Nursing Care of Inpatients With Borderline
ORIGINAL
Nursing Care
Blackwell
Malden,
Perspectives
PPC
XXX
0031-5990USA inARTICLES
ofPsychiatric
Inpatients
Publishing With Borderline Personality Disorder
Inc Care
Personality Disorder
Ann R. Bland, PhD, APRN, BC, Georgana Tudor, MSN, RN, and Deborah McNeil Whitehouse, DSN, APRN, BC
TOPIC. This paper reviews the current literature
on the nursing care of inpatients with borderline
personality disorder (BPD). Information is
included about the background and various
features of BPD, and recent conceptualizations
and predicted outcomes for BPD patients are
provided. The effect of caring for patients with
BPD on the nursing staff is discussed.
CONCLUSIONS.
and clinical supervision, the difficulties of caring
for patients with BPD for the nursing staff can be
reduced, and beneficial outcomes can be achieved
for the staff and patients.
NURSING IMPLICATIONS.
impact the entire multidisciplinary team.
Understanding the dynamics of patients with
BPD helps the staff to develop strategies to avoid
splitting, acting-out behaviors, and negative
impact on other patients and staff.
Search terms: Borderline personality disorder,
inpatient nursing care, nursing challenges and
responses, self-destructive behaviors
204
With proper education, support,
Patients with BPD can
Ann Bland, PhD, APRN, BC, is Associate Professor,
Department of Baccalaureate and Graduate Nursing,
Eastern Kentucky University; Georgana Tudor, MSN, RN,
is an alumna of Eastern Kentucky University, is a family
nurse practitioner; and Deborah McNeil Whitehouse,
DSN, APRN, BC, is Associate Dean, College of Health
Sciences, Eastern Kentucky University, Richmond, KY.
B orderline personality disorder (BPD) is a psychiatric
disorder with a pervasive pattern of instability in four
areas: affect regulation, impulse control, self-image,
and interpersonal relationships (American Psychiatric
Association [APA], 2000). Patients with BPD comprise
10% of psychiatric outpatients and 20% of psychiatric
inpatients (APA, 2000). They often require frequent
mental health services and are more difficult to treat
than individuals with other psychiatric disorders
(Cleary, Siegfried, & Walter, 2002; Lieb, Zanarini,
Schmahl, Linehan, & Bohus, 2004; Paris, 2005).
Patients with BPD represent a significant challenge
to mental health nursing staff who must balance a
therapeutic environment for recovery with limiting
impulsive, self-destructive behavior (Bland & Rossen,
2005). They are often overwhelmed by their emotions
and are frequently hospitalized during an acute crisis
(Comtois et al., 2003; Lieb et al.). Since frequent
hospitalizations are needed, the purposes of this
paper are to review the current literature related
to the inpatient nursing care of patients diagnosed
with BPD and propose solutions for the care of these
patients.
Origins of BPD
Personality disorder describes a set of personality
traits that lead to recurrent and ongoing subjective dis-
tress and impaired functioning. These deeply ingrained
traits represent enduring patterns of relationships,
thinking, behavior, and coping mechanisms. Of the
11 known personality disorders, BPD is the most
common, most complex, and one of the most severely
Perspectives in Psychiatric Care Vol. 43, No. 4, October, 2007
impairing (Gunderson & Berkowitz, 2003). The two
hallmark temperamental predispositions of BPD are
affective instability and impulse aggression. Patients
with BPD have severe instability of self-image, mood,
impulse, and relationships. They do not perceive
social cues accurately; they experience severe mood
swings; they are unable to control their emotions and
impulses; and they are unable to develop stable
relationships. Patients with BPD have the most diffi-
culty with negative emotions, and this accounts for
many of the behavioral problems they experience
(Bland, Williams, Scharer, & Manning, 2004). They are
extremely sensitive to environmental shifts, especially
in their interpersonal sphere. This highly sensitive
affective thermostat is present from a very early age
and may have both genetic and early environmental
origins (Gunderson & Berkowitz; Lieb et al., 2004;
Paris, 2005).
The BPD group scored higher for having
anger toward both mother and father and
showed evidence of unresolved trauma.
Genetic origins of BPD have not been studied
extensively. The few studies of twins and BPD (e.g.,
Torgersen et al., 2000) found a substantial level of
genetic effect in the development of BPD. BPD
patients are born with temperaments of aggression, a
genetic trait, and further research is being conducted
to isolate specific genes that may account for this
temperament (Gunderson & Berkowitz, 2003). Other
studies show that disorders of emotional regulation
(e.g., depression) and impulsivity (e.g., substance
abuse) are more common in relatives of BPD patients
than other populations. Diminished activation of the
brain’s serotonergic system has been demonstrated in
Perspectives in Psychiatric Care Vol. 43, No. 4, October, 2007
BPD patients. Neurological dysfunction (e.g., attention-
deficit/hyperactivity disorder and learning disabilities)
and brain wave irregularities similar to patients with
head trauma and epilepsy have also been identified
among these patients. All of these factors may
contribute to the behaviors found in BPD patients,
such as emotional dysregulation, impulse control,
and inaccurate perception of social cues (Gunderson &
Berkowitz).
Early environmental origins of BPD could be related
to a high incidence of parental loss, prolonged parental
separation, and feelings of neglect during childhood, all
contributing to the patients’ later fears of abandonment
(Barone, 2003). These fears may be based on actual
physical abandonment or a perception of emotional
abandonment, where the patients feel that they are
different, disconnected, or misunderstood by their
families (Gunderson & Berkowitz, 2003). Families of
BPD patients often invalidate the patients’ wants and
needs and will punish the patients for efforts made
to communicate their feelings and desires (Gunderson
& Berkowitz). An extreme form of invalidation is
sexual or physical child abuse. Childhood abuse is
reported by 40–71% of inpatients with BPD, and the
severity of sexual abuse suffered in childhood has
been linked to the severity of the borderline patho-
logy found in adulthood (Gunderson & Berkowitz; Lieb
et al., 2004).
According to Barone (2003), a specific type of parental
relationship can be identified in the family of the BPD
patient: an actively rejecting father and an unloving
and neglecting mother. In this study, patients in a BPD
group received less loving experiences from both their
mother and father and more rejecting and neglecting
experiences from both parents than the control group,
represented by college students and adults from the
same community. The BPD group scored higher for
having anger toward both mother and father and showed
evidence of unresolved trauma. They also scored sig-
nificantly higher on having a role-reversing experience
with their mothers during childhood (Barone). In
another study, Joyce et al. (2003) found that the
205
Nursing Care of Inpatients With Borderline Personality Disorder
combination of childhood abuse with parental neglect
is a more powerful risk factor for BPD than abuse
alone. They also found that the risk factors for develop-
ment of BPD are childhood abuse and neglect, a
borderline temperament, childhood and adolescent
psychopathology, alcohol and drug dependence,
hypomania, and depression.
Diagnostic Features of BPD
The Diagnostic and Statistical Manual of Mental Disorders
(4th ed., text revision, APA, 2000) lists the following
diagnostic criteria for BPD. A certain cluster of
symptoms indicates a personality disorder that gener-
ally presents by early adulthood and contains at least
five of nine criteria that represent four areas: affective,
cognitive, behavioral, and interpersonal (APA, 2000;
Lieb et al., 2004). Affective criteria include chronic feel-
ings of emptiness; affective instability due to a marked
reactivity of mood, such as intense episodic dysphoria,
irritability, or anxiety, which can last a few hours to a
few days; and inappropriate, intense anger or difficulty
controlling anger, which presents as frequent displays
of temper, constant anger, and recurrent physical
fights. Cognitive criteria include transient stress-related/
-induced paranoid ideation or severe dissociative symp-
toms, along with identity disturbance that presents as
striking, and persistent, unstable self-image or sense of
self. Behavioral criteria are forms of marked impulsivity
that include recurrent suicidal behavior, gestures, threats,
or self-mutilating behavior, along with impulsivity in
at least two areas that are potentially self-damaging
(e.g., reckless spending and driving, unsafe sex).
Suicidal behavior, which includes threats, gestures, and
ideation, are commonly seen in patients with BPD.
Self-mutilating behavior may present with or without
suicidal intent. Interpersonal criteria include frantic
efforts to avoid real or imagined abandonment, along
with a pattern of unstable and intense interpersonal
relationships that are characterized by alternating
between extremes of idealization and devaluation
(Hennessey & McReynolds, 2001; Lieb et al.).
206
Inpatient Treatment of BPD
Hospitalization for patients with BPD is usually
restricted to the management of crises, often related to
a self-destructive event, such as parasuicide or an
actual suicide attempt (Gunderson & Berkowitz, 2003).
Parasuicide, or false suicide, refers to all forms of
self-destructive behavior that do not result in death.
The danger with parasuicide is the potential of
accidental death without the actual intent to die
(Gerson & Stanley, 2003). High use of inpatient psychi-
atric services is related to a history of suicidal behavior
in the previous 2 years but not necessarily related to
the severity or number of suicide attempts. This high
use is related to the presence and severity of anxiety
disorders and poorer cognitive functioning and does
not correlate to depression, psychotic, or substance use
disorders (Comtois et al., 2003).
Patients with borderline personality disorder present
with an array of needs that must be recognized by the
mental health staff in order to adequately manage
their hospital stay. Safety is number one, and every
attempt needs to be made to assist the patient in feel-
ing safe on the unit and guiding the patient to behave
in a safe manner. The goal of hospitalization is to pro-
vide a safe environment that is removed from the life
stressor(s) that led to the self-destructive event. Within
the hospital environment, patients can withdraw from
the stressor(s) and gain control of their emotions and
a clearer perspective on the crisis (Bergman & Eckerdal,
2000). The inpatient treatment staff can assess the
patients’ psychological status and develop a comprehen-
sive plan of care. The current trend of short-term
inpatient treatment is not effective; therefore, outpatient
treatment of a minimum of 1 year, with biweekly
sessions, can be anticipated (Goin, 2001).
One of the greatest challenges for nurses is provid-
ing safe and effective care for hospitalized suicidal
patients with BPD. More than 70% of patients with
BPD have made suicide attempts as compared to 17%
of patients with other personality disorders (Zanarini,
Gunderson, Frankenburg, & Chauncey, 1990). The
Perspectives in Psychiatric Care Vol. 43, No. 4, October, 2007
potential for suicide attempts requires increased
observations and interventions to keep these patients
safe from their impulsive and reckless behavior.
According to experts, suicide contracts are not sufficient
to ensure patient safety (Workgroup on Borderline
Personality [American Psychiatric Association], 2002).
In addition, patients with BPD experience chronic
feelings of emptiness that can cause dependency issues
with the nurses, while simultaneously resisting devel-
oping a rapport with them because of the patients’
mood instability and previous negative experiences
with relationships. The patients’ intense emotions
vacillate between positive praise for the nurse and
abrupt negative ridicule, especially when they feel a
lack of support and understanding. The affective
instability experienced by these patients leads to
inappropriate, intense anger and frequent bouts of
temper that may lead to physical fights on the unit.
This affective instability presents a challenge to nurses
to provide a safe environment in which the patients
can express these mood swings without endangering
themselves or others (Paris, 2005).
The treatment staff helps the patients bridge
a connection between their self-destructive
actions and their feelings.
Due to the complexity of this disorder, nurses that
care for these patients must deal with the patients’
anger, dependency needs, attachment, and abandon-
ment issues (Hennessey & McReynolds, 2001). Move-
ment of patients from familiar home settings to an
institutional setting can activate safety and abandon-
ment issues within these patients. They can experience
disproportionate emotional responses, aggression,
and hostility that may oscillate with clingy and more
Perspectives in Psychiatric Care Vol. 43, No. 4, October, 2007
dependent behavior (Eastwick & Grant, 2005). Depression
and anxiety must be treated and suicide threats taken
seriously. Hospitalization is required for persistent
suicidal tendencies, serious drug/alcohol problems,
or life-threatening eating disorders (Workgroup on
Borderline Personality, 2002).
Treatment goals for inpatients with BPD are very
clear. First and foremost, a specific treatment plan for
inpatient management must be established, and all
personnel need to be aware of the perimeters and
adhere to the plan. The treatment staff must keep the
patients focused in reality and present all interactions
as occurring in the present, not in the past. The staff
needs to point out the patients’ self-destructive behav-
iors when they occur and identify to the patient the
results of these behaviors. The treatment staff helps
the patients bridge a connection between their self-
destructive actions and their feelings. Limits must be
set immediately on patients’ behaviors that threaten
others. Safety for the patient with BPD, for all the
other patients, and the staff needs to be established
before other treatment goals can be implemented.
Nursing Challenges With BPD
Verbal Abuse
The inpatient treatment staff, particularly nurses,
will receive verbal abuse from the patients with BPD
because of the inappropriate and intense anger that is
difficult for the patient to manage. Problems with
countertransference will quickly surface, and the nurses
must monitor their own reactions of frustration, irrita-
tion, and anger to avoid nonprofessional responses
(Hennessey & McReynolds, 2001). In addition to endur-
ing verbal abuse from patients with BPD, nurses face
many other challenges when trying to provide safe and
effective care for them. These patients have inter-
personal relationships characterized by affective instabil-
ity, impulsive aggression, intense feelings, and crises.
Their instability with interpersonal relationships and
lack of emotional control lead to relationships with
nurses that are filled with constant confrontation
207
Nursing Care of Inpatients With Borderline Personality Disorder
(Bland & Rossen, 2005; Eastwick & Grant, 2005).
Patients with BPD have difficulty with the intense
feeling of loneliness and may frantically try to avoid
real or imagined abandonment by hanging on to a
relationship, even after having alienated the other person.
This same clinging behavior can be demonstrated with
a nurse on the unit. As a result of this behavior, nurses
frequently struggle with balancing the needs and
demands of the BPD patient with the other patient
needs on the unit (Bland & Rossen). Nurses must also
cope with their personal reactions to the patients’
emotional mood swings. They must bear the brunt of
these emotional outbursts with equanimity and refrain
from responding emotionally themselves.
Alienation
Alienation of new nurses can occur when patients
with BPD react to staffing changes with anger and
physical confrontation due to their underlying fears of
abandonment. This unstable sense of self causes
patients with BPD to look outside themselves for
direction, rules, and guidance. They are very sensitive
to their environment and exhibit emotional instability.
This response puts an additional burden on nurses to
provide a sense of security with a calm environment
and firm limits. The impulsivity of the patient with
BPD may further complicate the treatment plan,
especially if the patient is recovering from substance
abuse or an eating disorder (Eastwick & Grant, 2005;
Hennessey & McReynolds, 2001; Workgroup on
Borderline Personality, 2002).
Manipulation and Splitting
Another challenge for nurses working with patients
with BPD is the manipulation and splitting of staff.
These patients view the world and people in terms of
absolutes. This view leads to the nurses being cate-
gorized into two groups: weak or strong, good or bad,
independent or dependent. Only a few nurses are
considered good. The good nurses are idealized, and
the bad nurses are ridiculed and berated. The good
and bad nurses can even shift categories as the patient
208
with BPD may idealize them at first and later devalue
them. This primitive defense mechanism of categoriz-
ing nurses into one group or the other is called split-
ting, and it reflects the polarization of the patients’
feelings into good/bad and love/hate. Each group of
nurses, good or bad, has to work with the label they
have been given until this issue is resolved via clinical
supervision and treatment team meetings (Bland &
Rossen, 2005; Goin, 2001). Education workshops and
team conferences are essential to assist the staff in
managing the splitting behavior and developing strat-
egies to offset this dynamic. Precipitous discharge of
these patients may occur when the conflicts, splitting,
and polarization of staff is still unresolved, leading to
impaired treatment team relationships and ineffective
patient treatment in the future (Bland & Rossen).
Anxiety in Patients
The patients’ response to stress or anxiety can be
another challenge for nurses. This reaction can lead to
the development of paranoia, paranoid ideas, or dis-
sociative symptoms (such as seeing themselves or the
world as unreal). The patients with BPD may become
psychotic and experience hallucinations or delusions.
The nurses must be alert to patients with BPD who are
experiencing transient, paranoid ideation in times of
stress and respond to the patients’ needs therapeutic-
ally (Paris, 2005; Workgroup on Borderline Personality,
2002). Psychotropic medications may need to be
administered and their effects monitored carefully
during hospitalization (APA, 2004; Jongsma, Peterson,
& Bruce, 2006).
Nursing Responses to BPD
Anger
Nurses often label patients with BPD as difficult
patients. Several types of behavior by these patients
reinforce the belief that they are difficult patients with
which to work. These behaviors are manipulation (of
nurses and others), self-mutilation, violence, patient
complaints, and noncompliance (APA, 2004; Nehls,
Perspectives in Psychiatric Care Vol. 43, No. 4, October, 2007
2000). Upon encountering these behaviors, the nurses’
beliefs that these patients are difficult can influence
their responses to these patients (Markham & Trower,
2003). Nurses feel frustration and anger when they
are perplexed by their patients’ destructive behavior
and emotional outbursts. Since patients with BPD
are hypersensitive to their environment, the nurses’
responses can seem extreme and intense to these
patients. Negative nursing responses can disrupt patient
care and ultimately be detrimental to both the patient
and the staff (Fallon, 2003; Markham, 2003).
Social Stigma
Social stigma has long been associated with mental
illness. There may be no psychiatric diagnosis more
laden with stigma and stereotypes than BPD (Nehls,
2000). Markham (2003) explored whether the nursing
staff’s responses were influenced by social stigma and
found that the nursing staff expressed higher levels
of social rejection toward patients with a diagnosis of
BPD than toward patients with a diagnosis of schizo-
phrenia or depression. Due to the potential for violent
behavior, patients with BPD were considered more
dangerous than patients with schizophrenia or
depression. This belief and perhaps previous experi-
ences of potential danger were associated with the
staff’s desire to maintain social distance from patients
with BPD (Markham).
Negative Judgments
Patients with a label of BPD attract more negative
responses from nurses than patients with other psychi-
atric disorders (Markham, 2003; Markham & Trower,
2003). Patients with BPD often present with a normal
appearance/affect, leading staff to believe these patients
have control over their behavior. When the patients
act out from their emotional instability, they may be
labeled as attention seeking or just acting out, leading
the nursing staff to react with more anger and less
empathy. When this happens, nurses consistently report
more negative personal experiences while working with
patients with BPD than patients with other disorders
Perspectives in Psychiatric Care Vol. 43, No. 4, October, 2007
(Markham & Trower). Nurses are less optimistic about
the possibility of positive treatment outcomes for
patients with BPD. They require clinical support to
avoid accepting undue responsibility for successful
treatment outcomes for these patients. Inevitable
treatment failures for patients with BPD may lead to
professional burnout of nurses (Markham & Trower).
Brief inpatient admissions with well-planned follow-
up support need to be the model of care, using a case
manager as the central and consistent point of reference.
This shift would allow these patients an option of using
acute inpatient facilities and provide them with more
control of their own care (Eastwick & Grant, 2005; Nehls,
2000). Clinical supervision by an advanced practice
psychiatric nurse could provide the nurses with much-
needed knowledge and emotional support while also
providing oversight and direction for the quality of care
given to the patients with BPD (Bland & Rossen, 2005).
Outpatient Follow-Up
Although only short-term crisis intervention can
be implemented for the inpatient, other therapies are
suggested for outpatient follow-up. Psychotherapy and
dialectical behavior therapy (APA, 2004; Workgroup
on Borderline Personality, 2002) are recommended as
primary treatment modalities to assist with the care of
patients with BPD and in understanding their behavior.
A meta-analysis of research studies indicated that
both forms of therapy were effective treatments for
personality disorders (Leichsenring & Leibing, 2003).
Traditional Psychotherapy
Psychotherapy with a trained psychiatric/mental
health professional needs to be a necessary component
of treatment (Goin, 2001). The structure of the thera-
peutic relationship needs to be clearly outlined with
rules and procedures at the beginning of therapy and
strictly followed throughout the therapeutic process.
Understanding the dynamics of BPD is critical to
working with these patients. Knowing that the patient
209
Nursing Care of Inpatients With Borderline Personality Disorder
has severe abandonment issues dictates the therapist
proceeding carefully with transference issues. The
therapist needs to be expecting the patient to idealize
and then devalue the therapy and therapist, often
with inappropriate and intense anger. Treatment of
comorbid conditions such as anxiety, depression,
substance abuse, or eating disorders must also be
addressed (Workgroup on Borderline Personality, 2002).
Evaluation of the need for medication for depression
and anxiety can be a specific avenue into making a
behavioral difference with a patient with BPD.
Knowing that the patient has severe
abandonment issues dictates the therapist
proceeding carefully with transference
issues.
Psychodynamic therapy uses exploration inter-
pretation to make the unconscious become conscious
by linking a feeling, thought, symptom, or action to
an unconscious meaning. The purpose of exploration
interpretation is to free the patient from unconscious
drives and motives that may interfere with his or
her ability to satisfy present needs (Workgroup on
Borderline Personality, 2002). This psychotherapy can
help the patient identify stressors, learn to control
feelings and impulses without losing control, and gain
new perspectives on dealing with identified problems
(Gunderson & Berkowitz, 2003). Psychotherapy, along
with psychiatric management, involves coordination
of the various aspects of care, helping with practical
problems, anticipating and responding to crises,
setting limits on the patient’s behavior, explaining the
disorder and its treatment to the patient and family,
and prescribing medications when necessary.
210
Dialectical Behavior Therapy
Dialectical behavior therapy (DBT) is a cognitive-
behavioral therapy that focuses on affective instability
and impulse control by teaching patients how to regu-
late their emotions (Linehan, 1993). DBT is a biosocial
theory that draws upon various approaches, such as
motivational interviewing, problem-solving, behavioral
therapy, cognitive therapy, and psychoeducational
skills-based strategies. Problem behaviors, suicidal
ideation, and behaviors that interfere with therapy
are addressed by the therapist in DBT. The treatment
focus is on distorted thinking and behavior, due in
part to poor regulation of emotion. For example, since
feelings follow thoughts, when cognitive distortions
are corrected, emotional responses are different,
and subsequent behavior is less impulsive and more
appropriate. It is helpful to ask the patient, “What
were you thinking (or saying to yourself) prior to that
behavior?” to elicit the cognitive distortions that need
to be examined and corrected. When the patient can
make an understandable connection between their
initial thought (often a cognitive distortion), the
emotional response to the thought, and the subsequent
behavior, self-understanding starts to take place. This
application of DBT on a continuous basis helps the
patient to gain control of their unregulated emotions
and impulsive behavior.
The therapist also works on developing the patient’s
ability to be comfortable with stress, change in their
environment, and learning positive ways to adapt. DBT
has been shown to be effective in bringing suicidal
behavior under control within a year; however, long-
term control of suicide with DBT is unknown at this
time (Paris, 2005; Swales, Heard, & Williams, 2000;
Talkes & Tennant, 2004).
Nursing Implications
Most inpatient treatment nurses lack sufficient
knowledge and skills to use appropriate cognitive-
behavioral therapy approaches when working with
Perspectives in Psychiatric Care Vol. 43, No. 4, October, 2007
hospitalized patients with BPD. Many nurses feel ill
equipped to care for these patients. These deficits are
due to a lack of appropriate training, clinical supervision,
and professional development (Bergman & Eckerdal,
2000; Bland & Rossen, 2005; Cleary et al., 2002). Clinical
supervision, additional training, and support can help
nurses feel better equipped to work with these patients
and alleviate their negative responses toward them
(Bergman & Eckerdal; Cleary et al.; Cutcliffe & Burns,
1998; Markham, 2003). Ongoing clinical supervision
can be provided by an advanced practice registered
nurse, such as a clinical nurse specialist or psychiatric
nurse practitioner (Bland & Rossen).
Nurses need to understand both the origins and
the functions of the patients’ problems (Gallop &
Reynolds, 2004). Gender stereotypes and stigmas
associated with the label of BPD must be discarded,
and a shift must occur in the way these patients are
viewed (Fallon, 2003; Nehls, 2000). The language used
to describe these patients with BPD needs to be
changed to emphasize the positive strengths and
possibilities instead of the negative, such as difficulty
and hopelessness (Eastwick & Grant, 2005). The patients’
behaviors are complex and arise from many causes
(biological, psychodynamic, and sociocultural) that all
work together to create the behaviors. The more staff
nurses understand the complexity of BPD, the easier it
will become to respond therapeutically and consist-
ently without anger, frustration, and fear.
Advanced practice psychiatric nurses who view
these patients in a holistic manner can frame research
and practice in a way that can positively affect their
patients’ lives (Fallon, 2003; Gallop & Reynolds, 2004;
Nehls, 2000). With proper training and support, nurses
can be educated about realistic expectations of treat-
ment outcomes to counter later pessimism that may
arise. Addressing these issues can modify negative
nursing responses and help alleviate negative working
experiences with patients with BPD (Bland & Rossen,
2005; Markham & Trower, 2003). Nurses who hold
positive attitudes about patients, have a sense of moral
commitment, are skilled interpersonally, and are able
Perspectives in Psychiatric Care Vol. 43, No. 4, October, 2007
to stay in a rational state of mind in the midst of
conflict can apply knowledge about the personality
disorder and work skillfully with these patients (Talkes
& Tennant, 2004). It is a tall order, and excellent train-
ing and supervision are critical to developing these
qualities and skills.
Conclusion
The value of hospitalization for the patient with
BPD cannot be underestimated (Fallon, 2003). Two
primary approaches for treating patients with BPD are
hospitalization for short-term supportive crisis care
and outpatient psychotherapy and dialectical behavior
therapy. Inpatient admissions are suggested to be brief
with well-planned follow-up support. Patients with
BPD credit these brief admissions with saving their
lives and for helping them to break a cycle of addic-
tion to the hospital (Nehls, 2000). The need for small
units with competent staff and flexibility according to
the needs of the patient with BPD was voiced by
nurses from one study (Bergman & Eckerdal, 2000).
This desire included various possibilities for acute
treatment, emergency hours, home-based networks, day
centers, and leisure activities (Bergman & Eckerdal).
A model of care can focus on a case manager who is
the central and consistent point of reference for patients
with BPD as they move from inpatient to outpatient
status (Eastwick & Grant, 2005). Patients with BPD
represent a significant challenge to nurses, but with
proper treatment programs, clinical supervision,
and the support of nursing staff, a new era in BPD
treatment can begin.
Acknowledgment. This review was partially funded
by the Ruth P. Council Grant Award from the Gamma
Zeta Chapter of Sigma Theta Tau International Inc. at
the University of North Carolina Greensboro School of
Nursing.
Author contact: ann.bland@eku.edu with a copy to the
Editor: mary@artwindows.com
211
Nursing Care of Inpatients With Borderline Personality Disorder
References
American Psychiatric Association. (2000). Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Washington, DC:
Author.
American Psychiatric Association. (2004). Practice guidelines for the
treatment of psychiatric disorders: Compendium 2004. Arlington, VA:
Author.
Barone, L. (2003). Developmental protective and risk factors in
borderline personality disorder: A study using the adult attach-
ment interview. Attachment and Human Development, 5(1), 64–77.
Bergman, B., & Eckerdal, A. (2000). Professional skills and frame of
work organization in managing borderline personality disorder.
Scandinavian Journal of Caring Sciences, 14, 245 – 252.
Bland, A. R., & Rossen, E. (2005). Clinical supervision of nurses
working with patients with borderline personality disorder.
Issues in Mental Health Nursing, 26(5), 507– 517.
Bland, A. R., Williams, C. A., Scharer, K., & Manning, S. (2004).
Emotion processing in borderline personality disorders. Issues in
Mental Health Nursing, 25(7), 655 – 672.
Cleary, M., Siegfried, N., & Walter, G. (2002). Experience, knowledge
and attitudes of mental health staff regarding clients with a
borderline personality disorder. International Journal of Mental
Health Nursing, 11, 186 –191.
Comtois, K. A., Russo, J., Snowden, M., Srebnik, D., Ries, R., &
Roy-Byrne, P. (2003). Factors associated with high use of public
mental health services by persons with borderline personality
disorder. Psychiatric Services, 54, 1149 –1154.
Cutcliffe, J. R., & Burns, J. (1998). Mental health. Personal, profes-
sional and practice development: Clinical supervision. British
Journal of Nursing, 7(21), 1318 –1322.
Eastwick, Z., & Grant, A. (2005). The treatment of people with
“borderline personality disorder”: A cause for concern? Mental
Health Practice, 8(7), 38 – 40.
Fallon, P. (2003). Traveling through the system: The lived experience
of people with borderline personality disorder in contact with
psychiatric services. Journal of Psychiatric and Mental Health
Nursing, 10, 393–400.
Gallop, R., & Reynolds, W. (2004). Putting it all together: Dealing
with complexity in the understanding of the human condition.
Journal of Psychiatric and Mental Health Nursing, 11(3), 357–364.
Gerson, J., & Stanley, B. (2003). Suicidal self-injurious behavior in
people with BPD. Psychiatric Times, 20(13), 59– 60.
Goin, M. K. (2001). Borderline personality disorder: The importance
of establishing a treatment framework. Psychiatric Services, 52(2),
167–169.
Gunderson, J. G., & Berkowitz, C. (2003). A BPD brief: An introduction
to borderline personality disorder—diagnosis, origins, course, and
212
treatment. New York: National Education Alliance for Borderline
Personality Disorders.
Hennessey, M., & McReynolds, C. J. (2001). Borderline personality
disorder: Psychosocial considerations and rehabilitation implica-
tions. Work: A Journal of Prevention, Assessment, and Rehabilitation,
17(2), 97–103.
Jongsma, A. E. Jr., Peterson, M., & Bruce, T. J. (Eds.). (2006). The
complete adult psychotherapy treatment planner (4th ed.). Hoboken,
NJ: John Wiley & Sons.
Joyce, P. R., McKenzie, J. M., Luty, S. E., Mulder, R. T., Carter, J. D.,
Sullivan, P. F., et al. (2003). Temperament, childhood environment
and psychopathology as risk factors for avoidant and borderline
personality disorders. Australian and New Zealand Journal of
Psychiatry, 37, 756–764.
Leichsenring, F., & Leibing, E. (2003). The effectiveness of psycho-
dynamic therapy and cognitive behavior therapy in the treatment
of personality disorders: A meta-analysis. American Journal of
Psychiatry, 160, 1223–1232.
Lieb, K., Zanarini, M. C., Schmahl, C., Linehan, M. M., & Bohus, M.
(2004). Borderline personality disorder. Lancet, 364, 453 – 461.
Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline
personality disorder. New York: Guilford Press.
Markham, D. (2003). Attitudes towards patients with a diagnosis of
“borderline personality disorder”: Social rejection and dangerous-
ness. Journal of Mental Health, 12(6), 595–612.
Markham, D., & Trower, P. (2003). The effects of the psychiatric
label “borderline personality disorder” on nursing staff’s percep-
tions and causal attributions for challenging behaviours. British
Journal of Clinical Psychology, 42(3), 243–256.
Nehls, N. (2000). Recovering: A process of empowerment. Advanced
Nursing Science, 22(4), 62–70.
Paris, J. (2005). Borderline personality disorder. Canadian Medical
Association Journal, 172(12), 1579–1583.
Swales, M., Heard, H. L., & Williams, J. M. (2000). Linehan’s dia-
lectical behavior therapy (DBT) for borderline personality disorder:
Overview and adaptation. Journal of Mental Health, 9, 7– 23.
Talkes, K., & Tennant, A. (2004). The therapy seesaw: Achieving
therapeutically balanced approaches to working with emotional
distress. British Journal of Forensic Practice, 6(3), 3–12.
Torgersen, S., Lygren, S., Oien, P. A., Skre, I., Onstad, S., Edvardsen, J.,
et al. (2000). A twin study of personality disorders. Comprehensive
Psychiatry, 41, 416–425.
Workgroup on Borderline Personality (American Psychiatric Associa-
tion). (2002). Borderline personality: New recommendations.
Harvard Mental Health Letter, 18(9), 4–6.
Zanarini, M. C., Gunderson, J. G., Frankenburg, F. R., & Chauncey, D. L.
(1990). Discriminating borderline personality disorder from other
Axis II disorders. American Journal of Psychiatry, 147, 161–166.
Perspectives in Psychiatric Care Vol. 43, No. 4, October, 2007