Calm in the Storm Working with people with Borderline Personality Disorder. Persons First. What is a Personality Disorder? 4/19/15

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1 Calm in the Storm Working with people with Borderline Personality Disorder Linda Hedenblad, MSE, CRC, MINT member VR Development Group Persons First What is a Personality Disorder? Our personality is who we are: how we think about ourselves, about others, and about the world influences the way we act no matter where or when. Mondimore, Francis Mark; Kelly, Patrick ( ). Borderline Personality Disorder: New Reasons for Hope (A Johns Hopkins Press Health Book) A personality disorder is said to exist when some personality trait, or more often, a particular group of personality traits, is so extreme and so outside the range of normal that a person has problems functioning in nearly all areas of life because of it. 1

2 Understanding BPD Borderline Personality Disorder is a persistent pattern of unstable mood, intense and unstable relationships and identity confusion. Five of the Following: Unstable and intense relationships Impulsive acts with a high risk of harm, such as spending, sex, reckless driving, substance use, shoplifting, or binge eating Rapid shifts from a normal mood to depression, irritability or anxiety Inappropriate, intense anger or lack of control of anger Suicide threats, thoughts, or behavior, or self-mutilation Persistent identity confusion, including self-image, sexual orientation, long-term goals or career choice, choice of friends, or values Chronic feelings of emptiness Frantic efforts to avoid real or imagined abandonment Brief, stress-related paranoia or loss of touch with reality Causes The cause is unknown at this time, but several theories are being looked at. There is some evidence that inheritance and other biological or biochemical factors may be involved in some people. Psychological factors are also involved for most patients. For example, having had childhood trauma (physical, sexual, or emotional abuse or neglect, or prolonged separation) is far more common in people with this disorder than in the general population. 2

3 Just the Facts Occurs in 1% to 2% of population Onset between 18 and 25 years of age 70% women, 30% men Affects all income groups Found worldwide 20% of inpatient psychiatric hospitalizations and 11% of outpatient Patients tend to have high numbers of emergency room visits Psychiatry: Borderline Personality Disorder/Impulse Control Disorders (Audio-Digest Foundation Psychiatry Continuing Medical Education (CME) Love Me Love Me Not Persons who have borderline personality disorder have a desperate need for nurturing that seems insatiable and can be so consuming and smothering to those around them that they end up losing exactly what they crave most: caring relationships. Mondimore, Francis Mark; Kelly, Patrick ( ). Borderline Personality Disorder: New Reasons for Hope Pervasive Emotion Dysregulation Emotion dysregulation is the inability, despite one s best efforts, to change or regulate emotional cues, experiences, actions, verbal responses, and/ or nonverbal expressions under normative conditions. Pervasive emotion dysregulation is when this inability to regulate emotions occurs across a wide range of emotions, problems, and situational contexts. (Linehan, Bohus, & Lynch, 2007) 3

4 Emotional Skin Borderline individuals are the psychological equivalent of thirddegree burn patients. They simply have, so to speak, no emotional skin. Even the slightest touch or movement can create immense suffering. Marsha Linehan, Ph. D., Time Magazine, 2009 Self-Harm I think it is safe to say that folks with borderline disorder are usually not skillful in their interpersonal communication styles. The problem is that they often can only express their emotional pain by screaming out how much they want to be dead, which is likely true. Self-harm, alas, regulates emotions for many. Marsha Linehan So Many Emotions The most striking of these is the multitude of bad feelings these individuals are constantly struggling with: depression, anxiety, helplessness, feelings of inferiority and of being an outcast. The authors of the study concluded that DSM- IV may understate the pain that borderline personality disorder patients feel. Mondimore, Francis Mark; Kelly, Patrick ( ). Borderline Personality Disorder: New Reasons for Hope (A Johns Hopkins Press Health Book) (Kindle Locations ). 4

5 Regulating Emotions Such difficulties with dysregulation lead to maladaptive behaviors (e.g., suicidal behavior, purging, abusing substances), because these behaviors function to regulate emotions or are a consequence of failed emotion regulation. Koerner, Kelly ( ). Self-harm Inability to damp down emotions also means that people with a borderline diagnosis can be carried away on their emotional waves into potentially selfdestructive behaviors. Psychiatry $60-$180 BILLION DOLLARS PER YEAR 5

6 Treatment 97% receive outpatient care 95% in individual therapy Other treatments include family/couples therapy, day treatment, and halfway houses Psychiatry: Borderline Personality Disorder/Impulse Control Disorders (Audio-Digest Foundation Psychiatry ) 56% in group therapy 72% have had ³1 psychiatric hospitalization Employment is Possible Accommodations may be needed. Potential Employment Challenges Difficulty relating appropriately with coworkers and supervisors. Inappropriate response to work/social situations. Difficulty concentrating on work activities Absenteeism or tardiness from work Need for increased time and attention to learn work skills Difficulty staying on task Limited stamina to perform work duties 6

7 Building a Support System Family and or other support system Medical doctor familiar with BPD Mental health professionals and/or psychiatrist Chemical dependency specialist if needed Job developers educated in BPD Emergency plans Clear lines of communication Understanding by everyone, especially client, on boundaries of these relationships Consultation available to all professionals at all levels Which Way Is Up? Susan cannot figure out what she wants to do, she has started several careers including teaching, script writing, retail, and medical technology, but nothing seems to be able to keep her interest. Susan keeps finding herself adding training classes and entry-level jobs to her resume. However, due to her identity issues, it is 10 years later and she is no closer to knowing what she wants to do for a living, nor has she finished any degree or certificate program. Attendance: Accommodations Allow flexible work environment: Flexible scheduling Modified break schedule Leave for counseling Work from home/flexi-place 7

8 Concentration Reduce distractions in the work area: Provide space enclosures, sound absorption panels, or a private office Allow for use of white noise or environmental sound machines Allow the employee to play soothing music using an earbud and computer or music player Plan for uninterrupted work time Purchase organizers to reduce clutter Increase natural lighting or provide full spectrum lighting Allow flexible work environment: Flexible scheduling Modified break schedule Leave for counseling Work from home/flexi-place Divide large assignments into smaller tasks and goals Use auditory or written cues as appropriate Restructure job to include only essential functions Provide memory aids such as schedulers, organizers, or applications Emotions Encourage the use of stress management techniques to deal with frustration Allow the presence of a support animal Allow telephone calls during work hours to doctors and others for needed support Allow flexible breaks Refer to employee assistance program (EAP) Fatigue Allow flexible work environment: Flexible scheduling Modified break schedule Leave for counseling Work from home/flexi-place Provide a goal oriented workload Reduce or eliminate physical exertion and workplace stress Implement ergonomic workstation design 8

9 Allow use of job coach Provide mentor Memory Provide minutes of meetings and trainings Use auditory or written cues as appropriate Allow additional training time Provide written checklists Use a color coding scheme to prioritize tasks Use notebooks, planners, or sticky notes to record information Provide labels or bulletin board cues to assist in location of items Organization Use daily, weekly, and monthly task lists Use calendar with automated reminders to highlight meetings and deadlines Use electronic organizers or mobile devices Divide large assignments into smaller tasks and goals Use a color coding scheme to prioritize tasks Panic Attacks Allow the employee to take a break and go to a place where s/he feels comfortable to use relaxation techniques or contact a support person Identify and remove environmental triggers such as particular smells or noises Allow the presence of a support animal 9

10 Sleep Disturbances Allow for a flexible start time Combine regularly scheduled short breaks into one longer break Provide a place for the employee to rest during break Allow the employee to work one consistent schedule Provide a device such as a Doze Alert or other alarms to keep the employee alert Provide work areas with sunlight or other natural lighting Stress Refer to counseling and EAP Allow telephone calls during work hours to doctors and others for needed support Allow the presence of a support animal Allow flexible work environment: Flexible scheduling Modified break schedule Leave for counseling Work from home/flexi-place Co-Worker Interaction Encourage the employee to walk away from frustrating situations and confrontations Provide partitions or closed doors to allow for privacy Provide disability awareness training to coworkers and supervisors JAN Accommodation and Compliance Series: Employees with Mental Health Impairments, By Beth Loy, Ph.D. and Melanie Whetzel, M.A. 10

11 Boundaries Lacking the capacity to soothe or comfort themselves when distressed, they need others to help them regulate emotions. This means they require constant reassurance and approval and are often extremely needy or dependent in relationships. They become attached to others quickly and often intensely, developing feelings and expectations of others that are not warranted. Mondimore, Francis Mark; Kelly, Patrick ( ). Borderline Personality Disorder: New Reasons for Hope (A Johns Hopkins Press Health Book) (Kindle Locations ) What can I do to deal with my Borderline Personality Disorder? Set clear, realistic goals. Be patient with yourself. Develop methods to manage specific problem behaviors. Avoid alcohol and street drugs. Accept the responsibility for managing your illness. Make a written schedule every day so your time is structured. Find a satisfying job Choose healthy role models. Make and keep at least one good friend. Work hard at being honest in therapy. Take medication if prescribed. Learn to express your feelings directly and appropriately. Remember you can't always change the way you feel, but you can always change what you do about it. Find a balance between work and fun. Contact Us Linda Hedenblad, MSE, CRC, Mint member Linda.Hedenblad@gmail.com VRDevelopmentGroup.com 11