Tag Archives: Nursing

My Experience with Professional Support for Autism #Write31Days

Yesterday’s post in #Write31Days was somewhat inspired by the day 3 question on the 30 Days of Autism Acceptance. The day 4 question asks about family and support. I may have to split this topic into several posts, as it is about both family and professional support. Today, I will talk about professional support.

I have been in the care system for years. As a child, I was in special education. As a teen, I didn’t get much in the way of professional support, but I sought it back out right after high school by going to a rehabilitation center for the blind. I was still undiagnosed at this point and I don’t think the staff had an idea that I could be autistic.

When I moved to an independence training home after the rehabilitaton program, the staff got to know me better and got the idea that I may “suffer from” autism. That was how the coordinator called it when she wrote my request for services for once I’d be living independently. I hated that word, “suffer”, but I’ll get to that at some later point.

Initially, the reason my staff wanted me to be assessed for autism was to confirm they were on the right track with their support approach. Obviously they weren’t, as they kept switching approaches and expecting little from me one day, then deciding all my challenging behaivor was attention-seeking and leaving me pretty much to my own rsources the next.

I was diagnosed with autism in March of 2007 and started meeting with a community psychiatric nurse (CPN) in training in April. Her supervisor was a bit of a weirdo, barely having read my records and making his own assumptions about what was going on with me. He was the first to mention impulse control disorder, which I got to be diagnosed with along with autism a year later.

The CPN-in-training herself was great. She gave me lots of coping tools, even though I didn’t fully understand the necessity at first. Unfortunately, as I was moving cities to go to univeristy, I had to stop seeing her three months later.

After being hospitalized, my interactions with nurses and treatment providers were quite varied. I had favorite and not-so-favorite nurses on each unit I stayed on. Particularly, my named nurse on the resocialization unit was great. So was the head nurse at that unit, who acted as a step-in named nurse to me too.

What I found the most helpful in a nurse, was if they took the time to really look at my needs rather than at protocols. That was clearly what I missed most at the last unit I stayed on. “Borderlines need to take responsibility,” a nurse – who later became one of my favoirte nurses at that unit – told me when I requested reminders to do my personal care tasks. I know that it wasn’t just that most staff didn’t believe I’m autistic, since they treated another patient with a more established autism diagnosis in a similarly dismissive way.

Now that I’m home, I think most of my staff do a good job of balancing protocols, which of course they have to adhere to, with meeting my needs. For example, my current CPN just reassured me this afternoon that she validates my need to be in a sensory group at day activities. She didn’t even say it’s not in line with my intelligence level.

My home support and day activities staff are great. My husband says it’s a regional thing. It isn’t, because the other day activity place I checked out and the mental health agency’s home support team, both of which are in the same city where I get my day activites, weren’t as accommodating at all.


N – #AtoZChallenge on Mental Health

Welcome to the #AtoZChallenge on mental health, day 14. Today’s letter is N. Another late post, because I slept through the day yesterday so wasn’t able to schedule it. Here goes.


Neuropsychiatry is the branch of psychiatry specializing in the effects recognized brain diseases have on people’s mental health and behavior. Of course, mental illnesses have a biological component too, but neuropsychiatry is particularly interested in conditions like epilepsy, Parkinson’s Disease and brain injury. Some psychiatric institutions have specialized neuropsychiatric units or outpatient clinics. Mine has both. The inpatient unit is mostly for people with brain injury. In my institution, a neurologist is in charge of directing the care on this unit.


Neurotransmitters are chemicals that the brain cells use to communicate. They commonly have multiple functions, hence the side effects of psychiatric medications affecting neurotransmission. Well-known neurotransmitters are serotonin and dopamine.

Serotonin is thought to play an important role in mood. A deficiency in it can cause mood disorders, such as depression or bipolar disorder. Unfortunately, an excess of serotonin caused by antidepressant use can cause serotonin syndrome, which is a potentially life-threatening condition. Serotonin syndrome is particularly associated with a type of old-school antidepressants called MAOIs.

Dopamine plays a role in different physical and mental functions. Dopamine is necessary for movement. Parkinson’s Disease is caused by a degeneration in the dopamine-producing cells in the brain. On the other hand, an excess of dopamine is linked to psychotic symptoms. First-generation antipsychotics (such as Haldol) block the brain receptors for dopamine. Like I said however, dopamine is necessary in movement. Hence, peoople on first-generation antipsychotics commonly experience tremors and muscle stiffness similar to Parkinson’s patients. This movement disorder associated with antipsychotic use is called Parkinsonism.


Many people with mental illness smoke. Among people with schizophrenia, as many as 90% do. It is well-known among smokers that cigarette-smoking relieves stress. This coul be psychological dependence though. However, research shows that nicotine actually helps decrease psychotic symptoms specifically. It is not just a matter of psychological dependence on nicotine that causes people with schizophrenia to experience fewer symptoms after smoking. As such, schizophrenics might unknowingly use nicotine as self-medication.


Obviously, mental hospitals employ nurses as support staff. Their primary tasks are to observe and facilitate the patients’ day-to-day functioning. Obviously, administering medications is a common task. However, nurses also use psychosocial interventions.

Community psychiatric nurses (CPNs) are employed by outpatient clinics to help support patients in the community. They often do some form of psychosocial counseling and are also often employed as case managers. As such, they do some tasks formerly done by social workers.

A Typical Day #Write31Days

31 Days of Mental Health

Welcome to day 27 in the #Write31Days challenge on mental health. Today, I will describe what a typical day is like living with my mental illness and as a psychiatric inpatient.

Usually, I am awoken by the staff at around 8:30 AM. They give me my mornign medication. My morning meds consist of my antipsychotic, a capsule of Prisolec for my reflux, and vitamin D. I get dressed and go to the living room for breakfast. The nurses usually prepare my breakfast, because I cannot put topping on my bread or mix yoghurt and muesli without making a big mess. I usually drink a cup of coffee and then go to my room to check my E-mail. In the institution, we have WiFi only in the front room, but I have subscrption Internet access in my room.

I generally go to day activities at around 9:30. Some people in my institution have fixed times when they have to go to their workshops, but I do day activities on the ward across from mine. You can dorp in there whenever you want (provided you don’t have to go to work elsewhere). I often stay for about an hour.

Morning coffee break is at 10:00 AM. At around 10:30, the domestic service worker usually delivers fruit, bread and other foods to the living room. On my side of the unit, the cupboards for getting food are not locked during the day, so you can get bread whenever you want. On the other side and on most other units, the cupboards are locked. There are pros and cons to each. A pro to keeping the cupboards open is it allows patients more freedom to eat when they feel hungry. A drawback is many patients make a mess out of the kitchen when they get their food. Another reason cupboards are locked, according to the nurses, is precisely to prevent us from eating whenever we want. I honestly believe this is a stupid rule: you shouldn’t have meal times enforced in the outside world either.

Lunchtime is at noon. Usually again, a staff member prepars my food. We used to have hot lunches, but the microwaved meal got moved to the evening. I remember at the blindness rheabilitation center, the patient councilwould have to be consulted on such decisions, but patients were not involved in this decision here.

I usually sleep for about an hour after lunch. At 1:45 PM, the early evening shift comes on. There are three nurses on the morning shift and two on the evening shift. When the early evening shift comes on, there may be time for me to be taken on a walk. I am trying to unlearn my habit of going to the town store everytime we go for a walk, but I’m so far not too successful.

I may go to day activities in the afternoon again. Day activities close at 4:00 PM. I will then go on the computer for a bit before making coffee for my fellow patients at 4:30. I get help making coffee, but do most things myself.

At 5:30, we have dinner. We used to be able to choose between about four microwaved meals that were served individually. Probably because of budget cuts, the unit moved to meals delivered in bulk. I cannot say anything good about the bulky meals. The biggest reason I hate them is that I’m a picky eater and all choice is gone. This evening, I forced myself to taste some mashed potatoes, but I could hardly keep them down.

In the evening, I usually go on the computer until around 7:30. We then get coffee again and watch the news. That is, when the unit’s soap opera binge watcher hasn’t switched the channel to some cheap series. She usually does. We have two TVs, one in the living room and one in the front room, but at 8:00PM, except when the head nurse works, they’re both tuned in to the Netherlands’ top soap opera. When the head nurse works, she insists on watching the eight o’clock news.

I usually have a chat with the evening nurse at around 7:45. This is so that, if I’m stressed during the day, I can vent off my issues before it escalates usually early at night.

Evening medication time is at 9:00 PM. We often get coke then too. At my former unit, we only got coke on week-ends, but here we get it pretty much everyday. On some days, we get chips or other snacks. Most people eagerly await their evening medicine even if there aren’t any snacks. My evening medication is only my antidepressant. I should be switching birth control, which I take with dinner, to 9:00 PM, so that I have the two pills at the same time.

I go to bed at anywhere between 9:30 PM and midnight. Today, I was on the phone with my sister for hours and had yet to complete this post, so it’ll probably be past midnight that I’ll be in bed. The staff sometimes have to remind me to shower before bedtime, but usally now I can think of it myself.

My (Somewhat Hypocritical) Opinion on Force in Mental Health and Developmental Disability Services #Write31Days

31 Days of Mental Health

Welcoem to day 25 in the 31 Days of Mental Health. Today, I’m inspired by yet another question from the 30-day mental illness awareness challenge. For day 25, the question is about your opinion on force or coercion in mental health.

I used to be a strong opponent of any form of coercion in mental health. I remember once in late 2007, when I was still on the acute unit, a fellow patient being medicated against their will. I saw this as a particularly nasty violation of the patient’s human rights, worse than for example seclusion. Now I know that for some people, if they have to choose between seclusion and rapid tranquilization, their choice is not always seclusion.

I used to believe, in my naivety that there is always an alterantive to force in mental health. I still believe there is in most cases. For example, studies of involuntary outpatient treatment don’t compare the programs to the same level of care but without the component of force. If they did, maybe it’d be shown that there is no advantage of forced treatment, and it is just the intensity of care that makes the difference. In this light, I remember one particularly poignant interaction I had with a nurse on the acute unit. She said that I’d be secluded if I needed more care than they could provide. Indeed, involuntary outpatient treatment is generally seen as a way of averting hospitalization. Now I’m not a big fan of psychiatric hospitalization, but I cannot help but believe involuntary outpatient treatment is just a convenient (for the providers and the government) way of saving money. So are most forms of force in mental institutions, as my interaction with the nurse illustrates.

Of course, a few people cannot be kept safe even with constant one-on-one attention, assuming the government would allow this. A notable example is the case of Brandon, a young man who had been restrained in his institution for people with developmental disabilities for years when the newspaper got word of it in like 2010. I was infuriated at such inhumane treatment as restraining a person for years, but my husband and many other people I spoke to countered that there simply was no alternative. Medications hadn’t helped (and besides, that’d be another form of force) and Brandon was so aggressive that he’d attack anyone coming close.

That being said, still, in many cases, force in mental health and developmental disability care is used as an alternative to proper care. I remember one example that I read about at the time Brandon’s case was in the news. A proponent of electroshocks as aversive therapy for people with severe self-injurious behaviors presented the case of a person who was hitting his eyes so vigorously that he was at risk of becoming blind. He described the situation of the nurses conferring at the nurse’s station while the man was blinding himself in the next room, adding something like: “And what quality of life does a person with an intellectual disability who is also blind have?”

I cannot begin to tell you all the things that are wrong in this situation. Nurses sit at the nurse’s station conferring (or drinking coffee) way too much rather than taking care of their patients. We do not know whether one-on-one attention would’ve prevented this man from blinding himself, because there was none. INstead, his treatment team chose to set him up with a shock machine. In addition, I totally understand a sighted, intellectually capable person’s judgment that an intellectually disabled person who is blind has no quality of life. However, the proponent of shock therapy hardly considered the effect whatever causes this person to self-injure has on his quality of life, possibly multiplied by the effects of electroshocks. We do not know whether the person in question had a painful medical condition. I assume the cause of his self-injurious behavior was unknown or could not be taken away, but I’ve heard parents and professionals advocating for aversives or restraints when the cause of problem behavior is known and can be removed.

I do use some double standards though. Being in a mental institution myself, and especially having seen some of the more severely mentally ill people, I have lost some of my naivety regarding forced treatment. Perhaps less self-righteously, when soemone bothers me, I’m happy to have them secluded, restrained or medicated. There are some people on my unit who are very regularly verbally aggressive or simply very annoying when psychotic. In those cases, though I would like to say I oppose force, I’ve actually been relieved when the nurses gave these people some PRN medication, often with only some sembleance of consent. I would like to believe that the guys who constantly talk to their voices are actually helped by a low-potency neuroleptic, but at least I do not know whether these people are bothered by their voices and if so, whether the PRN medication actually quiets their voices. I should care, but when it’s past 10PM and I want to sleep, quite frankly I don’t.

Terrible Things Mental Health Professionals Say

Heather Clark over at Raising Rebel Souls listed some horrible things “autism professionals” say. This made me think. Professionals can be terribly ignorant about autism. I have only dealt with a few people who claimed to be autism specialists, but I have to agree even they can made insensitive or ignorant comments. Those who don’t know much about autism but claim to know enough to diagnose and support autistics, are actually the worst.

Having an additional diagnosis of borderline personality disorder doesn’t make it any easier. I met a person with BPD when I was admitted to the locked acute ward in the big city in 2007. She was forcibly discharged then readmited or threatened with forced discharge many times because, according to her treatment team, borderlines develop institutionalization behaviors if they’re admitted long-term. Quite truthfully, I am the only person diagnosed with BPD on my unit and I don’t know anyone who hasn’t developed institutionalization behaviors, most worse than mine.

It’s quite common for mental health professionals to clash with “difficult” patients on the right approach to care, and I for one am a “difficult” patient. I don’t care. I may not always make decisions or exhibit behavior that is seen as “normal”, but that doesn’t mean that professionals can look into my head and determine why I do the things I do and what consequence will truly help me. We’ve left the days of pure behaviorism and most people would consider it dehumanizing if it were applied to them. Psychiatric patients are no exception. Here, I will list a few things that professionals say about or to me that are quite frankly terrible.

1. “You have a personality disorder so you need to take responsibility for yourself.” Everyone needs to take responsibility for themself insofar as they can. That’s nothing to do with one’s diagnosis. I am told that people with schizophrenia need to be treated more directively. For instance, if I had had this diagnosis, I would’ve been asked to come back and possibly gotten my privileges taken away if I ran off the ward. Now, I’m “allowed” to wander for hours. I don’t see how my behavior is any less dangerous now that I have a diagnosis of BPD than if I had been diagnosed with schizophrenia.

2. “You are an adult (with BPD), you should be able to remember to take care of your personal hygiene.” Well, the fact that I’m an adult says nothing about my memory – which is often better in children than adults. Forgetting to take care of one’s personal hygiene may not be common in BPD, but it freaking well is common in autism. Besides, whether it is comon in people with my diagnosis, doesn’t change my abilities. My profile of abilities and difficulties should lead to a diagnosis, not vice versa.

3. “You can hold down a conversation, so you aren’t autistic.” They never realize how one-sided the conversations are, because that’s normal for a professional-client conversation. Besides, not being able to hold a conversation is but one criterion of autistic disorder and isn’t even in the criteria for Asperger’s.

4. “You are so verbally capable.” I am, sometimes. Then again, when I am not, this is seen as deliberate manipulation and I’m left without help to “think on it”.

5. “Do you want some PRN medication?” Then when I answer “Okay”, they say: “So you did know what you wanted.” No, I didn’t, or if I did, I couldn’t communicate it. Saying “Okay” to a suggestion is a lot easier than coming up with said suggestion myself.

6. “You have theory of mind. After all, you apologize when you did something wrong.” Correction: I apologize when I think I did something wrong. I apologize way more often than is truly needed and quite often don’t apologize when I don’t realize I did something wrong. That is then seen as deliberate rudeness.

These are generally comments made to me, taking into account my diagnoses. I won’t say that people with schizophrenia or bipolar disorder don’t get nasty comments thrown their way. I just can’t speak for them.

There are also comments that makke it sound as though the staff are generally uncaring. For example, one nurse often says: “Nurses are too expensive to do cleaning.” True, we need to be encouraged to clean up after dinner or coffee, but it has nothing to do with nurses’ salary.

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Comfort Rooms: Not a Convenient Alternative to Seclusion

A few days ago, the owner of a blindness and mental health E-mail group I am on started a discussion about comfort rooms. Commonly, they’re seen as a kind of less restrictive alternative to seclusion or restraint, but this is a misconception. I have personally experienced being placed in the comfort room and not allowed to come out. Being blind, I also didn’t really notice the comfort room atmosphere, which should be relaxing. In all honesty, the comfort room at the locked ward in the big city institution I was in, was little more than a beautified seclusion room. While the comfort room at my current ward in the small town institution is more calming in its ambiance, I still sometimes get told that I can go into the comfort room in a tone of voice as if I’m being secluded.

In reality, comfort rooms are but one form of relaxation for an irritable patient. For others, going for a walk, listening to music or exercising on a stationary bike might help. I can see why nurses choose the comfort room over some of its alternatives, for a patient in a comfort room requires relatively little care. That is, they are presumed to require relativley little care. All five or so times I spent in comfort rooms, once in my current institution and about four times in the city one, I was left alone whether I wanted to be alone or could safely be alone or not. In this sense, the Netherlands is different from other countries, where patients in crisis are placed under special observation. Here, if you need more care than the staff can provide, you’ll be placed in seclusion or “seclusion light”, ie. the comfort room.

A key aspect of introducing comfort rooms, is that they need to be embedded in a philosophy where the patient is actively engaged in their treatment. Time in the comfort room needs to be a choice. I for one find the comfort room particularly ineffective, and would rather go for a walk or exercise. One reason why I find the comfort room ineffective, besides having been coerced into using it, is accessibility. I didn’t have a clue what was in the comfort room, so was essentially just seated on a couch or chair. Granted, the couch in my current ward’s comfort room is actually comfortable, but the chairs in the city institution comfort room were definitely not. I recommend staff acquaint patients, especially blind ones, with the comfort room at time they’re not irritable and maybe they’ll need to assist the patient sometimes again when they’re using the comfort room for relaxation for the first few times. Staff may not like this, as many view the comfort room as a convenient way not to have to bother with irritable patients while looking like saints for avoiding seclusion. However, seclusion is not a substitute for proper care, and neither is the comfort room.

“You Got Enough Attention Already.”

Last Sunday, I asked a nurse if I could speak with her. She said I could, but not then. A while later, she went on a walk with some other clients and I went along. Then was coffee break and I, some other clients and the nurse were chatting. All evening, the nurse was busy with other duties, so even though I periodically asked whether she had time for a talk, she never did. Then at 9:00 PM, I burst out into anger over her not being clear whether or when she could talk to me. This was when she said that we’d gone on a walk and had coffee together. “You got enough attention.”

Now let’s get the facts straight. There were other clients being attended to too whilst we were going for a walk and having coffee. Not a problem with me, but I can’t see how I was supposed to talk over my relatively private issue with the nurse at that point. I know that in legal terms, care is defined in minutes of attention, not needs being met. Then again, suppose I didn’t go for the walk or attend coffee break. Then the nurse would still have taken the other clients on a walk and had cofee with them. Would she have been any less busy then, had any more time to have a talk with me? Most likely not. Would I have been any more entitled to time with her to talk over my issue? I don’t think so, but her commetn about me having gotten enough attention, suggests I would.</P

Now let me get this real clear: I wasn’t freaking asking for attention per se, I was asking for a talk about a specific subject. If all I needed in my mental health care was enough attention, why would we hire expensive nurses, social workers and psychologists for it? Couldn’t a high school student meet the same needs? The thing is, in reality sometimes all people need is attention, and this is all understandable given that most mental health inpatients are rather isolated. That’s why I advocate volunteers or inexpensive workers being hired by mental health agencies to provide activities or a simple chat about the weather with the patients. That walk and coffee break didn’t require nursing supervision. Then again, that talk I wanted to have surely did.

I didn’t touch here on the connotations of the attention-seeking presumption, which are that mental health patients, and especially those with a certain diagnosis, like BPD, have an excessive craving for attention. Well, I for one don’t. I probably spend less time interacting with people than most currently mentally healhty individuals. I may sometimes draw attention to me in a negative way, but that still doesnt’mean I do it for attention. Let me just say I hate that attention paradigm that keeps floating around in mentnal health and especially personality disorder care.

"Use Your Words."

Last Friday, Neurodivergetn K wrote a post on the phrase “Use your words.”. I only read it today and, partly because I got triggered by this post, I am going to blow off some steam about this phrase. A lot may seem like a repetition of what Neurodivergent already said, but well, there can’t be too many autistics speaking up against NTs putting their own arbitrary standards of normalcy ahead of our needs.

As readers who’re familiar with me and my blog will know, I reside in a psychiatric institution. Its aim is rehabilitation. I’ve been on a ward that had an even more open rehabilitation-focused vision at least on paper, but staff there were much more willing to bend the rehab paradigm a bit to accommodate me than the staff on this ward are. Note that rehabilitation has two meanings in psychiatry, one in which the client is as much in charge of their care as possible, and the other where the client is trained to become (or appear) as normal as possible. I’m talking about the second meaning here, as I have absolutely no problem with the first.

“Use your words.” As I wrote in a comment on Neurodivegent’s post, this phrase is often accompanied by “You’re intelligent” or “I know you can do it” or some variation on this theme. Let me address these follow-up phrases too.

“You’re intellignet.” And now what? Firstly intelligence is not the same as speaking ability. Second, what if I weren’t intelligent? Would I be cut some slack then, or would my needs just not matter as much? A variation on this theme which I’ve come to hate almost as much is “You’re an adult”. It has its own implications in light of my multiplicity, discounting part of me that actually isn’t an adult. If I act like a child, maybe it’s because at that particular point I am a child? I know the staff aren’t going to buy into that since they’ve thrown out my DID diagnosis, but it’s not like I’m any less or more multiple now that we call it BPD.

On a related note, telling me that my abilities are incongruent, isn’t going to help me. I know they are. I know I’m sometimes able to do things that I can’t do at other times. I know I’m able to do seemingly complex tasks but not simple ones sometimes. I know I can have quite spontaneous-looking, appropriate conversations sometimes and barely make any sense of my words at other times. Telling me this is not possible is denying the obvious. Telling me this is not appropriate is like telling a blind person to look harder because they can hear fine or telling a person who is night blind that they should be able to see in the dark because they could see fine during the day. (I know many night blind people are also partially sighted, but I’m simplifying the situatioon a bit.) It’s not like developmetal disabilities like autism are any less real than visual impairment just because they’re more difficult to understand and seemingly easier to overcome through behavior modification.

Let me talk about that now: behavior modification. I was going to write a separate post on that, and maybe I will write one more. Here’s the thing: telling me to “use my words” will most likely get me to pull out a script. You didn’t know I had them, clueless neurotypical who knows me just enough to see my non-autistic appearance but not well enough to truly listen? I may have somewhat more elaborate scritpts than the example Neurodivergent gave, but I do have them. This is why, when I’m interrupted or distracted while executing the script for telling the staff I’m distressed and need help, I often end up having a meltdown. And this script gets interrupted a lot of the time, oftentimes even by staff. They want exact explanations of what I want or need from them, even if they know pretty well what I need. I’ve sometimes gotten to ask for my PRN when that’s not what I needed just because it was the shortest script in that part of my brain I could access. Asking for some quiet time with a staff member, which is what mostly helps me, is a much harder script to execute. Please know: “Can I say something/ I’m distressed,” is not okay. It’s got to be: “Can I please speak to you in a quiet place for a bit when you’ve got the time? I’m distressed.” Sometimes I think it’s NTs who are literal-minded.

Research Recommendations for Improving Treatment for People with Personality Disorders

Two studies in nursing journals that I read recently examine good practice for personality disorder treatment. Bowen (2013) specifically studied ideas for intervention with borderline personality disorder patients, whereas Fanaian, Lewis & Grenyer (2013) studied more general ideas for implementing personality disorder services. Bowen also emphasized direct intervention strategies, whereas Fanaian et al.’s study more focused on organizational structure. Bowen (2013) interviewed nine mental health professionals, four of whom were nurses, working at a specialist unit for patients with BPD. Key apsects of good practice mentioned by interviewees were:

  • Shared decison making: for example, service users and staff should meet in community meetings to discuss and think through decisions that a service user might otherwise make impulsively. This thinking thorugh also counters black-and-white thinking.
  • Rules should be actively recreated, rather than being strictly enforced or being abandoned. This is an offshoot from the shared decision making in the above bullet.
  • Patients should have social roles, such as jobs on the unit nd group therapy with a pratical focus. This is a way of bringing into the open and then challenging interpersonal difficulties that are so typical of BPD.
  • Social disturubances must not just be prevented, but also be used as an opportunity for learning.
  • Peer support, including feedback on behaviors, but also including compassion. One interviewee also commented that peer support can enhance the patients’ looking inward for the resources to help themselves, rather than viewing the staff as sole bearers of wisdom.
  • Open communication. For example, this unit had a structure whereby three service users were elected to discuss issues happening on the unit with the staff as a means of liaison.
  • Involvement with the person as a whole, seeing them as more than their BPD symptoms.
Bowen (2013) does highlight that not all of these aspects of good practice can be generalized. After all, this unit was a specialist unit for treating BPD and had its structure built so that these aspects of good practice could be met. For example, there were daily meetings, group therapy, and patients had jobs on the ward.

It was found that mental health workers on this unit had a pretty optimistic outlook on recovery from BPD. This is in contrast to research which shows that mental nurses have negative attitudes about BPD patients. Fanaian et al. (2013) emphasize this negative attitude towards people with personaltiy disorders as a major barrier to appropriate care.

Fanaian et al. (2013) had about 60 experienced clinicians in personality disorder treatment, including psychiatrists, psychologists, social workers, a nurse and a counselor sit in groups of four and brainstorm on topics relevant to personality disorder treamment. They overwhelmingly found that current practice in mainstream mental health settings is both poor and inaccurate. Ways to improve practice included:

  • More education and training on the subject. Some groups also recommended that workers in non-psychiatric settings who have frequent contact with personality disorered people, such as social services staff, be trained in personality disorders. Carers, such as family and friends, also were said to need education and training.
  • More support through supervision and leadership. For example, there should be more supportive and regular treatment team meetings. Clinicians also mentioned better access to Internet resources on treatmetn and assessment for mainstream mental health staff. There also should be greater support for staff approaching burn-out, as it was felt that staff working with personality disordered people have a high risk of burn-out and work-related stress.
  • A shift from risk management to recovery-focused treatment and case management. Acute hospitalization should be avoided when possible. Rather, patients with personality disordeers need intensive, multidiscipinary case management.
  • Clearer guidelines and protocols. Many groups of clinicians emphasized a consistent approach across teams, particularly when managing crises.
  • An attitude shift to decrease stigma. Some groups emphasized the fact that many health professionals have a negative attitude about personalityy disorder patietns, and this is a barrier to effective treatment.
Fanaian et al.’s (2013) study, like all studies, has its limitations. The clinicians participating in the study were invited to a personality disorders meeting based on expertise and experience. Therefore, it is not known whether these findings generalize well into mainstream mental health provision.


Bowen M (2013), Borderline Personality Disorder: Clinicians’ Accounts of Good Practice. Journal of Psychiatric and Mental Health nursing, 20(6):491-498. DOI: 10.1111/j.1365-2850.2012.01943.x

Fanaian M, Lewis KL, & Grenyer BFS (2013), Improving Services for People with Personality Disorders: Views of Experienced Clinicians. International Journal of Mental Health Nursing, 22(5):465-471. DOI: 10.1111/inm.12009.