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How can art therapy contribute to mentalization in borderline personality disorder?

What is therapeutic communication?

Therapeutic communication is a part of therapeutic relationship between the nurse and patient or physician and patient. It is defined as the interaction with the patient face to face in order to provide beneficial interventions related to the physical and emotional wellbeing. The nurses use therapeutic communication in order built a communication to easily get the health information of the diseased person. Therapeutic communication includes the interpersonal communication which is intended to help the patient. In the given case scenario the patient is suffering from the borderline personality disorder. It is a mental or psychological disorder marked by some pattern of self-image, varying mood, and behavior (NIMH, 2017). The patient has suffered a sexual abuse in her childhood and stresses due to the separation of her parents. She has been feeling guilty as she blames herself for the divorce of her mother and father and tried to commit suicide. In this case scenario, therapeutic communication can play a vital role for the better patient recovery. This essay aims to develop a discussion about how therapeutic communication can be beneficial in April's case. The skills required to develop communication with the patient and management strategies that can be applied to treat the disorder in this case scenario, will be discussed.


The epidemiological study of BPD shows that in the United States, 1.6 % of the total populations suffering from this disorder. Which means over 4 million people have BPD in America (Skodol, 2017). Women have the higher risk of developing this disorder than men. Among all the people diagnosed with borderline personality disorder, seventy-five percent are women with the ratio 3 females to one male. Some studies revealed that nearly 75 % of the people diagnosed with BPD make at least one attempt to commit suicide in their lifetime (Salters, 2018). The patient with borderline personality disorder shows various personality related symptoms such as irritation, anger, suicidal thoughts and demotivated. Therefore they should be dealt with more care. The causes of this disorder include genetic factors, environmental factors, and brain function. No specific gene is responsible for causing BPD; however, this disorder has strong hereditary connections (Chanen, & Kaess, 2012). The environmental factors include sexual or physical abuse and separation from the parents during childhood. Some of the symptoms of BPD associated with the neurological basis of the brain specifically the portion that controls decision making and emotions of the person (NAMI, 2018).  Nurses sometimes receive the verbal abuse from the person with BPD due to their inappropriate anger which is not easy for them to control. Skills required to build a therapeutic communication are different from the general interpersonal interaction. A nurse skilled in therapeutic communication helps him or her to understand the patient better. Communication is the important factor to initiate, elaborate and ends the relationship between a nurse and the patient.  To develop an effective therapeutic relationship a nurse must follow some rules of confidentiality-safeguard and privacy of the patient's rights. A nurse should allow the patient to express their thoughts, respect the person by considering the age, background, religion, race and socioeconomic in respecting personal space

Epidemiological study of borderline personality disorder

Nurses must control their own reaction to the frustration or anger. Building a therapeutic relationship with the patient might help the nurses and other health providers to provide better health care. Therapeutic communication is the first step in order to develop a therapeutic relationship. To make a better therapeutic communication a mental health nurse requires skills such as building trust, being empathetic, active listening, reflecting, motivating, encouraging and hope to offer. Developing trust in a therapeutic relationship with the patient is very essential. The patients with borderline disorder are not very open to discussing their medical situation with the unknown person ((Beck, Davis, & Freeman, 2015). Therefore a nurse should develop trust.  In this case, April has been blaming herself for the separation of their parents as she disclosed about her sexual abuse to her parents. So it is possible that she may not easily discuss her feeling to the nurse but developing the trust allows the patient to disclose how she is feeling and what she actually wants. This is the most important skills every nurse should have in order to establish a good therapeutic communication with the patient. Being empathetic is another essential skill for the nurse to provide better interventions for the patient with the borderline personality disorder, although empathy is confused with sympathy. Empathy allows the diseased person to develop a feeling that they are not alone (Roepke, Vater, Preißler, Heekeren, & Dziobek, 2013).


Effective Communication with the clients is directly linked with active listening. Active listening is the important part of therapeutic communication. Attentive listening is more than just hearing and remaining silent.  It allows the nurse to hear, process and purposefully comprehending the patient’s words and processing the words to understand the person’s situation and the signs and body language sent by the patient (Stoffers, Voellm, Rücker, Timmer, Huband, & Lieb, 2012). In the case of April, this skill might help to assess the problems associated with her mental illness and to help the client to express her feelings completely.  In some cases during the conversation the patient discuss something important, that should be the focus of the nurses and asks the patient to continue those statements. This develops a positive feeling that the nurse really wants to hear what is important to the patient.  In most of the cases the patient asks the nurses to advise them about the problems they have and what they should do, in this scenario being reflective is very important to develop a therapeutic communication. Sometimes it is useful to be silent and not speak at all. This can give both patient and nurse an opportunity to think about what comes next. It can also provide the patient time and space to understand the new topic. Using the touch method may also be beneficial in April's case, it may enable a nurse to develop a feeling in patient that somebody cares for her and she is not alone. While talking to the patient eye contact is necessary so that the patient can believe that the nurse really wants to understand the problem they have. Using touch such as holding a hand is widely used as co-therapy for the patient with mental illness. It is the most potent form of communication. While communicating with the patient a nurse should not ask the personal question as the patient sometimes not comfortable to tell. In the given case scenario the patient blame herself for the problems occurs in her parents’ relationship, for that she tried to commit. This type of patient should be dealt with kindness. A nurse should offer hope to the client by using statements such as don't worry, everything will be fine. A nurse can help the patient by telling her that she is not responsible for the issues occurs in her parent relationship ship and what she did was not wrong, she did the right thing by expressing the sexual abuse happened to her. By using these skills and techniques a good and goal achieving therapeutic relationship can be built with the patient (Riley, 2015)

Skills required for effective therapeutic communication


The borderline personality disorder can be managed by using some strategies in an inpatient setting.  One of the management strategies that can be used in April’s case is sleep enhancement. Regular sleep-wake cycles can be used to enhance the sleep pattern. The bedtime routine for the patient can be established, and snacks, foods, and drinks that interfere with sleep should be avoided. To enhance sleeping, exercises like brisk walking can be applied before 3 to 4 hours of bedtime. With sleep enhancement nutritional balance is also necessary to improve psychological health. Patient with the borderline disorder has increased chances of developing weight. In this case, their diet and nutritional intake should be managed well to decrease stress (Fredman & Rosenbaum, 2018). The patients can be provided Carbamazepine and lithium can be used to manage the self-injury behaviour in patient. Divalproex is the alternative of these medicines and used widely for aggression and impulsivity. Antipsychotic medicines can be used to manage transient psychotic episodes in which the patient shows thoughts disorganization, high levels of emotional instability and misinterpretation of reality (Mayo clinic, 2018). Low doses of these drugs should be used. If the patient is experiencing anxiety which usually occurs in a patient with BPD, non-benzodiazepine like buspirone can be used. This drug is considered as the ideal antianxiety medicine. Does not have effects like sedation, ataxia, withdrawal, tolerance and does not lead to abuse.

Splitting is the term that is used in psychiatry to understand the inability to hold the opposite thoughts, beliefs and feeling.  It is considered as the defence mechanism which allows the person with BPD to view people, situations and even themselves all or nothing terms. This enables the person to discard things they have already assigned as bad and to embrace the things they consider good. A person with borderline personality disorder may view the nurses as good as angel or bad as devil. If they view the person negatively, this may causes the development of hate and anger against the nurse. Because of this behaviour nurses should set some boundaries for their own safety. Sometimes the nurses also develop the negative thoughts about the person because of their behaviour and the patient also do the same, this might leads to cutting. Cutting is another issues that is associated with splitting. This can be managed in the ward by assigning the nurses that have patience and positive behaviour to their patient (Pec, aBob, & Raboch, 2014). A DBT specialist should be assigned to the patient and the behavioural management plan should be used to facilitate a consistent response for attempts of the April if she tries to split and manipulate the nurses.

Management strategies for borderline personality disorder

Some psychological therapies that can be implemented in the management of April's mental illness are Dialectical behavioural therapy, cognitive behavioural therapy, and Mentalization- based therapy. Dialectic behavioural therapy is the basically the modification of standard cognitive-behavioural techniques which is designed to treat BPD (NHMRC, 2012). It has been considered as the only data supported therapy for borderline personality disorder. It primarily focuses on educating the patient about four important skills that are mindfulness, interpersonal effectiveness skill, emotional regulation and encouraging distress tolerance without impulsivity. It motivates and the patient to practice mindfulness techniques likes meditation, self-soothing and regulating breathing. This therapy has been shown to be very effective in suicidal behaviour, treatment dropouts, psychiatric hospitalization, anger, substance abuse and some interpersonal difficulties (Linehan, Harned, Korslund, Gallop, Neacsiu, Lungu & Murray-Gregory, 2015). Cognitive behavioural therapy is another beneficial therapy that might be helpful in the given case scenario. This therapy helps to solve the issues such as negative thinking and behaviours related to BPD. The aim of this approach is to identify the negative thoughts and teach the effective coping strategies to the patient (Beck, Davis, & Freeman, 2015). Mentalization-based therapy is the third most effective therapy after DBT and CBT in order to teach the people not to become conscious about their own internal state. It also helps to develop empathy in a patient for other people (Springham, Findlay, Woods, & Harris, 2012). Emotional support should be the additional component of the treatment provided to April as she is emotionally broken due to her parent’s separation. A nurse should manage her emotional break and spend lots of time with the patient and discuss the issues with her.


Another approach that can be applied to the patient BPD management is the family approach. Aprils is disturbed due to the problems occurred in her family and she started consuming alcohol and overdosing on medications. By involving her family in her treatment may increase her chance to be healthy and recover fast. The study conducted by Kearney and Trull (2016), provided evidence that including the family member in the treatment of a patient with mental illness increase the recovery chances. According to an article published in Borderline Personality Disorder (2018) family therapy can help to understand the BPD patient better. The person with BPD generally forgets the activities they like to do, a nurse can help the patient to identify those activities and involve them.  

Understanding splitting and cutting behaviors

To summarise, a borderline personality disorder is a mental illness that can be caused due to the genetic, brain function and environmental factors. The symptoms associated with this disorder include anger, irritation, aggression, suicidal behaviour and sleeplessness (Ripoll, 2012). The patient mentioned in the case study is suffering from is a disorder which occurred due to the separation of her parents. For that, she blames herself because she disclosed to her mother and father about the sexual abuse happened to her. In this case scenario, a therapeutic communication can play a vital role to treat the patient.  To build an effective therapeutic communication with the patient’s nurses should have some skills such as developing trust, being empathetic with the patient, active listening, focusing, being silent while the patient is disclosing something important, and by telling the patient that she is not responsible for her parent’s separation. Some of the strategies that can be applied in April’s case include sleep enhancement and conducting the activities that are helpful to the person’s health. Some psychological therapies that can be applied to April's BPD management are Dialectic behavioural therapy, cognitive behavioural therapy, and metallization-based therapy. Including the family member to the treatment of the patient can also increase the chances of the patient’s recovery. The pharmacological drugs that can be beneficial in this case are carbamazepine, lithium, divalproex, and antipsychotic medicines.

References

Beck, A. T., Davis, D. D., & Freeman, A. (2015). Cognitive therapy of personality disorders. (3rd ed.). New York: Guilford Publications.

Beck, A. T., Davis, D. D., & Freeman, A. (2015). Cognitive therapy of personality disorders (1st ed.). Arlington, VA: Guilford Publications.

Belli, H., Ural, C., & Akbudak, M. (2012). Borderline personality disorder: bipolarity, mood stabilizers and atypical antipsychotics in treatment. Journal of clinical medicine research, 4(5), 301. doi: 10.4021/jocmr1042w

Borderline Personality disorder (2018). The family’s role in treating BPD. Retrieved from: https://www.borderlinepersonalitytreatment.com/family-role-in-treating-bpd.html

Chanen, A. M., & Kaess, M. (2012). Developmental pathways to borderline personality disorder. Current psychiatry reports, 14(1), 45-53. Doi: org/10.1007/s11920-011-0242-y

Kearney, C. & Trull, T. J. (2016). Abnormal psychology and life: A dimensional approach. (3rd ed.). Boston, USA: Cengage Learning.

Linehan, M. M., Korslund, K. E., Harned, M. S., Gallop, R. J., Lungu, A., Neacsiu, A. D., ... & Murray-Gregory, A. M. (2015). Dialectical behaviour therapy for high suicide risk in individuals with borderline personality disorder: a randomized clinical trial and component analysis. JAMA Psychiatry, 72(5), 475-482. doi:10.1001/jamapsychiatry.2014.3039

Mayo Clinic (2018). Borderline personality disorder. Retrieved from: https://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/diagnosis-treatment/drc-20370242

National Alliance on Mental Illness (2018). Borderline personality disorder. Retrieved from: https://www.nami.org/learn-more/mental-health-conditions/borderline-personality-disorder

National Health and Medical research council (2012). Clinical practice guidelines for the management of borderline personality disorder. Retrieved from: https://bpdfoundation.org.au/images/mh25_borderline_personality_guideline.pdf

National Institute of mental health (2017). Borderline personality disorder. Retrieved from: https://www.nimh.nih.gov/health/topics/borderline-personality-disorder/index.shtml

Ripoll, L. H. (2012). Clinical psychopharmacology of borderline personality disorder: an update on the available evidence in light of the Diagnostic and Statistical Manual of Mental Disorders–5. Current opinion in psychiatry, 25(1), 52-58. doi: 10.1097/YCO.0b013e32834c3f19

Roepke, S., Vater, A., Preißler, S., Heekeren, H. R., & Dziobek, I. (2013). Social cognition in borderline personality disorder. Frontiers in Neuroscience, 6, 195. doi: org/10.3389/fnins.2012.00195

Salters, K. (2018). Borderline personality disorder statistics. Retrieved  from: https://www.verywellmind.com/borderline-personality-disorder-statistics-425481

Skodol, A. (2017). Borderline personality disorder. Retrieved from: https://www.uptodate.com/contents/borderline-personality-disorder-epidemiology-clinical-features-course-assessment-and-diagnosis

Springham, N., Findlay, D., Woods, A., & Harris, J. (2012). How can art therapy contribute to mentalization in borderline personality disorder? International Journal of Art Therapy, 17(3), 115-129.

Stoffers, J. M., Voellm, B. A., Rücker, G., Timmer, A., Huband, N., & Lieb, K. (2012). Psychological therapies for people with borderline personality disorder. Cochrane Database Syst Rev, 8(8). doi: 10.1002/14651858.CD005652.pub2

Riley, J. B. (2015). Communication in nursing. Elsevier Health Sciences. (8th ed.). Missouri: Elsevier health science.

Fredman, S. J., & Rosenbaum, J. F. (2018). The application of nutrition to psychiatric illness. Retrieved from: https://www.medscape.org/viewarticle/480926

Pec, O., Bob, P., & Raboch, J. (2014). Splitting in Schizophrenia and Borderline Personality Disorder. PloS one, 9(3), e91228. doi: org/10.1371/journal.pone.0091228

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