Introduction
Several reasons make emotionally unstable personality disorder (EUPD) an underdiagnosed disease. First, it is hard to differentiate the condition because it has the same symptoms as bipolar disorder. For example, impulsivity and mood changes can be seen in the two illnesses. It makes it challenging to identify the problems affecting an individual’s behavior and create a suitable treatment plan because individuals with EUPD can also be bipolar. Different treatment methods exist for individuals with EUPD, but dialectical behavior therapy (DBT) is the most effective.
Dialectical behavior therapy involves a mental health nurse who supports and promotes the recovery of individuals with mental illness, assisting them in fulfilling their lives and living independently. The paper will assess three case scenarios related to individuals with EUPD and illuminate the responsibility of the mental health nurse in inspiring hope in these individuals.
Background
Harned, Korslund, and Linehan (2014) indicate that EUPD was initially associated with diseases like neuroses and schizophrenia, which made it difficult to diagnose. The first EUPD victims were observed about three millenniums ago, but its symptoms were brought to light in the early 20th century (Have et al., 2016). Some trends in illness diagnoses included biochemical studies and neuro and genetic imaging, which revealed that EUPD is linked to biological (brain) disturbances (May et al., 2016). However, the most significant trend was Marsha Linehan’s introduction of dialectical behavior therapy for EUPD patients in 1993 (Have et al., 2016; Linehan & Wilks, 2015).
Linehan and Wilks (2015) state that the epidemiology of EUPD shows that the disorder emerges during adolescence or at the beginning of adulthood. The most common causes of EUPD are biological, cognitive, and environmental factors (Have et al., 2016; Linehan & Wilks, 2015). Instances of biological and environmental factors include kids who face poor parenting and linked actions like persistent abuse, separation, and inconsistent care (Linehan & Wilks, 2015). Cognitive factors include genetic irregularities in the brain that affect perception and reasoning (Harned et al., 2014).
Behavior and Diagnosis of EUPD
Individuals with EUPD are uncertain about how they view themselves and can have intense mood swings (May et al., 2016). These feelings can change quickly, leading to emotional pain and unstable relationships (Have et al., 2016; Harned et al., 2014). These individuals also see things in the extreme, either all bad or all good. They can quickly change their interests and values and behave recklessly. EUPD patients are likelier to engage in impulsive behaviors like drug abuse, self-harm, suicide, and unsafe sex (Linehan & Wilks, 2015).
The facilitator is responsible for diagnosing EUPD patients through an interview about their behaviors (Reyes‐Ortega et al., 2020). The facilitator will ask about family mental illness histories and the individual’s symptoms (Have et al., 2016). Diary cards are essential for diagnosing EUPD patients (May et al., 2016). They are either an app or a form where the patients record the rate of varying emotions and the skills they utilize daily and track the usage of the target behavior (Harned, Korslund, and Linehan, 2014).
Dialectical Behaviour Therapy
DBT was created by Marsha Linehan to treat personality and interpersonal difficulties (Linehan & Wilks, 2015). DBT aims to direct the patient to consider the mental health nurse as a friend instead of a foe when being treated for EUPD (Yüce & Rios, 2020). The mental health nurse aims to acknowledge and corroborate the patient’s feelings while assuring the client that certain behaviors and feelings are maladaptive and providing suitable substitutes.
DBT is meant for individuals prone to suicide attempts and self-harm, who are then provided with new skills to transform their behaviors and attain a life worth living (Giannelli et al., 2019). Patients under the standard DBT program must commit for a year (May et al., 2016). The program gathers individuals with EUPD into a DBT skills training group facilitated by a mental health nurse (Yüce & Rios, 2020). The facilitator will use connectedness, hope, identity, meaning, and empowerment (CHIME) to guide the participants to heal (Yüce & Rios, 2020; Penas et al., 2020). The group aims to assist individuals in acquiring practical and effective skills they can use when distressed.
Group Tasks
Group members must perform certain task functions and maintenance roles to be productive and effective. First, they must initiate the session by suggesting goals, outlining problems, and proposing solution procedures (Gençer, 2019). Secondly, the members should seek information by requesting essential facts about their illness (Gençer, 2019). They must also provide information regarding their beliefs about what they are going through. Thirdly, they should clarify ideas by interpreting the information gathered, giving examples, and showing alternatives (Gençer, 2019). Finally, they restate, summarize, and determine a solution for their problem.
Maintenance roles for the group members include encouraging and supporting each other and ensuring their contributions are valid (Stratton et al., 2020; Giannelli et al., 2019). They should improve the atmosphere of the group by sensing relationships and moods, expressing the group’s feelings, and sharing feelings (Gençer, 2019). They must also harmonize to lower group tension by reconciling their differences. Some members should offer support by admitting mistakes and searching for alternatives (Van Dijk, Jeffrey, and Katz, 2013).
Nature, Function, and Purpose of the Group
The nature of group therapy involves a mental health nurse who provides psychotherapy to people in every session (Stratton et al., 2020). Group therapy provides more individuals access to psychotherapy, reducing their waiting time (Gençer, 2019). Group therapy is meant for everyone, especially those with scarce access to mental healthcare, like those residing in low-income locations (Gençer, 2019). Group therapy brings together people like Kayla, Fionn, and Bill, who share almost the same EUPD experiences.
The function of the group is to instill hope by providing evidence that previous and current members are progressing toward their objectives (Giannelli et al., 2019). Secondly, the facilitator uses the CHIME framework to reassure and support the participants during the entire treatment, which can improve their confidence and self-esteem (Reyes‐Ortega et al., 2020; Penas et al., 2020). Thirdly, the facilitator can help the members antagonize their childhood dynamics and experiences and teach how they shape their identity and personality (Gençer, 2019). Lastly, the mental health nurse can encourage the group to work on a common goal to acquire a sense of belonging (Gençer, 2019). It can provide comfort when members open up to the group, and they will be more eager to utilize the behavioral changes taught in the treatment.
Ricard, Lerma, and Heard (2013) note that the group’s purpose is to offer a safe environment for Fionn, Kayla, and Bill to discover the nature of their mental well-being and share their feelings. The group aims to provide a space to give support to and get support from others with similar illnesses (Van Dijk, Jeffrey, and Katz, 2013). In addition, group therapy provides exposure to new beliefs, thoughts, and behaviors that can shift their perspective (Gençer, 2019). Finally, group therapy offers a positive support system that ensures that individuals with EUPD do not feel alone (Stratton et al., 2020).
Group Dynamics
Group dynamics refer to the social process where individuals connect and perform in a group setting (Stratton et al., 2020). Kurt Lewin said that groups are powerful and dynamic beings capable of influencing communities and individuals (Gençer, 2019). The mental health nurse is responsible for assessing the dynamics of the group to understand it (Ricard et al., 2013). For instance, Kayla loses control and harms herself when angry, which the facilitator understands is a way of reconnecting due to dissociation. Fionn is struggling to socialize, which causes her to disengage and conduct risky behavior. Bill has a hard time controlling his emotions, which can be low or intense sometimes, and they affect his relationships.
Group dynamics ensure that members have specific roles (Stratton et al., 2020). For instance, some members may want to be leaders in the group, but they must possess qualities such as communication skills. Psychologist Bruce Wayne Tuckman created the five stages of group development in 1965 to describe the path the groups follow to mental wellness (Gençer, 2019). The five stages include adjourning, performing, forming, norming, and storming.
The Five Stages of Group Development
Forming
The forming stage, or orientation, is the first step of building the group. Members at this stage are just meeting one another, and they are filled with uncertainty and anxiety about the outcome of the group (Gençer, 2019). They are also discrete and cautious about their behavior as they seek acceptance in the group (Lo Coco et al., 2016). While some members may already feel that the team will not work at this stage, the role of the facilitator is to assure them that the aim of orientation is only to familiarize themselves with one another (Ricard, Lerma, and Heard, 2013).
In this case, the group has three members with EUPD: Kayla, Fionn, and Bill. Lo Coco et al. (2016) indicate that these participants are responsible for developing a team with direction, goals, and structure to start creating trust. The members can be grounded regarding the goals and mission of the team with an appropriate orientation process and can create expectations about the product and process of the team.
Storming
Patients are familiar with each other and confident about not hiding their behaviors. Friction can easily arise among the team members because their true habits have emerged and can clash with other individuals’ (Gençer, 2019). Kayla and Bill are currently at this stage. Kayla feels agitated because she feels the facilitator does not understand her, and Bill only has time to be sarcastic when it is his turn to speak.
Group members can also start challenging the facilitator, the objective of the group, or the learning styles (Lo Coco et al., 2016). Fionn refuses to cooperate with the facilitator because he thinks the therapy wastes time. The mental health nurse should not leave this unchecked because it can result in confrontations or tensions with other members or the facilitator (Gençer, 2019). The facilitator should also ensure that responsibilities and roles are clear at this stage so that the members are not frustrated by a lack of progress or overwhelmed by the workload (Ricard, Lerma, and Heard, 2013).
Norming
In this stage, the group members have started resolving their differences, respecting the authority of the facilitator, and appreciating each other’s strengths (Lo Coco et al., 2016). Since the group members are getting comfortable with each other, they are more willing to ask for assistance and provide constructive feedback (Lo Coco et al., 2016). They avoid task conflicts as harmony is essential at this stage (Gençer, 2019). They can now discuss team dynamics, share personal issues, and confide in one another to create high affection (Ricard et al., 2013).
The mental health nurse should step back at this stage to enable the group to self-manage (Stratton et al., 2020). The facilitator should enquire whether they have learned anything, determine if they have set reasonable goals, and create achievable plans to attain the objectives (Gençer, 2019). In addition, the facilitator will organize team-building events so that the group can accomplish this stage (Penas et al., 2020). The nurse can now concentrate on steering the group as there is less work to accomplish.
Performing
Now, the group is performing and flowing at its optimal potential. The individuals have learned to connect and put that experience into their interpersonal and personal processes (Lo Coco et al., 2016). Mutual trust among the participants improves their insight, assessment, and comprehension (Stratton et al., 2020). The members can assess, make decisions, and solve problems (Gençer, 2019). They are taking on more responsibilities and roles as required, as they have become fluid (Lo Coco et al., 2016).
The participants have undertaken constructive change, as the energy they had invested in creating group processes, familiarizing with one another, and forming the group is currently invested in attaining their goals (Ricard et al., 2013). The role of the facilitator is to ensure they find meaning, which is a component of the CHIME framework that will enable them to handle their difficulties (Stratton et al., 2020; Penas et al., 2020). The mental health nurse can delegate some activities and roles but monitor and assess the results (Gençer, 2019). The facilitator can also assist them in celebrating their accomplishments.
Adjournment
Reaching this stage is natural, as the group may want to celebrate the success and disband (Ricard et al., 2013). Since some groups prefer to define responsibilities and measure success, adjournment is a key part of the final process (Gençer, 2019). Adjournment is also called the mourning stage because some participants may feel sadness, as they feel it is the last time they are together (Lo Coco et al., 2016). It can slow down the productivity and progress of the group members (Reyes‐Ortega et al., 2020).
Other members can feel relieved that they have finished their work and want to accomplish other tasks. They may form new groups after the previous one closes, while others can choose to leave. The nurses should ensure they comprehend the emotional and social benefits of including new participants in their network (Gençer, 2019). The facilitator should also reassure them that disbanding the group indicates success rather than failure, as they are now in control of their emotions (Reyes‐Ortega et al., 2020).
The Recovery Model for the EUPD Patients
The path to rehabilitation is both a personal journey and one that is interconnected with the person’s society and community. The hallmarks of recovery are empowerment, meaning, identity, connectedness, and hope or CHIME (Penas et al., 2020). The group members first encounter others who share their belief in their capacity for recovery through connections. The facilitator should establish connections between the participants and the community, family, and friends since they can provide the patients with a strong network of supportive people (Penas et al., 2020).
Second, hope is crucial to healing because it embodies a long-lasting belief and optimism in one’s ability to push through obstacles. The facilitator should reassure the participants that while taking the chance of being hurt, unsuccessful, and frustrated, hope entails trust.
Thirdly, identity is a sign of the CHIME model essential to rehabilitation because it entails discovering oneself to move forward. In order to go on, the participants must deal with their sentiments of loss, rage, and hopelessness (Penas et al., 2020). The facilitator should assure them that finding identity involves acceptance of past suffering and lost time and opportunities. Fourth, finding meaning and purpose is crucial to healing. The participants learn coping mechanisms and problem-solving techniques to handle their difficulties and personalities (Penas et al., 2020). The facilitator should help the participants develop their skills in recognizing and managing major crises and stress spots.
Lastly, the participants must be empowered through a supportive healing ethos, which is essential to rehabilitation. Because empowerment decreases the mental and social repercussions of trauma and stress, it is necessary for their journey to recovery (Penas et al., 2020). They should receive proper medical care and housing, according to the facilitator.
Facilitation Skills
Nurse’s Confidence in the Ability of EUPD Patients to Recover
The confidence of the facilitator should motivate the group members to continue working even though the process seems difficult (Kaufman, Douaihy, and Goldstein, 2021). Fionn needs the most motivation because he does not believe the mental health nurse will help him change. The facilitator should express confidence and treat him as an individual rather than a patient (Romeu-Labayen et al., 2021). Confidence is a strong healing base for treating mental illness (Manges et al., 2016).
Patients are more satisfied when the facilitator has a positive facilitation attitude that minimizes medical errors and patient falls (Kaufman, Douaihy, and Goldstein, 2021). Confidence is the group members’ ability to recover, which is associated with hope, a sign of the CHIME framework for healing that provides the ability to overcome mental health anguish and attain improvement (Romeu-Labayen et al., 2021; Penas et al., 2020). When the group members are assured that the mental health nurse is confident in their recovery, they push harder to recover and maintain a strong therapeutic relationship (Manges et al., 2016).
Facilitator’s Non-Judgement
The group members can freely express themselves when the mental health nurse allows them to talk and listen without judging them. The mental health nurse should respond therapeutically and consciously instead of judging what the patients are saying (Romeu-Labayen et al., 2021). The facilitator should listen more keenly to Kayla, who feels misunderstood. The facilitator should know relational dynamics when describing difficult situations for her to accept and comprehend.
The nurse should note the influence of their beliefs and values when handling behaviors that contradict these values, like suicide attempts and self-harm (Manges, Scott-Cawiezell, and Ward, 2016). Not judging the participants might seem difficult for the facilitator, but it is essential to their nursing ethics (Romeu-Labayen et al., 2021). In addition, the facilitator should not react to the provocation of Bill, who responds sarcastically to therapy questions, when providing feedback and rather respond in a manner that authenticates the emotions that resulted in the behavior (Kaufman, Douaihy, and Goldstein, 2021).
The Facilitator Should Have a Sense of Humour
The group members feel calm, accepted, and protected when the mental health nurse has a sense of humor (Manges, Scott-Cawiezell, and Ward, 2016). In addition, they gain peace of mind, closeness, and trust with the facilitator and can show their emotions authentically (Romeu-Labayen et al., 2021). Bill makes sarcastic remarks when it is his turn to speak during the group session, which the facilitator struggles to comprehend. However, the nurse should note that cheerful disposition and optimism are the qualities the group members value in their facilitators (Kaufman, Douaihy, and Goldstein, 2021).
EUPD patients need laughter as it encourages relaxation and relieves anxiety. The therapeutic relationship between the facilitator and the patient gains reciprocity through humor, allowing for a more intimate and human connection. Humor has a reflexive effect when used in therapeutic relationships, as it enables the participants to decontextualize an event and see it from a varying point of view (Romeu-Labayen et al., 2021). For instance, the facilitator can enlighten Fionn that art and dance classes are good opportunities to find a girlfriend.
Inspiring Hope to EUPD Patients
There is no better way to inspire hope in EUPD patients than to offer them invaluable encouragement. Hope is a feature of the CHIME model the facilitator should use to focus on the patient’s strength and communicate honest faith that they can overcome and grow beyond their maladaptive patterns, behaviors, and beliefs (Romeu-Labayen et al., 2021). Encouragement also manifests when the group members are empowered to emotionally process distressing and intense emotions that encourage maladaptive behaviors, patterns, and beliefs (Manges, Scott-Cawiezell, and Ward, 2016).
Another way to inspire hope in the group members is to assure them that effective treatment results in symptom remission (Kaufman, Douaihy, and Goldstein, 2021). Recent research illuminates that out of those who get EUPD treatment, 50% experience symptom remissions when the facilitator goes back to check on them after about two years (Romeu-Labayen et al., 2021). The studies also show that less than 10% of symptoms reappear after treatment. It is hopeful and honest data that circles the internet and other research areas regarding EUPD (Manges, Scott-Cawiezell, and Ward, 2016).
Importance of Validating EUPD Patients
The facilitator validates the group members by accepting their emotions and thoughts non-judgmentally. Kayla and Bill will benefit more from verbal validation through phrases like ‘you are right’ and ‘I hear you’ because they feel misunderstood (Romeu-Labayen et al., 2021). Behavioral validation through smiling or hugging is also essential when responding to their request and can assist members like Fionn, who feels withdrawn.
Helping the group members realize their feelings, experiences, and thoughts are legitimate will help them successfully get through the treatment stages of DPT (Manges, Scott-Cawiezell, and Ward, 2016). However, only listen and accept when they express unachievable things non-judgmentally. Validating the group members will also ensure effective communication to avoid conflict, a decline in anger, and enhanced self-respect (Romeu-Labayen et al., 2021). In addition, it makes closeness, problem-solving, and building trust possible (Kaufman, Douaihy, and Goldstein, 2021).
Conclusion
DBT is considered a crucial treatment approach as it has been proven to have significant results when treating EUPD. The paper has identified adjourning, performing, forming, norming, and storming as the facilitators’ stages to create fruitful therapy groups. The attitudes of the facilitator that the group members consider essential in backing the therapeutic relationships have also been identified. They include being non-judgemental, confident that the patient will recover, and having a sense of humor.
The facilitator should give hope to group members by encouraging them that they will recover and offering honest statistical data regarding symptom remissions. The nurse should also help the group members feel validated by assuring them that their feelings, experiences, and thoughts are legitimate.
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