Boundaries Compassion Caring for People Living with Personality
Boundaries = Compassion Caring for People Living with Personality Disorders Lea C. Watson, MD MPH Geriatric Psychiatry Consultation and Training
Disclosure • Most people, even after experiencing extreme trauma, are resilient and do NOT develop Cluster B personality disorders • We ALL have some of the traits that will be described - especially when we are stressed • People who live in nursing homes as a byproduct of their personality disorder are among the most impaired individuals in our society • THIS talk is about them
Will you be there for me?
boundaries
BOLD
RAIN
Impairments in Personality Function (how a person experiences themselves and others) • Borderline • Narcissistic • Antisocial
Borderline Black/white, all or nothing thinking Unable to regulate emotions Impulsive, risk-taking and self-sabotaging Unstable self-image History of unstable relationships Fear of being alone, abandoned Frequent, intense displays of anger Moods change quickly in response to interpersonal interactions • Create chaos, “split” caregivers • •
Narcissistic Inflated sense of own importance Need for admiration Lack of empathy Fragile self esteem vulnerable to slightest criticism • Blames others instead of taking responsibility • Controlling • •
Antisocial • • Repeated illegal behaviors Deceitfulness, conning, lying Aggression - repeated fights/assaults Impulsivity Reckless disregard for safety of self/others Irresponsible- interpersonally and financially Lack of remorse
Adverse Childhood Experiences • No one is immune to the impact of trauma • Neglect, abuse, substance use, food/shelter insecurity, divorce, family incarceration • ACES affect health as well as emotional wellbeing • That’s why LTC disproportionately impacted!
Caregivers must be BOLD • B E the calm • O NE quarterback • L IMIT-setting • D ependable
Be the calm • Use neutral, confident tone and voice • Listen without talking for at least one minute • If they act out, raise voice or otherwise misbehave, excuse yourself and say you will not tolerate being disrespected but that you will be back to try again • Use clear, declarative language and “I” statements
One quarterback • This is the single most important rule!!!! • Avoids splitting and miscommunication • While they may have many providers, the team MUST unite and designate one principal “decider” • Game over once you are overruled or you overrule somebody else - one weak link sinks ship
Limit-setting • Telegraph how often and how long you will see them (once a week for 10 minutes) • Make rules about what constitutes an unscheduled visit request • Offer discrete choices vs. yes/no options (when would you like to take your shower, mornings or evenings? ) • Caution any controlled substances or sleep medications • Caution when getting outside consultants, soft work-ups • NO PRN’S - reinforces negative patterns • For severe patients, always see them with another provider or staff as a witness
Dependable • You MUST do what say you will do! (both the easy and the hard) • Show up for designated time, validate you are there for them even if you don’t agree on everything • Stick to your plan and don’t give in • Create the “safe container” • They are desperate to prove you wrong!
Shift focus from external to internal • As long as you keep the focus on an external fix they will keep pushing, pushing. • Take it (medications, special rules) off the table and they won’t have anything to push against • It’s a lot of pressure trying to control your environment
Trauma Informed Care • Understand that most personality impairments arise, at least in part, from trauma that prevented healthy psychological development • Impaired persons push you to fulfill the role of perpetrator (of neglect, abuse, not understanding them) • When you “take the bait” they actually get retraumatized • Safety, trustworthiness, transparency are key
Skills to offer patients • Help them identify self-destructive behaviors and distract themselves when feeling overwhelmed by emotions – Hold ice cube in one hand squeeze it – Creative arts, soothing music, relaxation tapes – Radical acceptance of this moment - “this too shall pass” – Do something for someone else – Know it will pass and celebrate not reacting – Recite prayer or mantra offering self-compassion
How to handle threats of self-harm? • Must take it seriously, but this does NOT always mean sending to the ED • Most important factors: Intent, means, access, history of serious attempt
Self care: RAIN Recognize negative emotions or thoughts Accept where you are right now (don’t push it away) Investigate (with curiosity) what’s going on Non-judgment about your experience SUPPORT EACH OTHER!
push pull repeat
Physical manifestation of psychological symptom attention “nothing more to do” referral attention
Physical manifestation of psychological symptom attention symptom Be BOLD increased distress tolerance increased sense of security Selfsoothing
Physical manifestation of psychological symptom attention Symptom Be BOLD increased distress tolerance increased sense of security Selfsoothing
Care not Cure - Best “care” is teaching distress tolerance - “Care” means being predictable and calm - “Care” means protecting them from harm - YOU have the resources in your home
boundaries = compassion
When you feel resistance, dread, avoidance know that it is a fraction of the vulnerability and fear they feel, even if it comes out as chaos and anger. Take a deep breath, set your intention to be BOLD and jump in. You are the heroes.
- Slides: 32