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Lea C. Watson, MD MPH Geriatric Psychiatry Consultation and Training
Boundaries = Compassion Caring for People Living with Personality Disorders Lea C. Watson, MD MPH Geriatric Psychiatry Consultation and Training
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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
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Will you be there for me?
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boundaries
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BOLD
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RAIN
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Impairments in Personality Function (how a person experiences themselves and others)
Borderline Narcissistic Antisocial
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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
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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
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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
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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!
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Caregivers must be BOLD
B E the calm O NE quarterback L IMIT-setting D ependable
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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
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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
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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
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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!
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Shift focus from external to internal
As long as you keep the focus on an external fix they will keep pushing, 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
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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 re-traumatized Safety, trustworthiness, transparency are key
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Skills to offer patients
Help them identify self-destructive behaviors and distract themselves when feeling overwhelmed by emotions Hold ice cube in one hand and 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
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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
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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!
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push pull repeat
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Physical manifestation of psychological symptom
attention referral “nothing more to do” symptom
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Be BOLD Physical manifestation of psychological symptom symptom
attention increased distress tolerance Self-soothing increased sense of security symptom Be BOLD
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Be BOLD Physical manifestation of psychological symptom attention
increased distress tolerance Self-soothing increased sense of security Symptom Be BOLD
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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
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boundaries = compassion
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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.
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