A patient with borderline personality disorder has had 21 admissions to the mental health unit, each precipitated by a suicide attempt usually resulting in superficial cuts on the arm
On this admission, the patient has developed a relationship with a highly supportive nurse. The patient has progressed to having a pass to spend an afternoon in a nearby shopping mall. The nurse is shocked when the emergency department calls to say that the patient has just been brought in with multiple self-inflicted lacerations. The nurse asks a peer, "Why? Everything was going well. How could she do this to me?" Which response(s) by the other nurse reflects objectivity and understanding of the patient's personality disorder? (Select all that apply.) a. "I know what you mean. You put a lot of energy into working with this patient. It must be disappointing to have her do something like this.".
b. "I could have told you this would happen. A patient like this always gets you in the end. I hope this will teach you not to get so involved.".
c. "I know the patient's behavior seems personal, but it's really not. Patients with borderline personality disorder self-injure to relieve numbing or anxiety.".
d. She was doing well here, where she was adjusted to the milieu and the people, but I suspect leaving here for the pass really increased her anxiety.".
e. "I wonder if all this could have been avoided if I'd clued you in on the patient. This is a usual pattern for her. She burned me once too when I first worked here.".
f. "People do not necessarily improve in a steady, lasting fashion; sometimes there are setbacks. It does not mean she isn't progressing overall.".
C, D, F
Helping the upset nurse understand that the patient's behavior does not reflect on the nurse's efforts but on the patient's circumstances changing would help the nurse avoid self-blame and anger. Intolerable feelings (or the absence of feeling, numbness) lead to self-injury, and it is likely that the pass increased the patient's anxiety or led to other overwhelming feelings that in turn led to self-injurious behavior. Such events are part of the process of recovery and do not necessarily mean that improvement is not occurring overall. The distracters are examples of negative countertransference reactions and loss of professional objectivity.
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