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Forensic Nursing Interventions With Patients With Personality Disorder: A Holistic Approach

Byrt, Richard RMN, RNLD, RGN, PhD, BSc (Hons)

doi: 10.1097/JFN.0b013e31827a9293
Review Article

ABSTRACT Research findings suggest that nursing assessment and care and psychotherapy of forensic patients with personality disorder should be based on a holistic approach that addresses a wide range of their needs. Such an approach should be in collaboration with patients, informal carers, and other professionals and informed by appropriate education, training, clinical supervision, and support. Holistic care includes areas (such as physical health, cultural, spiritual, and psychosexual needs) that are addressed to a limited extent in the literature on patients with personality disorder. Despite limitations in research evidence, findings suggest that some patients with personality disorder benefit from psychotherapies, sometimes facilitated by nurse-therapists, and therapeutic community principles. These interventions should take account of patients’ cultural and spiritual needs and perspectives. Helping patients to manage anger has potentially positive consequences for their physical health, personal and work relationships, and other areas. Research is needed to consider how to deliver holistic care with limited resources and in organizations, such as prisons, with conflicting goals.

Author Affiliation: Richard Byrt is retired, and until 2011, was lecturer - practitioner in nursing at Arnold Lodgemediumsecure unit, Nottinghamshire Healthcare NHS Trust and School of Nursing and Midwifery, De Montfort University, Leicester, UK.

The author declares no conflict of interest.

Correspondence: Richard Byrt, RMN, RNLD, RGN, PhD, BSc (Hons); E-mail: richard.byrt@virginmedia.com.

Received March 20, 2012; accepted for publication October 16, 2012.

Government policies and guidelines in the United Kingdom require forensic nurses to develop skills in caring for people with personality disorder (PD; Ministry of Justice, National Offender Management Service, 2011). Many accounts of forensic nursing of these individuals consider a narrow range of aspects of assessment and care. In contrast, in this paper, it is argued that forensic patients with PD require a holistic approach in response to a wide range of needs. These include those related to safety and reduction of risk; mental and physical health; culture, diversity, spirituality, sexuality; advocacy; and future employment. The delivery of holistic care by forensic nurses depends on close collaboration with patients; their informal carers (where appropriate) and other professionals. Also necessary is appropriate education, clinical supervision, and support (Murphy & McVey, 2010).

The nature and prevalence of PD and relevant assessment and care related to risk, communication, and therapeutic relationships have been considered elsewhere (Murphy & McVey, 2010). This paper is concerned mainly with areas that are covered to a limited extent in the literature on patients with PD. Besides key texts and reports, Cumulative Index to Nursing and Allied Health Literature, PubMed, and Google were searched for papers on the needs and problems of forensic and other patients with PD, including those related to physical health, culture, spirituality, relationships, sexuality, and employment.

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Patients’ Physical Needs

Individuals with PD often have poorer physical health than the general population, especially in relation to hypertension and heart disease (Chen et al., 2009). El-Gabalawy, Katz, and Sareen (2010) found that this was the case with people with borderline PD when other variables were adjusted. For forensic patients with PD, the evidence suggests that structured assessments of physical health should be completed at admission and at regular intervals thereafter. Specifically, assessment of: physical illnesses, including those that are long term or gender specific; family history of illness; weight and body mass index; details of diet; intake of, and dependence on, tobacco, alcohol, and other substances; specific physical symptoms; past injuries; sexual health (Rethink Mental Illness, 2011); sleep patterns (Sansone, Edwards, & Forbis, 2010); and dental health problems (Bloomfield & Pegram, 2012). Neuroimaging and other investigations should be carried out if there is a possibility of acquired brain injury, which sometimes results in behaviors similar to those of people with antisocial PD (Palgan, Radeljak, Kovac, & Kovacevic, 2010).

Taking prompt practical action in response to patients’ physical health needs may enable them to feel that their concerns are taken seriously and help establish a therapeutic alliance (Condon, Hek, & Harris, 2008). Physical health assessments and interventions are closely linked to those concerned with patients’ psychological, spiritual, and cultural needs. For example, antisocial PD may result in a patient taking risks with sexual health and acquiring injuries from reckless driving (Dumais et al., 2005) to impress peers and enhance self-esteem. Interventions, sometimes in liaison with primary care colleagues (Druss & Walker, 2011) include health promotion and education that enables patients’ active participation and providing care related both to specific physical health problems and features of PD. Nursing interventions and psychotherapy, based on holistic assessments, may, over time, enable patients to understand and change unhealthy behaviors. For example, patients with diabetes who covertly drink large quantities of sugary drinks, thus inducing hyperglycemia. In addition to emergency interventions, a forensic nurse could endeavor to understand the reasons for the patients’ behaviors, specifically the need to exert control, and reject authority. Such patients may be more likely to increase responsibility for the management of their diabetes, and regain feelings of being in control if the nurse is willing to listen, and understand their perspectives. Psychotherapy could help them appreciate reasons for unsafe behaviors and lead to positive changes in both physical and mental health (Jaunay et al., 2006).

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Diet and Exercise

The frequency of obesity and unhealthy diets has implications for forensic nurses’ assessments of patients’ dietary intakes, including “food and fluid intake charts,” and instruments such as the Malnutrition Universal Screening Tool (NHS Quality Improvement Scotland, 2003) to inform decisions about diet, including essential nutrients, related to patients’ weight (Archibald, 2008, p. 154). Also relevant are findings that a “supplement of vitamins, minerals and essential fatty acids” reduces violence in young prisoners (Bohannon, 2009, p. 1614). Nursing assessments can include evaluating factors, such as institutional cultures, boredom, and features of PD, that may result in high consumption of sugars and saturated fats (Long, Brillon, Schell, & Webster, 2009). Relevant features of PD include impulsivity, which may result in rash decisions about food intake, and comfort eating to cope with feelings of worthlessness.

Patients’ exercise levels also need to be assessed. Links have been found between unhealthy diet and lack of exercise in secure hospitals (Archibald, 2008). In these settings, exercise has reduced boredom and aggression (Tetlie, Heimsnes, & Almvik, 2009) and enabled patients to relax (Savage, Long, Hall, Mackenzie, & Martin, 2009). Exercise may provide stimulation for individuals with antisocial PD who are “sensation seeking” and easily bored (van Goozen & Fairchild, 2009). Cashin, Potter, and Butler (2008) found that regular exercise reduced prisoners’ feelings of hopelessness. However, physical exercise is likely to increase already existing angry arousal (Bushman & Huesmann, 2010). All these findings indicate the need to ensure that forensic patients with PD have opportunities for regular exercise, except when this is likely to increase aggression.

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Needs Related to Culture and Spirituality

Culturally sensitive and culturally competent nursing assessment needs to inform the meeting of specific requirements of forensic patients with PD, for example, diet related to culture and religion, and space and time for quiet reflection, prayer, or meditation. Meeting such needs is essential to some patients’ well-being and may enable them to find positive ways to manage anger and alleviate distress (Ford, Byrt, & Dooher, 2010). In much of the relevant literature, hope and meaning are viewed as components of spirituality relevant to patient care (Addo, 2006). Nursing assessment can identify the extent that patients experience hope and meaning and areas of their lives that contribute to this (National Institute for Health and Clinical Excellence [NICE], 2009a). Patients with PD frequently feel particularly hopeless, often because of adverse childhood and later experiences. Times of crisis or loss, including lack of freedom, are likely to increase hopelessness (Byrt & James, 2007). This may diminish if the nurse consistently conveys respect and interest and if structured programs, including nursing interventions, are provided (Aiyegbusi & Clarke-Moore, 2009). A wide range of positive experiences (such as education and exercise) may increase self-esteem and enable the individual to gain satisfactions, other than through offending (Byrt, Wray, & Tom, 2005). The van der Hoeven Clinic for prisoners with PD has provided vocational rehabilitation with aims tailored to individuals’ needs, including learning to cooperate with coworkers and establish regular work routines (van Dellen & van der Veer, 1992). Australian Government Job Access (2011) outlines various difficulties experienced by workers with PD and their solutions, including role play, are implemented to enable individuals to understand their communication with others.

Risk assessments should be sensitive to patients’ cultural backgrounds (Department of Health, 2007), for example, awareness that distress and aggression are influenced by trauma from war experiences (Ford et al., 2010). It is important to distinguish risky behaviors from those that are nonrisky and reflect patients’ cultures, for example, in Chandler-Oatts and Nelstrop’s (2008) study, nurses misinterpreted patients’ loud speech as a sign of aggression, rather than appreciating cultural factors that affected its volume. In addition, it has been commented that: “Concepts such as…antisocial PD are defined using value-laden terms…and sometimes cease to have meaning in different cultures” (Tseng, Griffith, Ruiz, & Buchanan, 2007, p. 473). Lee (2008, p. 8402) found that “cultural modifications” were needed in diagnosing and understanding people of Asian cultures with possible borderline PD.

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Psychosexual Needs

Staff awareness of their attitudes and values, based on clinical supervision and support, need to underpin assessment and care related to psychosexual needs of forensic patients with PD. Care includes ensuring that, within safety and security parameters, patients have access to toiletries, clothing and activities that are crucial to their identity as a woman or as a man. Also important is positive affirmation of patients’ sexual orientation and gender identity and recognition of a same-sex or unmarried partner as the most significant person in some patients’ lives. Patients may find it helpful if nurses convey empathetic understanding of psychosexual problems related to PD or incarceration, including difficulty in initiating or maintaining intimate relationships and sexual deprivations. These areas, although seeming obvious, are insufficiently considered in forensic nursing literature (Aiyegbusi & Byrt, 2006).

Forensic nurses have a duty of care to prevent harm from patients exerting power over each other and to be aware, from sensitive risk assessment, of their previous histories of relationships, including those where they have perpetrated and/or been victims/survivors of abuse. Many people with PD have had few intimate or satisfying relationships (Aiyegbusi & Byrt, 2006). Neelman (2007) reported that individuals with borderline PD were frequently dissatisfied with sex and engaged in impulsive, risky sexual behaviors. Bouchard, Godbout, and Sabourin (2009, p. 106) found that women with borderline PD were more likely to feel “sexually pressured by their partners.” Once patients have established therapeutic alliances with forensic nurses, they may welcome sexual health education (Aiyegbusi & Byrt, 2006) and begin to explore relationship and sexual difficulties, perhaps in psychotherapy, possibly with their sexual partner (Links & Stockwell, 2002).

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Relationships With Children and Early Intervention Programs

NICE (2009a) refers to the importance of assessing effects of patients’ behaviors, including offending, on family members. Research findings suggest that people with PD often have difficulty caring for their children (Wiegand-Grefe, Geers, Petermann, & Plass, 2011). Stepp, Whalen, Pilkonis, Hipwell, and Levine (2011) reported that “mothers with borderline PD”(p. 76) often swung “between extreme forms of hostile control and passive aloofness in their interactions with their children.”(p. 76) Although there is a danger of assuming that all patients with PD have difficulties with parenting, nurses need to be observant for any evidence of harm to children, document concerns, and report these to the manager responsible for child protection (NICE, 2009a). Several authors recommend early intervention programs to support parents with PDs and their children, and to address specific problems (Wiegand-Grefe et al., 2011). These include programs within jails (Kubiak, Kasiborski, & Schmittel, 2010) and those that divert women from custody (Cassidy et al., 2010), which enable mothers (and potentially, fathers) to continue caring for babies and young children, increase attachment, and learn parenting skills. NICE (2009a) states that many children with “conduct disorders” in childhood develop antisocial PD as adults and recommends early “identification of children at risk” (p. 9). Research findings indicate that intensive nursing and other interventions with parents, including vulnerable pregnant women, are successful in preventing antisocial PD in later life. Interventions include enabling parents both to alleviate parenting and other problems that result in young children failing to form attachments, and to address poverty and children’s educational difficulties (National Collaborating Centre for Mental Health, 2010).

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Psychotherapies and Therapeutic Communities

Research findings on the effectiveness of nursing and other interventions for people with PD are limited (NICE, 2009b; Woods & Richards, 2003). However, results indicate that some individuals with PDs benefit from psychotherapies (NICE, 2009b), sometimes facilitated by nurses with appropriate education and training (Bowness, 2008). The rest of this paper considers the use of social problem-solving, mentalization-based therapy (MBT), and therapeutic communities (TCs) in helping forensic patients with PD manage anger (Ford et al., 2010) and meet a variety of other needs. Research findings suggest that effective management of anger not only contributes to violence prevention but also reduces risks of hypertension, coronary heart disease (Morrison & Bennett, 2009), and road traffic accidents (Dumais et al., 2005). In addition, problem-solving, MBT, and TC principles provide patients with opportunities to creatively resolve conflicts in relationships with peers and staff, with possible applications in personal relationships and employment, and the reduction of offending at a stage of later recovery (Ford, Byrt, & Dooher, 2010).

Studies have found that problem-solving is effective in helping patients manage anger (McGuire, 2008) and long-term physical illnesses (Morrison & Bennett, 2009) and develop social skills (Huband, McMurran, Evans, & Duggan, 2007). In “Stop and Think!” (a type of social problem-solving), following baseline observations of violent behaviors, patients with PD are helped to identify ways that they manage anger and other emotions, recognize early signs of anger, and identify triggers. Patients are enabled to learn from offending and other situations where they have responded with violence. In “Stop and Think!” groups, facilitators and peers help each patient to consider choices in expressing anger, with discussion of the advantages and disadvantages of particular courses of action. For example, an individual may conclude that he has gained power from intimidating others but has found it difficult to sustain permanent employment or relationships as a result. Patients are encouraged to formulate strategies, which can be care planned, to manage anger, for example, channeling aggression through exercise or using relaxation techniques (Bowness, 2008), both of which are likely to contribute positively to patients’ physical and mental health (Morrison & Bennett, 2009). Patients who pray or meditate might choose to use these means to problem-solve. Problem-solving techniques can also help patients make healthy life choices. For example, with support of staff and peers, a patient with diabetes could problem-solve in planning exercise and finding alternative ways of coping with anxiety, instead of eating high-calorie food (Morrison & Bennett, 2009).

A randomized controlled trial of MBT found that individuals with borderline PD maintained improvements 5 years after treatment (Bateman & Fonagy, 2009). MBT increases patients’ capacity to “interpret the actions” and understand “feelings, beliefs, thoughts and intentions of oneself and others” (Blumenthal, 2010, p. 153). Assumptions about these areas are influenced by relationships and communication with parent and other significant figures in early childhood (Adshead & McGauley, 2010). Nurse therapists validate patients’ intense negative feelings and experiences (often related to childhood trauma), while enabling them to question and understand their perceptions of self and others and how these affect their personal relationships. Patients are invited to consider alternatives, for example, the possibility that not everyone hates them, and therefore, do not need to be responded to aggressively (Ford et al., 2010). MBT has consequences for the development of positive self-concepts and self-esteem. This may result in improved personal and work relationships (Blumenthal, 2010) and increased self-efficacy, with avoidance of behaviors that adversely affect physical or mental health, for example, failing to regulate diet in diabetes (Morrison & Bennett, 2009). MBT may also reduce offending because it enables patients to increase empathy and reduce misperceptions of others’ motivations (Blumenthal 2010).

There have been reductions in psychological distress and offending in many individuals with PD treated in prison and hospital TCs (Adshead & McGauley, 2010). In these organizations, the whole social environment is intended to be therapeutic. TCs provide residents with opportunities to learn from events, including situations where they behave aggressively, and to practice new ways of behaving and relating, for example, through shared activities requiring collaboration (Ford et al., 2010). This may help residents to learn skills in cooperating with others that can be applied in intimate relationships and in employment (van Dellen & van der Veer, 1992). In addition, individuals are enabled to change attitudes that contribute to offending. In one Californian prison TC, inmates address “accountability in criminality, violence, gang involvement, drug use” (Reentry Policy Council, n.d.).

In TCs, forensic nurses enable residents to develop responsibility by supporting each other, taking an active part in making decisions within the parameters of safety and security, and arriving at their own solutions to, and resolutions of problems (Ford et al., 2010). This can increase residents’ self-esteem and sense of control over decisions affecting their physical and mental health. Participants’ feedback may enable individuals to learn why they engage in self-destructive and risky behaviors affecting their health and to make changes (Jane, 2007), for example, to talk to others when faced with difficulties, rather than smoke heavily or self-injure.

Some psychotherapies and TC principles are based largely on Western, middle class values, but interventions need to take account of patients’ cultural and spiritual needs and perspectives (Byrt, Aiyegbusi, Hardie, & Addo, 2007). These include their linguistic, religious, and other ways of seeing the world and finding hope and meaning (Huppert, Siev, & Kushne, 2007). For example, O’Hearn and Pollard (2008) outline ways that materials used in dialectical behavior therapy can be adapted to meet the needs of individuals who are deaf. Patients’ spirituality may enable them to effectively manage anger, for instance, through artistic expression or quiet reflection, with time allowed for such activities in therapeutic programs.

Many patients with PD have families and peers who see physical violence as crucial to their identity and status. Staff need to appreciate patients’ difficulties in accepting other ways of managing anger because of culture clashes between previous experiences and professionals’ expectations (Byrt et al., 2007). There also needs to be acknowledgment of power imbalances between staff and patients and ways that these may influence therapeutic interventions (Schafer & Peternelj-Taylor, 2003). In some secure hospitals, nurses enable patients’ access to lawyers and advocacy services run by voluntary organizations (Garman, Kelly, & Waldon, 2003).

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Conclusion

Holistic approaches in the assessment and care of forensic patients with PD, contrast with those that concentrate on a limited range of needs and those that do not consider the patient as a whole person. An example is an understandable, but narrow, focus only on risk assessment and risk management, with an emphasis on restrictive measures to ensure safety. Such an approach, indicated in research findings (Byrt & James, 2007), fails to take account of evidence, reviewed in this paper, that forensic patients have a wide range of needs. Holistic approaches in assessment, care, and psychotherapy not only meet these needs more effectively but are also essential to risk management (Department of Health, 2007). In addition, helping patients to manage anger effectively, through culturally sensitive psychotherapy and TC principles, may potentially have positive consequences for their physical health and for personal and work relationships.

It is recommended that forensic nursing interventions with people with PD should be informed by education, training, and clinical supervision concerned with holistic care; in collaboration with patients, informal carers, and a wide range of professionals; and related to patients’ many needs, including those covered in this paper. However, more research is needed to consider the most effective ways of delivering holistic care with limited staffing and other resources. In addition, holistic care for prisoners may conflict both with other organizational goals (such as punishment) and with institutional environments that are not conducive to health (Douglas, Plugge, & Fitzpatrick, 2009).

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Acknowledgment

The author would like to thank the editor and reviewers of this paper for their helpful comments.

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      Keywords:

      cultural needs; holistic care; Personality disorder; physical healthcare needs; psychosexual needs; psychotherapies; spiritual needs; therapeutic communities

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