Predictably Unpredictable: Ethical Challenges in Caring for Persons with Borderline Personality Disorder Lunchtime Ethics Series, April 2015 Amanda Porter, PhD Clinical Ethicist, AHS Amanda.Porter@albertahealthservices.ca
Using a case study approach, identify and explore ethical challenges that can arise in the care of patients with borderline personality disorder.
A diagnosis that admits of wide variation, but is an enduring pattern of behaviour characterized by some combination of the following: Emotional instability and intense anger Strong fear of abandonment, and reassurance-seeking behaviour Chronic feelings of emptiness Unstable and intense interpersonal relationships Identity disturbance Impulsivity Recurrent suicidal behaviour and self-injury During periods of high stress, paranoid and dissociative symptoms (Aguirre and Galen, 2013)
Ms. B is a 25 year old woman who suffers an open fracture of her femur in a serious car accident. Following emergency surgery on her leg, Ms. B is admitted to an orthopedic floor in the hospital where she is expected to remain for at least a month. Ms. B has previously been diagnosed with Borderline Personality Disorder. Ms. B uses the call bell approximately 20 times a day, often demanding a warmed blanket. Tensions between staff and Ms. B are apparent, and Ms. B sometimes refuses routine blood pressure monitoring and intermittently refuses her IV antibiotics. Visits from Ms. B s family are infrequent. Over time, deep disagreements among the health care team evolve regarding how best to care for Ms. B and after numerous arguments many of her care providers are now reluctant to come into work.
In a survey of 229 mental health professionals published in 2002, 80% found that dealing with clients with borderline personality disorder was moderate to very difficult. 84% of staff felt that dealing with this client group was more difficult than dealing with other client groups. (Cleary, 2002)
Patient health Professional standards The relationship between the patient and members of the health care team The relationships between staff members Loss of job satisfaction, burnout, etc
Accommodating Approach: If you re nice to Ms. B, then she ll be nice to you. These other nurses just need to be nicer. Firm Approach: Ms. B is just taking advantage of us. She s just one patient but she takes up 90% of my time. She needs to learn that she s not more important than anyone else. Avoidant Approach: Just don t engage Ms. B. Don t get drawn in. Minimize your interaction with her as much as possible.
The stereotypes that we have of persons with BPD can affect how we interpret a patient s behaviour, leading us to develop negative attitudes towards that patient. These attitudes are detected by the patient, who then feels rejected, abandoned, judged, misunderstood, deprived, invalidated. Patient acts out" and we take this as confirming evidence of the earlier stereotype. Patients respond to the way they are treated by others. Negativity towards patients can be self-fulfilling.
Q: We don t usually say that a person becomes unworthy of attention because their condition is difficult to treat and resource intensive. Why do these kinds of sentiments sometimes arise in the care of some patients with BPD? Possible answer: Because we see patients with BPD as morally responsible and, therefore, unworthy of care. We may exaggerate the degree to which they are in control of and endorse their own behaviour.
Nyquist Potter argues that clinicians tend to think that unless a patient is hallucinating, deluded, or confused, then the patient is responsible for her behaviour. We tend to think, if the patient is responsible, then she is to blame for her behaviour and its consequences. The clinician s feeling of hopelessness, anger, and pessimism are blamed on the patient. Potter argues that we need to distinguish between accountability and blame The more we attribute control to the person, the less we feel empathy.
Practice mindfulness. Find the kernel of truth and validate. When is it appropriate to validate an emotion? Can you validate an emotional experience without endorsing or encouraging it?
Labelling a patient as difficult may be unfair, counterproductive, or both. We need to investigate why a patient is upset, engaging the patient in the process. At the same time, we cannot reduce or dismiss all conflicts as being entirely an outcome of labelling or lack of empathy. Consistent, empathetic, fair treatment by clinicians cannot guarantee a smooth relationship with Ms. B but it will likely help.
Pickard argues that patients with BPD may exercise a degree of choice and control, but control is not an all or nothing capacity. When patients act out we should neither absolve nor blame them. Need to separate responsibility, blameworthiness, and blame.
The word responsible can mean different things. Denying the responsibility of Ms. B is both undermining and counter-productive. Exaggerating the responsibility of Ms. B is unfair and counterproductive.
Moral distress occurs when one feels like one knows what should happen but one also feels powerless to bring it about. Clinicians may feel like they know what is right for the patient (e.g. Ms. B should receive her antibiotic), but feel powerless to make it happen (e.g. Ms. B refuses treatment). It may be useful to manage one s own expectations. Ask yourself: What does it mean to be a good clinician in this context? Appreciate that you re not a bad health care provider if you feel like you re struggling. Resist urges to endlessly placate, blame, or disengage.
Some conflicts will arise that are neither the result of blameworthy action on the part of the patient, nor a failure of the clinician. Some conflict will be no one s fault.
Involve specialized expertise Adopt a clear, consistent, well-reasoned, well-communicated approach Ensure that patients are heard, bend where it is reasonable to do so Address indications that the patient is upset (be active, not reactive don t wait until Ms. B explodes) Try not to be seduced by praise or crushed by criticism. Everyone needs to be accountable. (e.g. I m sorry that I was short with you ) Practice within scope Allow adequate time to diffuse anxiety and anger Recognize positive behaviour and positive changes Engage the patient calmly Hold off on serious discussions until everyone is calm. Share ideas, support colleagues. Avoid sliming and sarcasm Advocate for a system that enables all of the above
Avoid the tendency to view patients with BPD either as mere victims of illness or as willfully and deliberately causing havoc. Expect and address conflict, check biases, hold everyone accountable, cultivate empathy, and avoid blame (of oneself, one s colleagues, and the patient). Organize systems that support and equip staff to address the psychological needs of patients.
Blaise Aguirre and Gillian Galen, Mindfulness for Borderline Personality Disorder. (Oakland, CA: New Harbinger Publications, Inc.: 2013). Ann R. Bland & Eileen K. Rossen, Clinical Supervision of Nurses Working With Patients With Borderline Personality Disorder. Issues in Mental Health Nursing (2005) 26: 507-517 Canadian Mental Health Association, Borderline Personality Disorder (Info Sheet 2014), www.heretohelp.ca Michelle Cleary et. al. Experience, knowledge and attitudes of mental health staff regarding clients with borderline personality disorder International Journal of Mental Health Nursing (Sept. 2002) 11(3): 186-191 P. Fallon, Travelling through the system: the lived experience of people with borderline personality disorder in contact with psychiatric services Journal of Psychiatric and Mental Health Nursing (2003) 10: 393-400 Karen Fraser, Nurses confirming/disconfirming responses to patients diagnosed with borderline personality disorder Psychiatric Nursing (Dec. 1993) 7(6): 336-341 P.D. James, Psychiatric nurses knowledge, experience and attitudes towards clients with borderline personality disorder Journal of Psychiatric and Mental Health Nursing (Oct. 2007) 14(7): 670-678
Hanna Pickard, Responsibility without Blame: Philosophical Reflections on Clinical Practice in The Oxford Handbook of Philosophy and Psychiatry, K.W.M Fulford et. al. Eds. (Oxford: Oxford University Press, 2013): 1134-1152 R.E. Kendell, The distinction between personality disorder and mental illness British Journal of Psychiatry (2002) 180: 110-115. G.C. Langley & KH. Klopper, Trust as a foundation for the therapeutic intervention for patients with borderline personality disorder Journal of Psychiatric and Mental Health Nursing (2005) 12: 23-32 Klaus Lieb, Mary Zanarini et.al. Borderline Personality Disorder The Lancet (Seminar) (July 31 2004) 364: 453-461 Nadine Nehls, Being a case manager for persons with borderline personality disorder: Perspectives of community mental health centre clinicians. Psychiatric Nursing (Feb. 2000) 14(1): 12-18 Nancy Nyquist Potter, Blaming and Stereotyping and Their Effects on Healing from Borderline Personality, Keynote presentation at Journal of Mental Health Ethics Conference, 2011. http://jemh.ca/conferences/2011/index.html Joel Paris, et. al. The Case for retaining borderline personality disorder as a psychiatric diagnosis Personality and Mental Health (2009) 3: 96-100
Thank you! Amanda Porter, Amanda.Porter@albertahealthservices.ca