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Dialectical Behavior Therapy and Old-Fashioned, Good Communication
Sarah Ritter, MA, MSN, RN, APN, PMHNP-BC;
and Lois M. Platt, MS, PMHNP-BC, LCPC

N
ABSTRACT urses working on psychiatric
Psychiatric unit inpatients often have serious mental illnesses with comorbid inpatient units must manage
difficult patient behaviors.
personality disorders. Mental illnesses usually respond favorably to medication
Some of the most challenging behav-
and psychotherapy, but personality disorders do not. Two personality disorders iors are exhibited by patients with
are commonly seen on inpatient units: borderline and antisocial. These person- comorbid personality disorders, espe-
ality disorders may destabilize the milieu with disruptive behaviors and present cially borderline and antisocial per-
sonality disorders. In addition to pro-
a challenge to nurses. Difficult patient behaviors and therapeutic responses by tecting other patients and the milieu,
nurses are examined. Dialectical behavior therapy techniques and good com- nurses must interact therapeutically
munication skills may be used by nurses to (a) interact therapeutically with pa- with patients with personality disor-
ders, who may be disruptive. Good
tients with personality disorders and (b) protect other patients and the milieu.
communication skills in combina-
[Journal of Psychosocial Nursing and Mental Health Services, 54(1), 38-45.] tion with dialectical behavior therapy

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(DBT) give nurses the tools to manage Manual of Mental Disorders Cluster B staff to disagree about patient carea
some of the more destabilizing inpa- personality disorders: antisocial person- maneuver related to the ego defense
tient behaviors. ality disorder (ASPD) and borderline mechanism called splitting (Zanarini,
Personality disorders are character- personality disorder (BPD) (American Frankenburg, & Fitzmaurice, 2013).
ized by longstanding patterns of impair- Psychiatric Association [APA], 2013; Self-harm behaviors, such as cutting,
ment apparent in multiple domains, Langton, Hogue, Daffern, Mannion, burning, or scratching, are common
including cognition (e.g., perceptual & Howells, 2011). ASPD and BPD are among patients with BPD (Roth &
abnormalities, disruptions in the expe- characterized by impulsivity, manipu- Press, 2003). These behaviors neces-
rience of self), emotion (e.g., excessive lative behavior, irritability, and some- sitate watching the patient closely and
reactivity or intensity), interpersonal times aggression. may tax staffing resources. The hall-
behavior (e.g., social isolation, high- mark of BPD is avoidance of abandon-
conflict relationships), and impulse con- Antisocial Personality Disorder ment, either real or imagined. Patients
trol (Matusiewicz, Hopwood, Banducci, In forensic samples, the incidence with BPD may lie to gain admiration or
& Lejuez, 2010). Managing any of these of ASPD is estimated to be as high as nurturance from staff and often engage
behaviors on an inpatient psychiatric 70% (APA, 2013); the percentage is in power struggles.
unit is challenging, but violence (to less on general psychiatric units. Black,
self or others), aggression, and manipu- Gunter, Loveless, Allen, and Sieleni DISRUPTIVE BEHAVIOR
lation are usually the most problematic. (2010) note significant comorbidity On inpatient units it is common to
Often psychiatric unit inpatients are with BPD, substance use, and high see several types of disruptive behavior
treated for serious mental illnesses, such suicide risk. ASPD is characterized by exhibited by patients with ASPD and
as schizophrenia, bipolar disorder, and a pervasive pattern of disregard for, BPD. Each behavior is briefly examined.
major depression. These illnesses gen- and violation of, the rights of others.
erally respond to psychotropic medica- Patients with ASPD may demonstrate Aggression and Violence
tion with symptom stabilization. How- deception, criminality, lack of remorse, Aggressive and violent behaviors
ever, approximately one half of patients and a sense of entitlement (APA, 2013). may be the most distressing for staff
on an inpatient unit have comorbid Individuals with ASPD have also been and other patients. Although patients
personality disorders (Adshead & characterized by a tendency to malinger with serious mental illness, such as
McGauley, 2010). Although medi- and manipulate others for their own schizophrenia, psychosis, and bipolar
cation may help decrease distressing gain (Byrne, Cherniack, & Petry, disorder, may behave violently, the
symptoms, such as impulsive aggres- 2013; Kucharski, Falkenbach, Egan, & combination of psychotherapy and
sion and suicidal behavior (Howland, Duncan, 2006). Suicidal threats may medication may help these patients
2007), patients with severe personality be manipulative or genuine and must control behavior, given enough time.
disorders may continue to behave in be carefully assessed. Often irritable However, patients with personality
ways that are disruptive or destructive and violent, these patients may blame disorders may continue to have violent
because of their personality structure. the victim and experience frequent outbursts as a result of their personality
Currently, no U.S. Food and Drug arrests. Lying and stealing are typical structure rather than acute mental ill-
Administrationapproved drug treat- behaviors, as well as impulsivity, lack ness. Abracen et al. (2014) noted that
ment exists for aggression; prescribers of insight, and bad judgment. Patients BPD and ASPD are among the person-
often use a trial-and-error method, with ASPD may also be charming and ality disorders most likely to commit
which may complicate the clinical superficially likable, which allows them two or more instances of violence.
picture. Mauri et al. (2011) note that to manipulate others more effectively. Another distressing behavior
the effects of psychotropic drugs on present on psychiatric inpatient units
aggression and violence are unclear and Borderline Personality Disorder is pre-meditated versus impulsive vio-
undifferentiated. The occurrence of BPD on psychi- lence. In patients with ASPD, manipu-
atric inpatient units is estimated to be lative behavior may take the form of
OVERVIEW OF THE TERRIBLE TWO between 20% and 40% (Aguirre, 2012; calculated (or instrumental) violence
PERSONALITY DISORDERS APA, 2013; van den Bosch, Sinnaeve, for a perceived gain (Walsh, Swogger,
The two personality disorders most Hakkaart-van Roijen, & van Furth, & Kosson, 2009). In this case, the
likely to be seen on psychiatric inpa- 2014). Patients with BPD tend to dis- nurse must be aware of the patients
tient units are among those in the fifth rupt the milieu and interfere with other history and intervene by keeping other
edition of the Diagnostic and Statistical patients treatment. They often cause patients safe.

Journal of Psychosocial Nursing Vol. 54, No. 1, 2016 39


Manipulative Behavior bad may overwhelm and destroy the episodes of self-injury due to intense
Manipulative tactics are common good. Patients act this out in reality emotional response to interpersonal
and may be used by patients who feel by arbitrarily deciding that certain issues or conflicts (APA, 2013). It is
powerless. There is a power differen- individuals or experiences are all important to note that individuals
tial between the nurse and patient good and others are all bad; they who practice parasuicide are at just as
because the nurse is the ultimate are splitting, or mentally keeping in- much risk for actual suicide as those
decision maker. This reality, as well dividuals apart by idealizing the good who have attempted suicide in the
as past experiences that may include and devaluing the bad. These designa- past (Roth & Press, 2003).
physical and sexual abuse or incarcer- tions can reverse repeatedly. Splitting
ation, may make patients feel espe- may be especially destructive if staff CURRENT TREATMENTS
cially powerless. Potter (2006, p. 148) are not aware of what is happening Given current knowledge and skills,
defines manipulation as behavior and enable patients manipulations. it may be said that no treatment exists
that is intended to produce a belief Patients behaviors may incite argu- for a personality disorderonly the as-
or action in another. Manipulative ments among staff members, some sociated symptoms and behaviors. Suc-
behavior may take many forms, such of whom may bend unit rules to give cess in treatment has more to do with
as deception, angry verbalizations or them what they want. A united staff amelioration of these behaviors and
actions, disruption of the treatment that enforces unit rules and refuses to symptoms rather than the disordered
plan, covert aggression, devaluation, allow patients to either idealize or de- personality itself (Bateman, Gunder-
intimidation, demands, ultimatums, value can usually defend against this son, & Mulder, 2015; National Col-
compliments, clinginess, exaggera- destructive type of manipulation, but laborating Centre for Mental Health,
tion, and secretiveness. may be challenging because of high 2009, 2010). There are interventions
Often the feelings evoked in turnover rates of staff and separate that nurses may perform to help symp-
nurses by patients with a person- staffing during the weekends. toms and keep the psychiatric unit
ality disorder (a process known as safe.
countertransference) inform nurses that Parasuicidal Behavior
they are being manipulated. When Parasuicide refers to any self- Dialectical Behavior Therapy and
working with manipulative patients, injurious behavior, which may rep- Borderline Personality Disorder
nurses may feel trapped or pressured resent a maladaptive attempt to cope DBT is a form of cognitive-
to comply with their demands. To with intense and overwhelming emo- behavioral therapy (CBT) adapted
avoid acting out ones own negative tion. There is evidence that self-inju- by Linehan (1993) to decrease sui-
feelings, it is important for nurses to ry may become an addictive process cidal behavior by patients with BPD.
realize that the patients interpersonal (Roth & Press, 2003). It may also DBT has been influential, as it is
manipulation is part of the pathology. be a form of manipulation with the one of the only treatments that spe-
Manipulation may be the only way the goal of eliciting concern and care for cifically targets this often challenging
patient has gotten needs met in life. others, engaging in a power struggle, personality disorder. A longitudinal
Unfortunately, when effective, ma- or obtaining mood altering drugs. study described by Hrz, Zanarini,
nipulative behavior is reinforced and Patients in forensic populations may Frankenburg, Reich, and Fitzmaurice
becomes habitual. It is also possible engage in self-injury for secondary (2010) revealed patients with BPD
that the patient may not realize that gain more frequently than other used more psychiatric services (in-
being direct (i.e., asking politely and patients (Roth & Press, 2003). The patient and outpatient) than those
having a calm discussion with a deci- behavior often involves cutting ones with other personality disorders. A
sion maker) may accomplish the same own skin on the extremities, but can treatment that may help stabilize
goal as manipulation. include other behaviors. Skin may chronically unstable patients is a
be burned with a cigarette, match, welcome tool. DBT was originally
Splitting Staff or pencil eraser. Per the current au- designed to be used in an intensive
Splitting is a type of manipulative thors (L.P.) observations, patients outpatient treatment format, with
behavior that may be especially dis- have been known to use whatever patients receiving group and indi-
ruptive and is used often by patients they can find to self-injure (including vidual treatment. Since its inception,
with BPD (Leichsenring, 1999). It the serrated cardboard edge of a tissue much research has been done that
is a primitive defense mechanism box); therefore, any item that may be supports the effectiveness of DBT for
in which patients attempt to keep used in this way must be controlled BPD (Bloom, Woodward, Susmaras,
good and bad separate, both in by staff. & Pantalone, 2012; Linehan et al.,
their mind and the world. From the Regardless of patients motiva- 2006; Swenson, Sanderson, Dulit, &
patients point of view, unless good tion, self-injury is a cause for concern. Linehan, 2001; van den Bosch et al.,
and bad elements are kept apart, the Patients with BPD may have frequent 2014).

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How Does Dialectical Behavior Therapy and experiences are either all good or results were mixed for the reduction
Differ from Cognitive-Behavioral all bad to a view that recognizes good of anger and violent behaviors. To ex-
Therapy? and bad. DBT therapists also use a plain this disparity, the authors noted
DBT has much in common with dialectic understanding of the patient that variations of DBT used did not
CBT. Both treatments require a col- by accepting him/her as a person while adhere to the original Linehan (1993)
laborative relationship between the fostering change. Consistent with this, model. The authors concluded that
treatment provider and patient for DBT therapists encourage the patients DBT is helpful in inpatient settings,
meaningful work to occur. This work self-acceptance while also working to but advocate further testing. A proto-
includes an initial assessment of change his/her behavior. The DBT col for a randomized controlled trial
patient behaviors and goal setting. Be- model includes crisis support services for short-term inpatient DBT is cur-
haviors are carefully defined so prog- to deter suicide attempts and weekly rently being tested (van den Bosch et
ress may be measured. DBT makes use phone consultations to incorporate al., 2014).
of cognitive-behavioral techniques, new skills in daily life. Treatment is Although current psychological
focused on emotion regulation, inter- treatments of BPD (including DBT)
personal effectiveness, distress toler- improve outcomes on life-threatening
ance, and mindfulness. Peer supervi- behaviors and psychiatric symptoms,
sion for involved clinicians is also part they fail to improve social functioning.
It may be said that no of the treatment protocol, mainly to Patients with BPD continue to suffer
treatment exists for a assist the therapeutic process and help in relationships and demanding social
clinicians manage countertransfer- contexts, such as work and school
personality disorder ence, which may be negative and in- (Bateman et al., 2015).
only the associated tense (Linehan, 1993; Maltsberger &
Buie, 1974). NEWS ABOUT ANTISOCIAL
symptoms and behaviors. In addition to outpatient settings, PERSONALITY DISORDER
researchers have suggested DBT Current treatment options for
ASPD are not as promising as those for
BPD. A review of treatment techniques
for patients with ASPD (Gibbon et al.,
2010) concluded that although some
techniques were helpful in curbing sub-
stance abuse, no studies reported signif-
icant changes in any specific antisocial
behavior. A more recent review by
Bateman et al. (2015) concluded that
evidence for effective treatment of all
personality disorders is insufficient,
with the possible exception of BPD.
No convincing evidence exists that the
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core domains of impaired interpersonal


relationships, identity problems, and
social dysfunction improve with treat-
ment.
Patients with ASPD are associated
with having violent behaviors. As pre-
viously stated, currently no empirically
such as exposure, problem solving, as an option for BPD on inpatient supported psychotherapeutic treat-
management of negative outcomes, units (Bloom et al., 2012; Linehan ment modalities exist for this disorder
skills training, and cognitive modifica- et al., 2006; van den Bosch et al., (Davidson et al., 2009). However, out-
tion. The difference lies in the use of 2014). Bloom et al. (2012) compared patients with a history of aggression
a philosophy called dialectics, in which 11 studies that examined DBT in participating in a trial of CBT reported
opposites are brought together in the inpatient settings and reported re- more positive beliefs about others,
mind to form an understanding of the ductions in suicidal ideation, self- increased social functioning, and
whole. For example, a patient who injurious behaviors, and symptoms of less alcohol use (Davidson et al.,
uses splitting is encouraged to change depression and anxiety that lasted up 2009). One disappointing finding
from a worldview in which individuals to 21 months after discharge. Study about CBT was that a decrease in

Journal of Psychosocial Nursing Vol. 54, No. 1, 2016 41


aggressive behavior was not statisti- THERAPEUTIC USE OF be when a nurse must be firm when
cally significant when compared to SELF THROUGH GOOD giving an important direction due to
other treatment modalities (Davidson COMMUNICATION threatened safety. In most situations,
et al., 2009). A study by Maghsoodloo, Empathic but Firm keeping a positive tone dampens stress
Ghodousi, and Karimzadeh (2012) Nurses may use their own interpreta- and supports coping skills neurocogni-
found that 62% of incarcerated patients tion of a situation to help patients with tively by supporting working memory
with schizophrenia had a comorbid personality disorders see things differ- and problem solving. Negative emo-
diagnosis of ASPD compared to 23% ently. For example, patients may try to tions in the environment increase
of non-incarcerated patients. In these avoid negative consequences by ratio- the demand on emotion regulation by
incarcerated patients, aggression was nalizing their behavior or projecting the prefrontal cortex, which may be
related to impulsivity as measured by their feelings onto others. Nurses must quickly overwhelmed by negative affect
the Psychopathy Checklist-Revised calmly and firmly enforce unit rules (Delaney, 2009).
(PCL-R; Maghsoodloo et al., 2012). that relate to patients behaviors. If
In this situation, DBT may be useful patients reacted violently because they Countertransference
in treating the impulsivity underlying believed they were disrespected by Negative countertransference may
aggressive behavior. another patient, nurses may empathize cause nurses to lose the ability to
empathize and, as a result, act in a
nontherapeutic manner. Countertrans-
ference is loosely defined as the health
Psychiatric nurses must practice therapeutic use of care providers emotional reaction to
the self, primarily through good communication the patient. Often it is rooted in nurses
experiences with other important
techniques. individuals from the past, especially
during childhood. Nurses may or may
not be aware that this dynamic is
STRATEGIES AND NURSING with their feelings, but patients must occurring. When this psychological
INTERVENTIONS experience the consequences of their process occurs in the patient, it is
Good nursing practice may be actions. An example of a nurses thera- called transference. Consider a patient
helpful in managing disruptive be- peutic response: with a personality disorder who may
haviors and improving some psychi- I can understand why you feel the way lie or use intimidation to create an
atric symptoms. Learning about be- you do. Theres some truth in what you ostensibly logical and convincing argu-
havior may help nurses understand say, but you attacked your roommate and ment designed to make a nurse grant
patients with personality disorders; there are consequences to that action. his/her wishes. The demand could be
however, nurses must also learn Next time, lets work together to find something as trivial as more to eat or as
strategies and specific interventions. a strategy that avoids violent behavior major as discharge from the unit. The
Psychiatric nurses must practice but still upholds your self-respect. In the patient tries to make the nurse believe
therapeutic use of the self, primarily end, it does not matter what the other that only his/her perspective is valid
through good communication tech- person says or thinks about you. Vio- and that all others (i.e., the nurses) are
niques. lence leads to negative consequences, incorrect. The nurses feeling of being
Bateman (2012) identified five and I am concerned about what is in invalidated or devalued may stimulate
common characteristics of evidence- your best interest. negative countertransference.
based treatment, paraphrased below, This response shows empathy and Feelings of resentment or even
to guide nurses in their interventions consideration of the patients point of hatred toward patients may cause
with patients with personality disor- view, but also objectivity and a determi- nurses to avoid or shorten interac-
ders: nation to follow the rules. The quality tions with them. In response, patients
Provide patients with a struc- of empathy is therapeutic for patients may demand even more attention
tured approach to problem solving; and enhances trust and rapport. and nurses may respond by being
Encourage patients to practice challenging or combative. Nurses and
self-control; Positive but Firm patients are then engaged in a power
Help patients connect feelings to Nurses may help patients with struggle, as nurses take on the hostile
events and actions; personality disorders by maintaining communication style of the patients
Be active, responsive, and vali- a positive tone during interactions, (Evans, 2011).
dating with patients; and which may help patients cope with Conversely, nurses who try to
Discuss countertransference issues increased demands to exhibit appro- love all of their patients and suppress
with staff members. priate behavior. An exception may negative countertransference are at

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risk for unconsciously acting it out
(Maltsberger & Buie, 1974). The only
defense against negative countertrans- KEYPOINTS
ference is for nurses to be fully aware Ritter, S., & Platt, L.M. (2016). Whats New in Treating Inpatients With Personality
Disorders? Dialectical Behavior Therapy and Old-Fashioned, Good Communication.
of the negative feelings, accept them,
Journal of Psychosocial Nursing and Mental Health Services, 54(1), 38-45.
and try to be as objective as possible
when communicating with patients 1. Antisocial personality disorder and borderline personality disorder (BPD) are
(i.e., focusing on the facts rather than the most commonly seen (as well as the most difficult to treat) personality
feelings about patients). It is impor- disorders on inpatient psychiatric units.
tant to remember the nature of the
2. Dialectical behavior therapy works well for treating patients with BPD,
disorder and that the patients ways of especially those with suicidal ideation.
interacting with society may be what
led to hospitalization. 3. Therapeutic communication techniques, such as empathy and positive
Nurses who work in forensic set- attitude (coupled with firm adherence to unit rules), may (a) help inpatients
tings may struggle to control their own with personality disorders control behavior and (b) maintain safety on the
unit.
feelings. Remaining nonjudgmental
when managing patients such as pedo- 4. Negative countertransference is unavoidable when working with difficult
philes, murderers, and sex offenders, or patients. Nurses must be fully aware of negative feelings to avoid
those with personality disorders, may unconsciously acting them out.
be difficult. Nurses must be aware of
an unspoken type of violence in the Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to the Journal at jpn@healio.com.
health care setting, in which knowl-
edge of patients histories makes them
feel psychologically violated. Nega- ness, pacing, and excessive movement; More recently, CBT has been spe-
tive countertransference (e.g., fear, physical or verbal self-abuse; verbally cialized for the forensic population. It
revulsion, disgust) may cause nurses to demeaning or hostile behavior; unco- is often offense-focused and examines
withdraw from patients and focus more operative or demanding behavior; and the topics of criminal attitudes, sub-
on their own safety rather than thera- impulsivity and impatience (Hankin et stance abuse, and impulsivity, which
peutic engagement (Jacob & Holmes, al., 2011). are empirically supported correlates
2011). Tools for assessing violence risk of criminal risk (Polaschek & Daly,
include the empirically supported 2013). These cognitive-behavioral
MANAGING DIFFICULT BEHAVIORS PCL-R (Hare, 2003) and Forensic Early group therapies are traditionally per-
Managing Aggression and Violence Signs of Aggression Inventory (Fluttert formed by trained psychologists. Nurses
To prevent aggressive or vio- et al., 2011). Recognizing that attacks able to attend these groups may benefit
lent behavior, it is helpful to know a often occur among patients of the same in working with difficult patients.
patients history, use a statistically vali- gender, and outlining specific expecta-
dated measure to assess the risk of vio- tions for behavior and consequences Managing Splitting and Other
lence, and address agitation as soon as for those violations, may help maintain Manipulative Behavior
it is recognized. calm on units. It is also worth noting Patients using manipulative behavior
To reduce episodes of aggression, that harmony among staff was more treat others like objects. Manipulation
one must be familiar with its precur- useful in preventing violence than is goal-oriented (i.e., designed to get
sors. Violence typically results when other tactics commonly used, such as the patient what he/she wants, without
patients are generally agitated, experi- having more male nurses (Cornaggia, regard for the needs or feelings of
ence restrictions (e.g., unit rules), or Beghi, Pavone, & Barale, 2011). others). Manipulators form interper-
provoked by others. Patients who are When patients become agitated, sonal relationships to control or take
continually violent show more signs nurses must use de-escalation tech- advantage of others (Stuart, 2013). In
of agitation that those who are not niques, such as directing them to an an inpatient setting, manipulation may
continually violent. In their article environment with less stimulation (e.g., be used to avoid taking responsibility
on agitation in the inpatient psychi- a quiet or patient room) and ensuring for behavior, obtain special favors, or
atric setting, Hankin, Bronstone, patient and staff safety. If nonpharma- avoid unpleasant tasks, among others.
and Koran (2011) discuss the behav- cological de-escalation techniques do Sometimes manipulative behavior
ioral antecedents of aggression and not sufficiently calm patients, the pro- is not recognized until one or more
violence. Some of the more salient tocol for pharmacological intervention of these outcomes occur. As previ-
behaviors include explosive or unpre- should then be used as a last resort to ously stated, manipulation is common
dictable anger; intimidation; restless- ensure safety. and often used by patients who feel

Journal of Psychosocial Nursing Vol. 54, No. 1, 2016 43


national Journal of Offender Therapy &
powerless. Nurses who are knowledge- 2003). These patients often have BPD Comparative Criminology, 58, 765-779.
able may predict patient manipulation along with other psychiatric diagnoses. doi:10.1177/0306624X13485930
and use therapeutic communication Nursing interventions include estab- Adshead, G., & McGauley, G. (2010). Caring
combined with objective rule enforce- lishing a system to manage parasuicide for individuals with personality disorder in
secure settings. In A. Bartlett & G. McGauley
ment to manage this behavior. with components recommended by
(Eds.), Forensic mental health: Concepts, sys-
A good way to avoid engaging in Roth and Press (2003): tems and practice. Oxford, UK: Oxford Uni-
a power struggle with manipulative Access to sharp items is restricted. versity Press.
patients is to refuse to take the bait. Patients must inform staff when Aguirre, B. (2012). Borderline personality disorder
When patients cannot have what they the urge to self-harm is strong. in adolescents. Retrieved from http://www.
Patients are taught healthy ways psychiatrictimes.com/articles/borderline-
want, they may criticize nurses, calling
personality-disorder-adolescents#sthash.
them incompetent or insensitive. A of coping with intense emotions. z76x1zRK.dpuf
nurse may simply respond, Maybe I A quiet room with cameras may American Psychiatric Association. (2013). Diag-
am, without any other comment. In be used to monitor patients who feel nostic and statistical manual of mental disorders
this way, the nurse is agreeing with the urge to self-harm. (5th ed.). Arlington, VA: Author.
If self-harm occurs, patients Bateman, A. (2012). Treating borderline
the patient and it is hard to argue with
personality disorder in clinical practice.
an agreeing individual. Of course, the cannot be left alone. American Journal of Psychiatry, 169, 560-563.
nurse must continue to enforce unit After self-harm, patients must doi:10.1176/appi.ajp.2012.12030341
rules and behavioral expectations, but agree not to self-harm in the future. Bateman, A., Gunderson, J., & Mulder, R.
this strategy helps avoid an escalating If a patient continues to self-harm (2015). Personality disorder 3: Treatment of
personality disorder. Lancet, 385, 735-743.
power struggle. It does not matter what while in the quiet room, restraints are
doi:10.1016/S0140-6736(14)61394-5
patients may say or think at the time necessary. Black, D., Gunter, T., Loveless, P., Allen, J., &
because their critical statements are After an incident of self-harm, Sieleni, B. (2010). Antisocial personality dis-
designed only to serve their own imme- patients must list the events leading to order in incarcerated offenders: Psychiatric
diate interests. the feelings of self-harm. comorbidity and quality of life. Annals of
Clinical Psychiatry, 22, 113-120.
Although nurses may understand
Bloom, J., Woodward, E., Susmaras, T., &
the dynamics of splitting and other CONCLUSION Pantalone, D. (2012). Use of dialectical
manipulations, the behavior may still Behaviors exhibited by psychiatric behavior therapy in inpatient treatment of
cause disruption on the unit. Manipu- inpatients with BPD and ASPD may borderline personality disorder: A system-
lation and splitting are managed by be complex and challenging to address. atic review.Psychiatric Services, 63, 881-888.
doi:10.1176/appi.ps.201100311.
having clear unit rules as well as good Currently, no treatment exists for per-
Byrne, S., Cherniack, M., & Petry, N. (2013).
communication among staff members. sonality disorders, but there are treat- Antisocial personality disorder is associ-
It is helpful to review rules frequently ments for symptoms (e.g., aggression, ated with receipt of physical disability ben-
with patients, perhaps in a daily goals impulsivity, manipulation, parasuicidal efits in substance abuse treatment patients.
group, and give them the opportunity behavior). DBT has been effective Drug and Alcohol Dependence, 132, 373-377.
doi:10.1016/j.drugalcdep.2013.01.004
to comment and discuss unit issues in treating these difficult symptoms,
Cornaggia, C., Beghi, M., Pavone, F., & Barale,
with nurses. It is helpful to review especially in patients with BPD who F. (2011). Aggression in psychiatry wards: A
expectations about behavior in a group are self-injurious. Using the relation- systematic review. Psychiatry Research, 189,
setting so everyone hears the same ship formed with patients, as well 10-20. doi:10.1016/j.psychres.2010.12.024
information. Staff and patients must as good communication skills (e.g., Davidson, K., Tyrer, P., Tata, P., Cooke, D.,
Gumley, A., Ford, I.,Crawford, M.J. (2009).
be clear about policies and procedures empathy, limit-setting, cooperation
Cognitive behaviour therapy for violent men
on the unit so patients who are persis- with peers), nurses may aid patients with antisocial personality disorder in the
tent or well-liked will not be allowed rehabilitation and maintain a peaceful community: An exploratory randomized con-
to manipulate successfully. Asking and therapeutic milieu. Nurses must trolled trial.Psychological Medicine, 39, 569-
patients to wait for a decision about a also be aware of countertransference to 577. doi:10.1017/S0033291708004066
Delaney, K. (2009). Reducing reactive
request until a nurse has had time to avoid being manipulated, getting into
aggression by lowering coping demands and
talk with other staff members is also a power struggle, or withdrawing from boosting regulation: Five key staff behav-
a useful intervention. These practices patients. Skilled psychiatric nursing iors. Journal of Child & Adolescent Psychiatric
may help eliminate the effect of patient care can make a difference in the lives Nursing, 22, 211-219. doi:10.1111/j.1744-
deception. of patients with personality disorders. 6171.2009.00201.x
Evans, M. (2011). Pinned against the ropes:
Understanding anti-social personality-
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A., & Howells, K. (2011). Personality National Collaborating Centre for Mental MS, PMHNP-BC, LCPC, Teaching Associate and
traits as predictors of inpatient aggres- Health. (2010). Antisocial personality disorder: Psychiatric Nurse Practitioner, University of Illinois
sion in a high-security forensic psychiatric Prevention and management. Retrieved from at Chicago, 845 S. Damen Avenue, Room 1036,
setting: Prospective evaluation of the http://www.nice.org.uk/CG77 Chicago, IL 60612; e-mail: lplatt2@uic.edu.
PCL-R and IPDE dimension ratings. Polaschek, D., & Daly, T. (2013) Treatment Received: July 29, 2015
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and Comparative Criminology, 55, 392-415. Aggression and Violent Behavior, 18, 592-603. doi:10.3928/02793695-20151216-03

Journal of Psychosocial Nursing Vol. 54, No. 1, 2016 45


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