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The core concept `professional skills of mental health work' includes four descriptive categories labeled empathy for persons with BPD, interest in treating the disorder, feelings of professional frustration and need for a common outlook. Each category, consisting of several substantive codes grounded in the data, is described below and illustrated by extracts from interviews. Briefly, the responses frequently present a picture of, on the one hand, the importance of empathy, nearness and warmth, and on the other frustration, powerlessness, anger and confusion. Fluctuations between feelings of hope and hopelessness are reported and also the importance of a shared common outlook between the members of the nursing staff.
Empathy for persons with BPD. This category, comprising the codes nearness, warmth, holding and security, illuminates significant attributes in the caregivers' personal equipment to deal with the feelings of helplessness of the patient. Many interviewees described it thus:
"These patients project feelings making me feel I understand nothing up to I understand very much. They need care and security but at the same time they are not able to receive it. However, as staff you must still be there. You have to let it be and be capable of waiting for the patient and after a time it turns. You never have to give up and feel guilty when they pessimistically describe their situation. If you act in a cautious and gentle manner, it may turn out very well."
"You became very important, you have a feeling of there isn't anybody else, though this is often a myth."
Some of the interviewees considered that the environment of the ward can be negative and provoking for the patient if the nursing staff does not show enough empathy.
Interest in treating the disorder. This category, comprising the codes curiosity, demanding, excitement, gladness, includes the caregivers' way of describing the internal forces which motivated the caregivers to hold on to the patients and to keep in touch with helping the patients to cope with their symptoms.
"You always have a hope to be of some help, that there will be a change. Then you have to start again. Work with different ways of structuring."
Feelings of professional frustration. This category is built on four substantive codes, feelings of inadequacy, powerlessness, anger and sorrow; that is, all the feelings the patients themselves do not have the possibility to be in contact with. The interviewed caregivers had doubts about their professional skills, although they knew that the difficulties depended on transference of feelings. At the same time they also thought about the inadequacy of society concerning these patients who should be listened to. A group of patients nobody wants to deal with, a heavy patient group, they said. Many of the respondents felt that their own work became heavy with a high work load, lack of time, too much responsibility and offered few possibilities to exert any influence; feelings of inadequacy were evoked. However, the work also aroused frustration/powerlessness and anger. The informants described different types of maneuvers by the patients towards the staff and the inability of the patient to behave outside the ward (e.g. carving, shoplifting, pyromania). There were also notions of difficulties on the part of the staff to `stand by' in the relationships with the patients.
"The patients consider nothing can help them. I will say, `don't you understand that I will help you'. You get frightened over your own anger. On those occasions you question your professional skills. You must not forget that they transfer their feelings. It is easy to be indifferent, that is to allow things; however, a later `no' and you are worthless. The patient has an unsafe and fragile identity."
One of the caregivers said: "When their self-esteem is attacked and offended, they have to attack the surrounding environment in any way. They must get rid of the feelings they cannot keep to themselves. As a caregiver, you get used to it."
Another caregiver said: "They are stable in their aggressiveness. And you never learn. You make plans but in the next second you are knocked down. You get feelings of disappointment, anger, tiredness. It takes time before you learn to hold a distance. The testing doesn't terminate until there is calmness in the relationship.
Many of the interviewees expressed feelings of powerlessness/sorrow, often depending on whether the patients are young and want to be the centre of attention. They arouse parental feelings and are often treated more like children than grown-ups. `Besides that, other groups of patients take after or imitate or get frightened and wonder what will happen at those maneuvers'.
Need for a common outlook. This category, comprising the substantive codes inadequate knowledge of BPD symptoms, different points of view regarding holding feelings and lack of perspective of wholeness.
"What you can give an inpatient is some breathing space, you hope. The patient may meet some good object to internalize."
Another interviewee said: "I think the staff can give examples of feelings by behaving plainly. A professional staff gives the patients a feeling that they cannot destroy a person with their rage."
"If a girl comes for acute treatment, there must be a chain of care to follow. The girl needs a shelter. In the meantime you have to investigate if there are any social problems, e.g. addiction. If so, this is the first thing to concentrate on."
Reflection Exercise #6