[Lack of empathy in teenagers, a weakness in the therapeutic relationship]

The capacity to recognise others as being different from oneself is an essential element of empathy. Achille's treatment in a child psychiatry unit illustrates the clinical presentation of a teenager who lacks this social skill. The use of the Griffith Empathy Measure improves the screening and evaluation of this disorder, with the aim of being able to provide the young patient with adapted support.

Acceptance and commitment therapy-based self-management versus psychoeducation training for staff caring for clients with a personality disorder: a randomized controlled trial

People diagnosed with a personality disorder (PD) are often a stigmatized patient group. This can affect the care they receive, their progression, and the well-being of staff caring for them. Interventions targeted at health care professionals that aim to improve attitudes toward these patients and improve staff well-being do exist; however, evidence for their effectiveness is limited. The present study compared a self-management, Acceptance and Commitment Therapy-based training intervention (ACTr) with a Psychoeducation Training (PETr) intervention in their effectiveness in improving attitudes toward PD patients, staff-patient relations, and staff well-being. Both interventions were successful at improving attitudes and measures of staff-patient relations up to 6 months after training; however, staff well-being did not change for either group. The implications for staff training and future research are discussed.

[The management of perpetrators of sexual violence]

Sexual violence and crimes arouse rejection and hatred in our society. Perpetrators of sexual violence must comply with psychiatric treatment, without necessarily having requested it. Caregivers find it extremely difficult to engage themselves in the management of these patients. This context has favoured the setting up of specific consultations, signalling a potential new area of care.

[Changes in adolescence and changes in care]

Adolescence is a period renowned for giving rise to changes, the outcome of which is unknown or uncertain. It is necessary to take into account the malaise, resulting from a problem of intersubjectivity and social bonds. Excesses of individualism as a response to the weakness of the being are conveyed by risk-taking behaviour. Caregivers must stay on course, not be discouraged and favour creative approaches, either individually or in a team.

[An original therapeutic approach: the regulars' table]

Reintegrating psychotic patients or those suffering from severe personality disorders in the relationship with other people is not easy. A part-time therapy centre in Saint Louis has developed a specific programme for these patients: the Stammtisch, Alsatian for "the regulars' table". Due to the minimal presence of the nurses, the patient's desire is brought to the fore. The patients thereby spontaneously work on their impaired social interaction.

Forensic nursing interventions with patients with personality disorder: a holistic approach

Research findings suggest that nursing assessment and care and psychotherapy of forensic patients with personality disorder should be based on a holistic approach that addresses a wide range of their needs. Such an approach should be in collaboration with patients, informal carers, and other professionals and informed by appropriate education, training, clinical supervision, and support. Holistic care includes areas (such as physical health, cultural, spiritual, and psychosexual needs) that are addressed to a limited extent in the literature on patients with personality disorder. Despite limitations in research evidence, findings suggest that some patients with personality disorder benefit from psychotherapies, sometimes facilitated by nurse-therapists, and therapeutic community principles. These interventions should take account of patients' cultural and spiritual needs and perspectives. Helping patients to manage anger has potentially positive consequences for their physical health, personal and work relationships, and other areas. Research is needed to consider how to deliver holistic care with limited resources and in organizations, such as prisons, with conflicting goals.

[The illustrated depression scale, an innovative tool]

As an aid to daily practice in mental health, the Fribourg Mental Health Network in Switzerland has developed an innovative tool to measure the symptoms of depression, the Illustrated Depression Scale. It provides a simple and quick assessment of the symptoms of depression and their evolution during hospitalisation.This article gives an overview of the development of this scale, its psychometric qualities and its use in practice.

An inclusive approach to personality disorders

Personality disorder is one of the most misunderstood of mental health disorders. Historically, people with this diagnosis have experienced exclusion and rejection from mainstream mental health services and wider multi-agency services. This article describes the development of a new strategy to build strong, seamless links across multi-agency services with the aim of providing timely interventions, improving patient experience and reducing the likelihood of transitions to more costly services.

[A young girl with an inconsistent identity]

Lola experiences herself as "too beautiful" and attemps to invest a body that she ignores, the meaning of which she gauges only through the adornment. In her quest of men that might teach her being as a woman, this teenager ends up loosing herself. Lola acts "as if" in placing herself in the posture of object of the mother or object of men.

Staff and patient's perceptions of each other's interpersonal style: relationship with severity of personality disorder

Extreme and varied reactions are often encountered when working with patients with personality disorders. Similarly, patients with personality disorder may also hold polarised opinions of the staff involved in their treatment. This study explored the relationship between severity of personality disorder and interpersonal style in patients admitted for treatment to a secure psychiatric unit. Up to four nurses rated each patient's interpersonal style using the Impact Message Inventory, a self-report transactional inventory. Patients then rated the interpersonal style of these same staff. Contrary to expectations, severity of personality disorder was not associated with patients' interpersonal style or to variance in nurses' assessments of patients' interpersonal style. However, patients with more severe personality disorder tended to show greater variability in their assessment of nurses' interpersonal style, specifically their appraisal of staff members' interpersonal dominance. Implications for the assessment of offenders admitted for treatment of their personality disorder are discussed.

Forensic nurses' perceptions of labels of mental illness and personality disorder: clinical versus management issues

Anecdotally, forensic psychiatric nurses generally have a more negative perception of people diagnosed with a personality disorder and this negativity is focused more towards managing the behaviours rather than on treatment efficacy and clinical outcomes. This study reports on research carried out across the High, Medium and Low secure psychiatric services in the UK. One thousand two hundred questionnaires were distributed with a response rate of 34.6%. The results indicated a statistically significant difference across High (z = 9.69; P < or = 0.01), Medium (z = 11.06; P < or = 0.01) and Low (z= 9.57; P= 0.01) security with a focus on the management of people with a personality disorder using the Wilcoxon paired samples test. There was also a statistically significant difference in relation to a more clinical/treatment focus for those with a diagnosis of mental illness in Medium (z = 9.69; P < or = 0.01) and Low (z = 9.57; P < or = 0.01) security but not in the High security services. Finally, the results showed significant differences between High, Medium and Low security on each of the four scales of Personality Disorder Clinical-Personality Disorder Management and Mental Illness Clinical-Mental Illness Management. This raises issues of stigma, prejudice and discrimination and suggests a refocus on skills development, acquisition and application for those with a label of personality disorder.

Nurses take the lead in setting up an innovative service for people with personality disorder

This article describes a novel community based service for personality disorder. Initially a pilot scheme in Oxfordshire, this nurse led service was so successful that other areas have set up similar programmes. Based on four tiers of therapeutic care, the service has substantial user involvement andaims to help people with personality disorder lead more fulfilling lives.

Reclaiming the humanity in personality disorder

This paper provides a commentary upon the nursing care of individuals diagnosed with personality disorder and associated education courses. The discussion focuses upon recent policy trends in the UK as a point of departure. This policy discourse is critical of mainstream mental health services in previously operating to exclude such individuals. One of the consequences has been a recent growth in interest in relevant training courses, many of which devote significant attention to staff attitudes regarding this client group. Various previous researchers and commentators have remarked upon the implications for practice of a perceived negative attitude among care staff. We reflect upon our own anecdotal experience of developing and delivering new university-based courses for practitioners working in the field of personality disorder to offer a particular critique of the UK context, in which this policy, training, and practice is framed. Social constructionist theories are drawn on to offer insights into public and practitioner discourse and the possible effects on therapeutic relationships. The available discourse constructs individuals with a diagnosis of personality disorder as essentially different from other people. We argue that staff training and practice development initiatives are likely to be more successful if such discourse is challenged, and attempts are made in therapeutic encounters to recognize shared characteristics and positive attributes as much as perceived difference and negative attributes. We refer to this as a re-engagement with common humanity. Despite the singular national context, the discursive themes explored are not necessarily restricted to the UK.

Managing inpatients who have personality disorders

An increasing number of personality disorders services are being developed in medium secure settings. This specialised field is extremely challenging and professionals entering it must be equipped with the knowledge and skills to work effectively with this client group. This article aims to raise awareness of common issues and provide recognised and widely used management strategies.

[The nursing experience of applying MRM model to personality disorder]

This article describes the nursing care of a schizophrenia patient with DSM-IV axis II diagnosis of borderline personality disorder. The patient presented psychiatric symptoms and signs, such as poor emotional control, manipulative behaviors, low self-esteem, and poor interpersonal relationships. The core symptoms of the personality disorder led to the admission of the patient, so this article mainly deals with the problem of borderline personality and its management. Through holistic nursing assessment, the author confirmed the diagnosis and found that the patient had some related mental health problems, such as, ineffectiveness of coping skills, impairment of social interaction, disturbance of self-concept, and low self-esteem. The author therefore applied the Modeling and Role Modeling model during the process of interpersonal mutual interaction, in order to establish the nurse-patient relationship, to accept the patient's point of view, to promote the patient's capacity for positive thinking, to establish healthy goals, to enhance the sensation of control, to make behavioral contact with the patient, to teach the patient proper conduct to deal with difficulties of emotional control, to improve the patient's interpersonal relationships, and to improve the process of self-identity. During the period of care (Feb. 14th, 2003 - June 6th, 2003), there was marked improvement in the patient's emotional control, adaptive abilities, and self-identity. The results revealed that, from the point of view of the patient, the nurse can improve the patient's willingness to participate in health promotion, to receive help from others, to learn and grow from past experiences and to develop the ability of self-control and mastering of one's own life.

Student psychiatric nurses' approval of containment measures: relationship to perception of aggression and attitudes to personality disorder

Difficult and challenging behaviour by inpatients is a feature of acute psychiatric ward life. Different methods are used to contain these behaviours, and there is international variation in which are approved of or used. Previous research suggests that staff attitudes to patients may affect their willingness to use, or choice of, method. The aim of this study was to explore the relationship between approval of containment measures, perception of aggression and attitude to personality disorder. A survey of student psychiatric nurses was conducted, and using three attitudinal questionnaires related to aggression and containment. An association was found between positive attitude to patients and the approval of containment methods that involved nurses being in personal contact with patients. There was evidence that students' attitudes to patients deteriorated over time. The results highlighted the importance of (and linkage between) staffs' feelings of anger and fear towards patients, and their preparedness to use containment measures.

[Nurses' assertiveness training and cognitive therapy experiences with an outpatient suffering from low self-esteem]

The experiences during nine meetings with a psychotherapy outpatient suffering from low self-esteem between 1/1/02 to 4/10/02. Using comprehensive nursing assessment practices for guidance, two conclusions were arrived at regarding the patient's mental health: a) an imbalance in individual response ability, and b) long-term problems with low self-esteem. This assessment was used to help the authors practice appropriate nursing skills associated with assertiveness training and cognitive therapy and to establish a trusting, caring, and accepting relationship with the client. The treatment plan included attempts to increase personal confidence and to promote suitable skills for improving living functions, enhancing relationships, and practicing social behavior.

A self-psychology approach to narcissistic personality disorder: a nursing reflection

TOPIC

The use of Heinz Kohut's self-psychology perspective in understanding and providing care for patients with narcissistic personality disorder (NPD).

PURPOSE

To describe how nurses can apply the self-psychology perspective as a way to understand the development of self for individuals with NPD and to enhance the therapeutic relationship between the nurse and patient with NPD.

SOURCES

Theoretical literature; the author's clinical experience.

CONCLUSIONS

Self-psychology provides nurses with a theoretical perspective that can enhance the interpersonal relationship between the nurse and patient with NPD.

Effectiveness of nursing interventions in people with personality disorders

BACKGROUND

Nurses usually provide care for people with personality disorders on a day-to-day basis. Consequently, it is important to establish how effective nursing interventions are for those with personality disorders, both in terms of general management and more specific therapeutic approaches. These are also issues of current political and professional debate. The crucial question, however, for planners, providers and commissioners of services is, What research evidence is there about effectiveness? There is also a need to determine what further research is necessary to evaluate programmes for managing or modifying behaviours.

AIM

The aim of this paper is to report on a systematic review of the literature on the effectiveness of nursing interventions in people with personality disorders, whether delivered by nurses alone or in combination with other health care professionals.

METHOD

The review was conducted according to the United Kingdom National Health Service Centre for Reviews and Dissemination guidelines. Literature was identified from electronic database searching, footnote chasing, hand searching of journals and contact with authors of studies. Narrative synthesis was undertaken in relation to study design, participants, and type of intervention.

FINDINGS

Eighteen separate studies were included in the review: four randomized controlled trials, four non-randomized controlled trials, seven before-and-after studies and three case studies.

CONCLUSIONS

There is a weak evidence-base for what constitutes effective nursing intervention with people with personality disorders. There is stronger evidence from mixed disciplines intervention studies than from nursing only intervention studies. Studies of interventions based on psychological approaches show greater improvements in outcomes than nursing management studies.

Managing personality disorders: making positive connections

This article has outlined what the author believes to be the essential elements of support, guidance and training for staff working with people with personality disorders. It can be argued that programmes without these elements compromise not only the quality of care but also staff wellbeing. HMP Whitemoor, Cambridgeshire, is currently piloting a programme for the assessment and treatment of severe personality disorders. The multidisciplinary team is actively working towards the principles as defined in this paper, and is also involved in the development of skills competencies to underpin the whole process. There are several studies underway relating to the needs of the prison's staff team and these will evaluate the aforementioned principles and thereby refine the staff support, supervision and development structures. There is no apology made for the focus of this article being on staff needs. Without them being met, any service designed to care and manage people with personality disorders cannot exist, thus returning the people this programme is designed to help to a chaotic and crisis-driven existence.

Manipulation: description, identification and ambiguity

The word manipulation is frequently applied to some of the difficult-to-manage behaviours of the personality-disordered patient. However, the term is rarely defined, and a review of both the clinical and research literature shows that little has been written about its definition and identification, let alone its clinical management in both in- and outpatient settings. Recent empirical work conducted with nurses in forensic settings has demonstrated the range of behaviours that professionals refer to as 'manipulative', thus clarifying the use of the term and allowing the provision of a more precise definition. The scope of manipulation in everyday life, management practice and politics is perhaps relatively small, although manipulation can occur in all areas of human activity. Social behaviour is doubly ambiguous with respect to judgements of manipulation, as such judgements involve a moral evaluation combined with the identification of deception on the basis of little or partial evidence. The implications of this social ambiguity for clinical psychiatric practice are that professionals need to guard themselves from two polar faults: seeing manipulation everywhere; or being blind to its presence. In order to achieve a cautious moderation, staff need to hold both alternatives in mind at all times.

Manipulation: searching for an understanding

Manipulative behaviour is one of the reasons why some psychiatric professionals dislike personality-disordered (PD) patients and dislike working with them. Being manipulated arouses strong negative emotions towards the manipulator and can have severe repercussions on the ability to care for or treat those suffering from personality disorders. In order for practitioners to cope with manipulative behaviour and manage their emotional responses towards it, it is necessary to find ways to understand or construe that behaviour, so that moral condemnation and rejection of the patient can be avoided. This article offers a summary of three such methods of interpreting manipulation which are to be found in the literature: manipulation as normal behaviour; manipulation as unconsciously motivated; and manipulation as cognitive distortion. These three viable schemes for the understanding of manipulation provide not just a means to enable a non-judgmental approach, they also provide ways to manage that behaviour in a therapeutic manner.

The prevalence of personality disorders, psychotic disorders and affective disorders amongst the patients seen by a community mental health team in London

BACKGROUND

There is a lack of information regarding the prevalence and co-occurrence of personality disorders, psychotic disorders and affective disorders amongst patients seen by community mental health teams. This study aims to describe the population of patients served by a community mental health team in South London in terms of demographic and clinical characteristics.

METHOD

Computerised hospital records and keyworkers' caseloads were used to identify 193 patients. The Standardised Assessment of Personality was used to assess personality disorders and the Operationalised Criteria Checklist was used to assess psychotic and affective disorders.

RESULTS

Fifty-two per cent of patients met the criteria for one or more personality disorders, 67 % of patients had a psychotic illness and 23 % had a diagnosis of a depressive disorder. Community psychiatric nurses (CPNs) mainly saw patients with psychotic illnesses. The non-psychotic patients seen by CPNs had extremely high rates of personality disorder. Patients seen by psychiatrists and psychologists had significantly lower rates of personality disorder.

CONCLUSIONS

The prevalence of personality disorder is high amongst patients seen by community mental health teams. Possible explanations for this are presented and implications for community care are discussed.

Personality disorders in the primary care setting

Patients who suffer from personality disorders often exhibit self-destructive behaviors in the clinical setting and are noncompliant. By recognizing the disorder and intervening, primary care providers can help improve patient outcomes and minimize damaging clinical interactions. This article discusses the different types of personality disorders and provides diagnosis, treatment, and referral guidelines.

Medusa appears: a case study of a narcissistic disturbance

TOPIC

A detailed case study of the brief psychotherapy of a college student with a narcissistic disturbance, discussed through the lens of relational psychoanalytic theory and including a description of important interventions.

PURPOSE

To promote greater understanding of psychoanalytic theory and therapy with a particular young adult population, and to underscore the importance of empathy and the therapeutic relationship to successful psychotherapeutic outcome.

SOURCE

The author's own clinical practice.

CONCLUSIONS

The therapeutic alliance is fundamental to the psychotherapeutic change process. Empathy is not just a means to a better healing relationship; it is in itself healing. Accurate empathy within the therapeutic relationship is essential to developmental unfolding, especially where sustained, age-appropriate emotional responses to developmental needs were lacking and an integrated sense of self failed to develop.

Triumvirate nursing for personality disordered patients: crossing the boundaries safely

As the issue of the treatment and effective management of personality disordered patients comes under close scrutiny in the wake of the Fallon Inquiry, we offer a brief overview of the nature of the challenges involved in nursing this difficult group of patients. Traditional methods of setting limits and defining boundaries are no longer convincing amidst the allegations of multidisciplinary staff being culpable, at one level or another, for their contribution in this tragic inquiry. In this paper we offer a strategic mechanism of constructing nursing care for this difficult group of patients and provide a framework for crossing boundaries safely through a multidisciplinary framework. We term this triumvirate nursing. Nursing management of those patients considered to have personality disorders is traditionally very difficult. This difficulty, in part, stems from the inability of nurses to strategically develop therapeutic relationships in a safe manner. Crossing boundaries is a necessary part of therapeutic exploration and relationship building; triumvirate nursing offers a safe mechanism for undertaking this. Creative thinking is a necessary part of the future development of the nursing management of these disorders.

A model of psychosocial care for severe personality disorder

This paper describes the development of a preliminary model of psychosocial outreach nursing for patients with severe personality disorder. Through a grounded theory approach the outreach nurse evaluates their role and spheres of psychosocial intervention. Psychodynamic theory enhances an understanding of the nurse-patient relationship and the nature of the patient's difficulties, facilitating appropriate nursing interventions.

Nursing care of personality disorders in the medical surgery setting

When patients with personality disorders are treated for medical conditions in an acute care setting, nurses are frequently unaware of the diagnosis. Yet the behavior patterns can create problems for both patient and nursing staff. This article will (1) present an overview of personality disorders; (2) examine personality characteristics of patients with borderline and antisocial personality disorders and the difficulties that arise from splitting, impulsiveness, suicide attempts, manipulation, and aggression; and (3) discuss intervention strategies the nurse who encounters a patient exhibiting a personality disorder can use.

Assessing and intervening with anger disorders

Nurses often find angry patients threatening. In this article, current research will be synthesized to provide guidance to nurses whose specialty area may not be psychiatric nursing. Guidelines for assessing and intervening with angry clients will be provided. Such guidelines are likely to be useful to nurses in every clinical setting, from the emergency room to the rural clinic to the high-tech hospital unit. Nurses will also learn some techniques for managing their own anger at uncooperative or hostile clients.

Impaired personal boundaries: a proposed nursing diagnosis

TOPIC

How impaired personal boundaries play a significant role in mental illnesses and co-dependency.

PURPOSE

To demonstrate the value of having a formal nursing diagnosis of "impaired personal boundaries."

SOURCE

A concept analysis of personal boundaries, which describes the physical, emotional, intellectual, and spiritual dimensions of personal boundaries.

CONCLUSION

The author recommends a new nursing diagnosis of "impaired personal boundaries," which provides a basis for the plan of care for clients with this difficulty.

Coping Strategies: A Psychoeducational Approach to Post-Traumatic Symptomatology

Survivors of extensive childhood abuse frequently present complicated clinical dilemmas in the inpatient setting; they experience complex post-traumatic and dissociative symptomatology, such as flashbacks and other reexperiencing phenomena, as well as intense affects and self-destructive impulses. Such patients seek recommendations of how to manage their post-traumatic symptomatology, as well as how to tolerate intense affects and maintain safety. The nursing staff at McLean Hospital's Dissociative Disorders Program have developed a psychoeducational approach that patients have found useful. Coping strategies, which the patients learn to formulate, help clients stall impulsivity and dissociative episodes through the use of healthy diversions, grounding techniques, and support networks.

Using Roy's model in a special hospital

Using a nursing model to help systematise the care of a young patient in a special hospital resulted in tangible improvements in his behaviour, yet Francesca Miller found that it raised questions about the function and value of nursing for this client group. Her study reveals how she had to cope with her own negative feelings about the nature of her patient's offences and how the use of basic counselling skills, and encouraging the patient to take responsibility for his own care, achieved notable developments in his social skills. But despite this, she is left to ponder, 'at what cost?'

Integrating Three Approaches to Counter Resistance in a Noncompliant Elderly Client

1. The term "resistance' has been defined primarily in the psychoanalytic literature and is a significant issue in the treatment of mentally ill people. This issue needs to be addressed for the change process to begin. 2. An understanding of resistance from psychoanalytic, cognitive, and behavioral perspectives will enable the nurse to assist the client in achieving mental health. 3. Countertransferance can be used to understand the client's motives, hence becoming aware of therapeutic goals, or it can hinder the therapeutic process. 4. The psychiatric-geriatric population is complex. With the acceptance that an elderly client can benefit from psychotherapy and with an understanding of different approaches, the client may experience symptom relief.

The sexual addict: a challenge for the primary care provider

Sexual compulsion is now recognized as a true addictive process that may manifest itself through a wide range of behaviors. Recognition of this disorder in primary care settings may be difficult because of the ego defenses of denial and rationalization that characterize this disorder. Cues in the medical and sexual history as well as behavioral cues may suggest the presence of sexual addiction. The alert primary care provider should play a significant role in the recognition of sexual addiction.