“managing challenging behaviors associated with personality disorder and serious mental illness”
DESCRIPTION
Rebecca Fromme, Ph.D. McGuire VAMC Geriatrics and Extended Care. “Managing Challenging Behaviors Associated with Personality Disorder and Serious Mental Illness”. 64 year-old, married Vietnam veteran 100% SC: PTSD, Impaired Vision, Diabetes, Loss of Lower Leg Cognitively intact - PowerPoint PPT PresentationTRANSCRIPT
Rebecca Fromme, Ph.D.McGuire VAMCGeriatrics and Extended Care
64 year-old, married Vietnam veteran
100% SC: PTSD, Impaired Vision, Diabetes, Loss of Lower Leg
Cognitively intact Dialysis 3 days per week Long history of poor compliance,
CLC admission in 2009 for amputation and rehab of right lower limb, recent readmission for wound on other foot
Frequently refused dialysis, and when he did go, he only stayed for 1-2 hours (rather than full 4 hour session)
Frequently refused meds, refused blood sugar checks Very poor food choices, would not follow diabetic diet, made
it impossible to keep his blood sugars level Refused care, then later demanded a shower “RIGHT NOW” Verbally and physically threatening to staff, particularly
nurses Caught smoking in his room Used foul language when he did not get immediate attention Refused to attend PT so that he could be strengthened and
fitted for prosthesis, but demanded the prosthesis anyway
Extensive diabetic education from Geriatricians, Dietician, NP, Nursing Staff, RT, and OT on multiple occasions
Pleading Encouraging Nagging Scolding Escorting to cafeteria to make healthier choices Psychiatry Consult Increasing ALL OF THE ABOVE
Challenging behaviors continued Medical providers and staff became more
concerned, frustrated, worried, guilty Staff decided to regroup, try something
else…..
Longstanding pattern of maladaptive relationships
Poor ability to understand others’ point of view
Lack of empathy on how his behaviors affect others
Poor recognition of his own responsibility in current
circumstances
Fixed way of responding to staff, regardless of the
situation
Emotional dysregulation
Manipulative behaviors
Unhappiness
Socially maladaptive/Complete disregard for unit rules
Psychology met with treatment team to inform them of results of cognitive evaluation- Behaviors not a result of cognitive impairment, inability to remember the rules, or inability to remember what he should be eating
Mr. W’s food choices are conscious choices, and he has right to make them even if we don’t agree- PATIENT-CENTERED CARE
Nagging, pleading, scolding only serves to trigger control issues and increases resistant behaviors
Instead, praise, encourage, reinforce those times he does behave appropriately- HARM REDUCTION
Do not engage in a “battle of the wills” Understand that not all situations can be “fixed”- CARING NOT
CURING Practice de-escalating conflicts before they occur
Check yourself first– remember not to take it personally. It’s about the situation, not you
Deal with the person’s emotions first. Problem solving cannot occur if the person is fuming!
When hostility is rising, diffuse it early with an empathic statement
Most people will DRASTICALLY de-escalate once the emotion has been recognized and they have a minute to vent
Speak to the other person as if he/she IS NOT upset Inquire, don’t interrogate Set limits, if necessary. Return later when patient is
calmer.
Instead of: “That’s never going to work”
“That’s not my problem”
“I don’t work that way, I have high standards”
“I don’t have time right now”
Try: “I don’t have enough info to see how
this will work” “I don’t understand how you feel I
can help in this situation”
“I have concerns about doing it this way. I’d like to suggest another way that leads to the same goals”
“I’m handling several emergencies today, but if you let me know what you need I will get to it as quickly as I possibly can”
Summarize the patient’s chief concerns Interrupt less Increase empathy, attempt to name
the patient’s emotional state “You seem quite upset. Can you help me
understand what’s going on for you right now?”
Offer regular, brief summaries of what you are hearing from the patient “What I hear from you is that……. Did I get that
right?”
Discuss the fact that the relationship is less than ideal
Offer ways to improve care “How do you feel about the care you are receiving
from me?” “It seems to me that we sometimes don’t work
together very well.” “You look a little confused. Would it help if I explain
it again?”
Clarify the reason for the patient seeking care Indicate what part the patient must play in
caring for his/her health Revise expectations if they are unrealistic
(both yours and the patient’s) “What’s your understanding of what I am recommending and
how does it fit with your ideas of how to solve your problems?”
“I wish I (or a medical miracle) could solve this problem for you, but the power to make the important changes is really yours.”
Fewer aggressive episodes Slightly improved compliance with
dialysis through compromise Reduced verbal abuse Reduced staff stress Improved patient satisfaction