Working with Borderline Personality and Self-Neglect

Welcome to an essential training overview for Adult Protective Services (APS) caseworkers and supervisors!

This episode draws from a specialized training program designed to equip non-clinicians with evidence-based strategies for managing cases involving clients with borderline personality traits who demonstrate self-neglecting behaviors.

We’ll explore practical intervention techniques while emphasizing professional boundaries and caseworker well-being.

In this episode, we cover:

• Understanding the Intersection of Personality Disorders and Self-Neglect
  • Key Focus: How borderline personality disorder (BPD) traits manifest in older adults who self-neglect, recognizing the impact of past trauma on current behaviors, and why traditional engagement approaches may fail.
  • Identity and Culture: We discuss how issues with a person’s sense of self, often stemming from early life experiences or mistreatment, can be reflected in disordered living spaces. It’s crucial to understand that self-neglect isn’t just about not following rules, but often deeper identity problems.
  • Intersectionality: Learn how factors like culture, race, gender, and economic status profoundly influence how individuals see themselves and experience the world, making identity problems worse for those who feel marginalized. A balanced approach considers these backgrounds, financial situations, and personal histories when assessing safety.
  • Engagement Strategies and Intervention Planning
    • The PACE Framework: This foundational approach for caseworkers stands for Partnership, Acceptance, Compassion, and Empowerment. It respects the client while addressing safety concerns.
      • Key elements include validating feelings while discussing needed changes, starting with small, safer changes, focusing on strengths, and using consistent boundaries during emotional outbursts.
    • The “4 A’s” Methodology: Essential techniques for non-clinicians working with these populations:
      • Absolute Worth: Showing respect regardless of behaviors or living conditions. This involves explicitly separating a person’s intrinsic value from their behavioral manifestations.
        • Practical Example: A caseworker assures a defensive client that their value as a person exists completely separate from the cluttered conditions of their apartment. Documentation should also reflect this separation, focusing on factual observations rather than judgments about character.
      • Autonomy: Letting people make choices within safety limits.
        • Practical Example: Instead of imposing a solution for medication management, a caseworker presents options like a medication organizer or reminder system, allowing the client to choose what works for them.
      • Affirmation: Pointing out strengths and recognizing incremental progress.
        • Practical Example: Even in a severely hoarded apartment, a caseworker affirms a client’s thoughtfulness for maintaining a clear pathway to the bathroom or their ability to categorize items, leveraging these strengths for intervention planning.
      • Accurate Empathy: Understanding feelings without agreeing with unsafe behaviors.
        • Practical Example: When a client expresses fear about losing independence, a caseworker responds, “It sounds like these changes feel like significant losses to you. The thought of accepting help might represent a threat to your sense of self,” demonstrating understanding beyond surface emotions.
  • • Implementation and Crisis Management
      • Documentation: Caseworkers must write down observations in clear, factual language, separating facts from opinions, and including the client’s perspective. This helps build stronger cases if legal action is needed.
      • De-escalation Techniques: Specific strategies to calm situations when clients become upset. These are evidence-based protocols that address identity threat responses and safety management.
        • Strategic Distance Calibration: Maintaining optimal interpersonal distance (minimum 1.5 meters) to facilitate psychological safety and enhance caseworker physical security.
        • Validation-Based Threat Diffusion: Acknowledging emotional experiences without reinforcing neglect patterns, using phrases like “I understand this feels intrusive”.
        • Autonomy Reinforcement: Offering incremental choices even within mandated interventions, which reduces aggressive responses.
        • Redirection Through Environmental Refocusing: Shifting focus to neutral environmental elements to interrupt escalation.
        • Strategic Disengagement: Systematized disengagement protocols when escalation continues, prioritizing caseworker safety while preserving the professional relationship.
      • Least Restrictive Approach: Caseworkers should choose interventions that solve safety problems while restricting the person’s freedom as little as possible, starting with small changes that don’t greatly affect independence.
    • Professional Resilience and Supervision
      • Self-Care Strategies: Caseworkers need specific self-care techniques like calming exercises, separating work from personal life, writing about difficult cases, and knowing when to ask for help. Organizations should support these practices.
      • Supervisory Framework: Good supervision creates a safe space for caseworkers to discuss difficult cases and their own feelings, helping them understand how personal beliefs might affect their work.
        • Reflective Supervision: Unlike regular supervision, this focuses on professional growth through discussing real experiences.
        • Debriefing Sessions: Structured sessions are crucial after difficult cases to process what happened, manage emotions, and find meaning in challenging experiences. This prevents burnout and improves long-term client care.
    This framework emphasizes providing comprehensive support to clients while ensuring the well-being and effectiveness of the caseworkers themselves.