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John (not his real name) is a 31-year-old male who presented to mental health services after concerns by his GP of not sleeping, getting into rages, and a reported history of depression with suicidal thoughts. His defacto relationship had broken down 6 months previously. He presented in an agitated state with the belief that all his problems were a result of his defacto partner leaving, and if mental health services could not fix that relationship there was no point having treatment. An assessment by the community mental health nurse from the service revealed that: (i) John had been discharged from the army on medical advice; (ii) a number of aggressive incidents occurred during his time in the army, John believed it was always someone else at fault, felt victimized, and was intensely suspicious about some colleagues; (iii) a number of presentations to Accident and Emergency Departments for ‘accidents’; (iv) a lack of a support network; (v) poor relationship with parents whom he described as ‘cold’ and ‘drunkards’; (vi) childhood history of sexual abuse by an uncle; (vii) repeated thoughts of self harm; (viii) separated from his defacto and three young children; and (ix) poor physical health.
The GP had commenced John on antidepressant medication, which he was taking erratically in combination with alcohol. As the nurse began to form a therapeutic alliance with John, the thoughts of self-harm increased, and he began cutting himself on the arms and legs – almost always requiring suturing. These incidents had previously resulted in presentations to accident and emergency departments for accidental cuts. Due to increasing chaos, isolation, anger, and thoughts of selfharm and repeated cutting a decision was made by the GP that John would be admitted involuntarily to the local mental health inpatient unit.
Hospitalization unfortunately only fuelled his anger, and he continued to self-harm and voice suicidal thoughts. Staff found him a difficult management problem on an acute inpatient facility due to his angry outbursts and severe incidents of self-harm. As a result, he was often sedated or given medication via intramuscular injection whilst being restrained. This perpetuated his anger because he believed that no one understood or cared how he felt and he began to physically threaten staff. These outbursts elicited strong reactions from staff, causing both the patient and staff anger to escalate. A decision was made by the treating psychiatrist to discharge John from hospital due to a lack of improvement in his mental state. He was diagnosed as having a Borderline Personality Disorder. Follow up was negotiated with the GP and community mental health nurse.
The plan was to see John weekly at a set time and adopt a behavioral framework of care. He was to see his GP fortnightly for support and to address a number of physical issues. For any relationship to work it is important to think about the things that we like about the other person. Often this is overlooked when we see people with BPD and therapists are left seeing patients they dislike. It is, therefore, important to find something you like about the patient before embarking further into therapy if the therapeutic relationship is to succeed. What stood out with John was that he deeply cared for his children and, despite the difficulties, he kept in regular contact with them. The connection between therapist and the client is considered the first priority.
The need to set clear boundaries was paramount, given John’s outbursts of anger. The therapy commenced talking about his anger and acknowledged these feelings, but was openly discussed that at times the anger was out of context with the preceding events. Although in the sessions it was fine to discuss disagreements about treatment, it was also made clear that the therapist would not accept angry outbursts directed at them. There also needed to be an acceptance that therapists can make mistakes and that the idea of a perfect therapy relationship is not a reality. During sessions, triggers for John’s anger and the distress related to past issues were explored. The fact that the community mental health nurse had agreed to keep seeing him was a very important turning point, as he felt that nobody cared if he lived or died. The nurse was also involved in regular clinical supervision.
As John was not working, it was important to find activities to fill his time. Initially this was difficult due to his lack of motivation, distress and the lack of activities in a small town. A list was drawn up of desirable activities, which included walking, fishing, writing down his thoughts and relaxation tapes for short periods of time.
John was a very reluctant participant in this because of the pain he felt, but the alternatives were to sit, feel the pain and possibly self-harm, or to engage in a distracting activity. John continued to self-harm weekly for some time before improvement occurred. In therapy, John was able to discuss triggers for the cutting and the feelings it elicited. People with BPD have grown up in invalidating environments and, therefore, it is important not to be disappointed when plans do not work out, but to understand how difficult it is for them to change and to continue to encourage and remain hopeful.
Information on borderline personality disorder was given to the GP, family and John. Mental health services commonly overlook psychoeducation in relation to personality disorder. Although the information raised as many questions as it answered for John, it also explained a lot about how he felt. The process of explaining and answering his questions greatly enhanced his engagement in therapy as he now felt somebody else understood what was happening to him.
Both the literature and the case study show there is a need for further research into the ways in which mental health services deliver treatment to men who present with aggression and/or antisocial behaviors. The development of systems of treatment is necessary to engage men and to enable therapy to remain consistent and sustained in the face of difficult and complex symptoms, as well as ensuring therapy is delivered to males in a form they are able to utilize. The role of trauma needs to be recognized as the basis of many men’s antisocial behavior if mental health services are to move towards providing a service that meets the needs of this population.
-Stewart, Don; Harmon, Karen. International Journal of Mental Health Nursing (2004)
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