1. 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

3. 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

4. Will you be there for me?

5. boundaries

6. BOLD

7. RAIN

8. Impairments in Personality Function (how a person experiences themselves and others)
Borderline
Narcissistic
Antisocial

9. 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

10. 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

11. 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

12. 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!

15. Caregivers must be BOLD
B E the calm
O NE quarterback
L IMIT-setting
D ependable

16. 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

17. 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

18. 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

19. 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!

20. 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

21. 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

22. 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

23. 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

24. 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!

26. push
pull
repeat

27. Physical manifestation of psychological symptom
attention
referral
“nothing more to do”
symptom

28. Be BOLD Physical manifestation of psychological symptom symptom
attention
increased distress tolerance
Self-soothing
increased sense of security
symptom
Be BOLD

29. Be BOLD Physical manifestation of psychological symptom attention
increased distress tolerance
Self-soothing
increased sense of security
Symptom
Be BOLD

30. 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

31. boundaries = compassion

32. 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.