Staff Nurse Perceptions of the Impact of Mentalization-Based Treatment (MBT) Skills Training on Clinical Practice when working with Borderline Personality Disorder (BPD) in Acute Mental Health Admission Wards: A Qualitative Analysis.

DSM-5 diagnostic criteria for borderline personality disorder (APA, 2013)

A pervasive pattern of instability of interpersonal relationships, self-image and affects, and marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated by five (or more) of the following:

 

1 – Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5

2 – A pattern of unstable and intense interpersonal relationships characterized by alternating between extremes of idealization and devaluation

3 – Identity disturbance: marked and persistently unstable self-image or sense of self

4 – Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex, substance abuse, reckless driving, binge eating). Note: Do not include suicidal or self-mutilating behaviour covered in Criterion 5

5 – Recurrent suicidal behaviour, gestures or threats or self-mutilating behaviour

6 – Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria, irritability or anxiety usually lasting a few hours and only rarely more than a few days)

7 – Chronic feelings of emptiness

8 – Inappropriate intense anger or difficulty controlling anger, (e.g., frequent displays of temper, constant anger, recurrent physical fights)

9 – Transient, stress related paranoid ideation or severe dissociative symptoms.

Note: DSM-5 diagnoses as ‘borderline personality disorder‘ ICD-10 diagnoses as ‘emotionally unstable personality disorder‘. MBT developed using DSM criteria.

Borderline Personality Disorder (BPD)

4 Wards within a Unit 28 Beds per Ward Mixed Sex Patients aged 18 – 65 Also 14 – 18 year olds in one ward Staff on Shift Patterns An accident and emergency for mental

health A melting pot of diagnoses and disorders

Acute Mental Health

Evidence-based and developed Specifically for BPD

Mentalizing is how we implicitly and explicitly interpret the actions of oneself and others

Empathy as a foundation The Not Knowing Stance Provide Alternative Perspectives Restrained Imagination - Aims to encourage

patients and staff to see themselves from the outside, others from the inside

Common sense view of the mind Cost-effective

Mentalization-Based Treatment (MBT)

BPD accounts for estimated 20% of psychiatric inpatients

Associations with frequent and lengthy admissions

BPD carries a diagnostic baggage and a negative staff perception

No studies on staff perceptions of MBT MBT studies limited to specialised settings MBT Skills Training is a new and compact

two day workshop

Why do this study?

Ethical and R&D approval Purposive sampling of staff nurses, across 4

acute mental health wards, who had completed MBT Skills Training

50% participation – 9 from 18 2 x Focus Groups with a neutral facilitator Semi-structured topic guide Thematic analysis – 3 cycles of coding

Methodology

Staff Perceptions on BPD Inpatient Care Impact on Staff Impact of MBT Skills Training Clinical Supervision Changed Perceptions of BPD

5 Key Themes

Inpatient Environment BPD Behaviour on a Ward BPD Effect on the Ward Admission Pattern Ability to Work Effectively with BPD

Staff Perceptions on BPD Inpatient Care

Personal Distress Uncomfortable Emotions Negative Perceptions

Impact on Staff

Empathy Use of MBT Changes in Staff Benefits of MBT MBT Limits

Impact of MBT Skills Training

Attendance Benefits of Group CS One to One Clinical Supervision Informal Clinical supervision

Clinical Supervision

Yes! An understanding of reasons behind

behaviour Awareness of the impact of feelings of

abandonment More empathy towards people with BPD

Changed Perceptions of BPD

BPD is extremely challenging for staff nurses in acute mental health

Staff experience significant personal distress

MBT gives staff a ‘secret weapon’ Clinical Supervision provides support,

reassurance and ‘ammunition’ Staff had a better understanding of BPD and

more empathy as a result

Summary

All staff nurses attend MBT Skills Training MBT is offered as part of the pre-registration

nursing programme Group Clinical Supervision is offered weekly

and within protected time Further research into MBT skills training and

inpatient care of BPD

Recommendations

“Tolerate intense anger, aggression and hate” (ICP)

Any Questions?

daniel.warrender@nhs.net

Thank You!