fits their personality, their culture, etc. Quick Empathy Statements: How sad What a bummer Uffda Oh, wow

65 Five Step Process How much time could you save each day if some people would own and solve problems that they have created for themselves? 1. Provide empathy, (e.g. Oh that s not good. ). 2. Send an empowerment message, (e.g. What are you going to do? ). 3. Offer a menu of suggestions,(e.g. Would you like to hear what others have done? ).

66 Five Step Problem Solving Technique: 4. Ask the patient to process after each suggestions, (e.g. How will that work for you? ). 5. Give the person permission to solve or not solve the problem they created, (e.g. Send the Good Luck message.).

67 Please note: There is copyright materials in this handout from Love and Logic and Mayo Healthcare. As a result, I would ask that you not reproduce any of the information for distribution. Thank you in advance!

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