Denise, a 19-year-old woman, has been admitted informally to an acute mental health ward; this is Denise's first admission. Denise was being treated for depression by her GP; prior to her admission Denise attempted to kill herself by cutting her wrists. Subsequently a short admission was arranged with the aim of devising a comprehensive care package.
After speaking about the circumstances leading up to her suicide attempt Denise became increasingly tearful and distressed, and started demanding to see a doctor. After being told that the doctor was on their way and would arrive in about 10 minutes, Denise became angry demanding medication to calm her down; she then proceeded to run towards the ward's doors shouting that she wanted to go home. At that moment the doctor arrived on the ward and Denise also immediately calmed down.
During the assessment process Denise disclosed that being angry if she did not get her way was not unusual for her. She also mentioned that she felt awful after these bouts of anger. She described herself as a "terrible person who was out of control" and she just wanted to die. After assessing Denise the nurse started to formulate a plan of care.
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(a) What type of psychological interventions would the nurse consider implementing?
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Correct answer: The delivery of psychological interventions would depend on the skills of the mental health nurse though generally they should be able to deliver the following types of psychological interventions:
- Build a collaborative and therapeutic relationship based on a person-centred approach.
- Normalise an individual's experiences of mental distress.
- Take a "strengths approach".
- Maintain safety and effectively manage challenging behaviours.
- Explore the individual's capacity to change.
- Modify thought processes – identify, challenge and replace negative thoughts.
- Focus on the individual controlling and regulating their behaviour – promoting and enhancing healthy ways of coping.
- Prevent social isolation and promote social functioning.
- Focus on relapse prevention – early warning signs and self-monitoring of symptoms.
- Signpost to self-help and relevant support groups.
- Therapeutically support recovery.
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(b) Currently Denise has been admitted informally to the ward. Due to Denise's impulse control difficulties this may change. On this basis what does the nurse professionally need to know when managing Denise's legal status?
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Correct answer: The nurse would need to:
- Understand and apply current legislation in a way that protects Denise.
- Act in accordance with the law, relevant ethical and regulatory frameworks, and also take into account local protocols/policies.
- Respect and uphold Denise's rights
- Know when to actively share personal information with others when the interests of safety and protection override the need for confidentiality.
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(c) Denise is subsequently diagnosed with a "borderline personality disorder". What other types of personality disorders are there?
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Correct answer:
The three main clusters and types are:
- Cluster A – paranoid, schizoid and schizotypal.
- Cluster B – antisocial (type: dissocial), borderline (type: emotionally unstable), histrionic, and narcissistic (not included in types).
- Cluster C – avoidant (type: anxious), dependent, obsessive-compulsive (type: anankastic).
The following is a list of some of the personality traits that an individual diagnosed with a specific personality disorder may exhibit:
- paranoid – suspicious and excessively sensitive;
- schizoid – emotional coldness, little interest in other people;
- schizotypal – odd beliefs and unusual appearance;
- borderline – instability of mood, impulsive;
- histrionic – excessive attention seeking;
- narcissistic – grandiose and arrogant;
- antisocial – disregard of self and others;
- avoidant – feelings of inadequacy;
- dependent – submissive behaviour;
- 0bsessive-compulsive – a preoccupation with orderliness.
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(d) What specific psychological interventions would the nurse deliver?
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Correct answer: The types of psychological interventions the nurse may deliver include:
- boundary setting;
- promoting healthy ways of coping;
- motivational interviewing and pre-therapy work;
- delivering specific therapeutic approaches/therapies.
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(e) How could the nurse learn from their experiences of working with Denise?
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Correct answer: To aid practice learning the nurse would need to reflect in a structured way by:
- identifying and describing the experiences;
- examining the experiences in depth and teasing out the key issues;
- critically processing the issues;
- learning from the experiences by implementing future actions that improve the nurse's practice.
Consider Chapters 14, 20, 29 and 37.
Denise has now been on the ward for over 6 months. Each time discharge has been arranged Denise self-harms or threatens suicide. Denise has now agreed to go to a therapeutic community, a place has been secured and Denise is now engaging in pre-therapy work.
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(a) What other treatments besides a therapeutic community are recommended for individuals diagnosed with a borderline personality disorder?
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Correct answer:
- cognitive behaviour therapy – group and individual;
- behavioural approaches;
- mentalisation-based approaches;
- dialectic behaviour therapy.
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(b) While working with Denise the primary nurse has found the relationship at times to be quite stressful. What are the signs of stress?
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Correct answer: Stress manifests in different ways such as:
- sleep problems;
- loss of appetite;
- difficulty concentrating;
- constantly feeling anxious;
- feeling irritable and/or angry;
- having repeating thoughts;
- worrying;
- avoiding certain situations and/or people;
- an increased use of alcohol;
- headaches;
- muscle tension.
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(c) What strategies could the nurse use to manage their stress?
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Correct answer:
- engage in physical activity;
- engage in something that makes them laugh;
- learn relaxation and/or deep breathing techniques;
- take control of the situation;
- seek support and talk;
- problem solve;
- eat a healthily diet;
- drink plenty of water;
- be mindful.
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(d) What process should be utilised as a way to support the primary nurse to improve their practice?
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Correct answer: A common method of systematically reflecting on practice is through the clinical supervision, which is a formal activity where a clinical supervisor facilitates the nurse to reflect upon their practice and identify strategies that focus on improving their practice.
Consider Chapters 20, 34 and 37.
