SPECIAL EDITION 2016

 

Facilitation of self-empowerment of women living with borderline personality disorder: A concept analysis

 

 

N. Ntshingila^{I, *}; A. Temane^II; M. Poggenpoel^II; C.P.H. Myburgh^III

^IDepartment of Nursing Science, Faculty of Health Science, University of Johannesburg, South Africa
^IIDepartment of Nursing Science, Faculty of Health Science, University of Johannesburg, South Africa
^IIIDepartment of Educational Psychology, Faculty of Education, University of Johannesburg, South Africa

 

 

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ABSTRACT

BACKGROUND: Borderline personality disorder is characterised by a pattern of instability in interpersonal relationships, self-image, affects and marked impulsivity.
Objective : The objective is to define the central concept of "facilitation of self-empowerment".
METHOD: Analysis and synthesis reasoning methods as indicated by Walker and Avant (2011) were used to define the central concept.
RESULTS: A definition of the concept "facilitation of self-empowerment" was formulated from the dictionary and subject definitions.
CONCLUSION: The central concept is important for developing a model as a frame of reference to assist psychiatric nurse practitioners in facilitating the mental health of women living with borderline personality disorder.

Keywords: Concept; Analysis; Facilitation; Self-empowerment; Borderline personality disorder

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1. Introduction

Women living with borderline personality disorder are difficult to manage in most treatment settings due to various behavioural challenges evident in the condition. Given the duty to care by psychiatric nurse practitioners, the amount of contact evident between the patient and the psychiatric nurse practitioner, other treatment modalities may be relied upon to support borderline personality patients. The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (2013, p. 646) indicates that borderline personality disorder is diagnosed on the basis of a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity beginning in early adulthood and presenting in a variety of contexts. Borderline personality disorder is associated with a range of negative connotations. Patients who suffer from borderline personality disorder are characterised by psychosocial impairment and high mortality. Up to 10% of patients commit suicide; a rate almost 50 times higher compared with the general population. They are likely to experience negative interactions with mental health care professionals because of their highly challenging behaviour, which includes disruptions in the ward, manipulation and splitting of mental health professionals. Splitting is a defence mechanism most commonly used by patients with borderline personality disorder where they feel ambivalent and experiences are divided into good and bad (Sadock, Sadock, & Ruiz, 2015, p. 744). Their behaviour in the ward is seen as a microcosm of their internal world and serves as a way to survive in a world that is unpredictable and dangerous (Callan & Howland, 2009, p. 13). Their suffering often goes unacknowledged and thus increases their readmission rates into psychiatric institutions (McDonald, Pietsch, & Wilson, 2010, p. 87).

 

2. Background

Concept analysis is an important part of theory development compliance, involving concept identification, definition and analysis so as to contribute to the development of a model to assist psychiatric nurse practitioners in facilitating the mental health of women living with borderline personality disorder (Walker & Avant, 2011, p. 63). Analysis allows one to clarify, refine or sharpen concepts, statements or theories. It also allows the researcher to examine and re-examine existing knowledge about the phenomena as a means to improve the accuracy, currency or relevance of the exiting body of knowledge (Walker & Avant, 2011, p. 64). The researcher conducted a study titled "Facilitation of mental health of women living with borderline personality disorder" through a qualitative, exploratory, descriptive and contextual means. Women diagnosed with borderline personality disorder who were admitted to a psychotherapy unit were interviewed and asked to tell their life stories. During these in-depth phenomenological interviews, the women diagnosed with borderline personality disorder described their experiences of living in an unsafe space during childhood, chronic feelings of emptiness, unstable interpersonal relationships, compromised mental health, as well as their yearning for facilitated mental health (Ntshingila, Poggenpoel, Myburgh, & Temane, 2016, pp. 113-117). Direct quotations of the themes have been summarised in Table 1. From the analysis of the interview data, the researcher identified the emerging central concept as the "facilitation of self-empowerment" of women living with borderline personality disorder. This paper looks at the concept of self-empowerment of women living with borderline personality disorder however similar concepts were discovered in understanding and treating patients with borderline personality disorder.

A similar concept was discovered by Dr J.F. Masterson between 1926 and 2000 a medical doctor (Daws, 2013). Masterson approach to treating patients with borderline personality disorder came about after working extensively with adolescents and adults with borderline personality disorder. In Masterson's work it was discovered that borderline personality disorder patients had a developmental arrest of the emerging self which was because of the unacknowledged emerging self from the mother in childhood. This resulted in behavioural challenges known as acting out such as truancy, drug use and socially unacceptable behaviour. Masterson came about with the concept of self-activation to treat patients with borderline personality disorder. The concept self-activation of patients with borderline personality disorder focused on an approach to working with patients with borderline personality disorder and this approach is described as follows:

•Clear and definite boundaries

• Clarifying the level of borderline organisation

• Establishing clear goals

• Containing by process of confrontation and clarification

• Working through abandonment depression

• Support through communicative matching (Daws, 2013, p. 2)

The Mastersonian approach looked at managing the acting out behaviour in patients with borderline personality disorder and working through the depression by support and psychotherapy.

Another approach to working with patients with borderline personality disorder was by Marsha Linehan, a Professor in Psychology, the originator of Dialectical Behavioural Therapy (DBT) which came after the 1970's (Dimeff & Linehan, 2001, p. 10). The understanding of borderline personality disorder is that it is a biological and environmental disorder (Linehan, 1997). Linehan's treatment model, assumed that firstly people with borderline personality disorder lack important interpersonal, self-regulation and distress tolerance skills. Secondly this model assumed that personal and environmental factors often both block and to inhibit the use of behavioural skills that clients do have, and reinforce dysfunctional behaviours (Dimeff & Linehan, 2001, p. 10). Treatment in DBT is focused on acceptance, distress tolerance, emotional regulation and interpersonal effectiveness (Linehan, 1997). In DBT the self is also addressed in terms of the patient with borderline personality disorder learning to regulate their emotions and behaviour.

The above mentioned approaches indicate the concept of "self" as important in managing borderline personality disorder patients. The purpose of this paper attempts to understand how self-empowerment can be facilitated in women living with borderline personality disorder. It will also examine the dictionary and literature definitions of the concepts "facilitation" and "self-empowerment" and "developing a model case". The researcher used the initial steps of Chinn and Kramer's (2011) theory development, namely concept identification, concept definition and concept analysis. The concept analysis findings of this paper will assist in developing a model to facilitate self-empowerment of women living with borderline personality disorder.

 

3. Objective of the study

The objective of this study was to define the central concept of "facilitation of self-empowerment" of women living with borderline personality disorder.

 

4. Research method

The researcher used analysis and synthesis as reasoning methods to identify the concept "facilitation of self-empowerment". The researcher used different reasoning strategies in order to formulate logical deductions about the concepts derived from the life stories of women living with borderline personality disorder. The researcher used the analysis and synthesis reasoning strategies described in Walker and Avant (2011, p. 64).

4.1. Analysis

Concept analysis is a process of examining the basic elements of a concept which is concerned with the actual and possible uses of the words that convey the concept meanings (Walker & Avant, 2011, p. 158).To enable the researcher to fulfil the analysis of concept, essential attributes of the concept "facilitation of self-empowerment" were determined. This was done by means of the dictionary and subject definitions of the concepts "facilitation" and "self-empowerment" respectively. Dictionary definitions are definitions obtained from dictionary sources, both hard copy dictionaries and online dictionaries. Subject definitions were obtained from various fields of studies for example, psychiatric nursing, psychiatry and psychology. See Table 2 for a summary of dictionary and subject definitions of the concepts "facilitation" and "self-empowerment".

 

 

Note: In this section, bold text is used to provide evidence of how the essential criteria for the definition of the concepts were identified from the dictionary and subject meaning that was established.

4.1.1. Dictionary definitions of the concept "facilitation"

The Oxford Dictionary Online (2014, p. 1) defines facilitation as make easy/easier, ease, make possible, make smooth/smoother, smooth, smooth the path of, smooth the way for, clear the way for, open the door for; enable, assist, help, help along, aid, oil, oil the wheels, lubricate, expedite, speed up, accelerate, forward, advance, promote further, encourage and simplify.

The Oxford South African Pocket Dictionary (Soanes, 2013, p. 316) defines "facilitate" as to make easy or easier.

According to Dictionary.com (2014, p. 1), the word facilitate means to assist the progress of a person.

The Merriam-Webster online dictionary (2014, p. 1) defines "facilitation" as to make something easier or help cause something, to help something run more smoothly and effectively.

The Free dictionary (2015, p. 1) defines facilitation as the condition of being made easy (easier) and the act of assisting or making easier the progress or improvement of something.

4.1.2. Subject definitions of the concept "facilitation"

Facilitation is derived from the word "facile" that means easily done or doing something easily; it is thus defined as a process through which a person makes it easier for others to do something (Thomas, Paul & Cadle, 2012, p. 12). With the purpose of determining the definition of facilitation, the researcher explored different fields that use this concept. These fields include nursing, mental health care and psychology. The use of related concepts such as facilitate, facilitation and facilitator were also studied to improve the subject definition of this concept. The Theory of Health Promotion (University of Johannesburg, 2011, p. 7) defines facilitation is a dynamic, interactive process for the promotion of health through the creation of a positive environment and the mobilisation of resources, as well as the identification and bridging of obstacles in the promotion of health. Schwarz (2002, p. 5) defines facilitation as the process of helping a group to increase their effectiveness by improving its processes and structure. Schwarz (2002, p. 47) further suggests that a facilitator must hold the values of valid information, free and informed choice, internal commitment and compassion.

Wilkinson (2012, p. 4) defines a facilitated meeting as a highly structured meeting in which the facilitator guides the participants through a series of steps to arrive at a result that all participants create, understand and accept.

Jenkins and Jenkins (2006, p. 1) describe a facilitator as someone who restores personal energy, maintains respect, finds sources of ideas and inspiration and battles the human propensity toward self-limitation, caution, mediocrity and dependency. It is also stated that the role of a facilitator is not to make people do things but rather to enable them to release their energies and potential.

McCain and Tobey (2004), in the context of education, describe facilitation as "to make easy", since it is the facilitator's responsibility to guide the learning process and to make the journey as smooth and as rewarding as possible. The facilitator guides the learners to the learning destination. The goal of the facilitator role is to equip learners to development themselves and to keep growing by means of continual learning.

According to Barnhart (1988), in Hogan (2002, p. 10), facilitation, from a communication perspective, means as easy to do, of persons courteous, to perform and to make it easy. Facilitation is said to involve some of the highest level of human interaction and communication skills. Facilitation is concerned with encouraging open dialogue among individuals with different perspectives in order to explore diverse assumptions and options (Hogan, 2002, p. 10). Facilitation is a process that enables people to hear and take notice of each other's viewpoints and to perhaps shift from polarised paradigms. The process enables participants to identify and work through "emotional baggage" that might have been blocking communication and productivity (Hogan, 2002, p. 33).

Thomas et al. (2012, p. 12) describe the benefits that can be achieved by means of effective facilitation. The first benefit is quality. Quality can be achieved when better decisions are made for the reason that all the interested parties are present, ensuring that the facilitated process is applied and that techniques relevant to the issue are used. The second benefit is ownership. When participants are given the opportunity to voice their concerns or when they submit to leadership in an attempt to take full responsibility, they assume ownership. The third benefit is productivity. Productivity enables participants' increased efficiency and leads to less arguments and endless discussions. The last benefit is collaboration. To achieve this benefit, the researcher ensures that all stakeholders are involved in discussions, allowing the participants to air their perspectives, resulting in greater possibility of collaboration.

4.1.3. Dictionary definition of the concept "self-empowerment"

Dictionary.com (2015, p. 1) defines self-empowerment as deriving the strength to do something out of one's own thoughts and based on the belief that one knows what is best for oneself.

The Canadian Oxford Dictionary (Barber, 2005) defines self-empowerment as the act or an instance of empowering oneself that is about developing your human potential to achieve the best you can, make choices, transforming those choices into desired actions and taking charge of your own life.

4.1.4. Subject definitions of the concept "self-empowerment"

Self-empowerment means taking charge of your own life, illness and care (Shernoff, 1992). It also means that you become the active partner of those experts who are responsible for your care to mutually determine what is best for you, and/or what course of action you wish to pursue regarding your plans for the future, as well as treatments or the lack of them (Shernoff, 1992). Struzzo et al. (2013, p. 2) define self-empowerment as a "social process of recognising, promoting and strengthening the patient's ability to satisfy her own need, involving mobilisation of the resources needed in order to feel in control of his own life". Struzzo et al. (2013, p. 2) suggest that for one to feel self-empowered, one needs to feel secure and connected and develop a sense of meaning and coherence. The theoretical foundation of self-empowerment, according to Struzzo et al. (2013, p. 3), includes the following key attributes:

▸ person as a value;

▸ behaviour as a consequence of the personal perception of success or failure; and

▸ Personal empowerment as a measure of change and of self-efficacy, allowing passing from a perspective of need to a perspective of desire.

In Mackintosh's (1995, p. 1275) theory of self-empowerment, he states the following four factors that are considered central to the concept of empowered action for the individual:

1. environmental circumstances that may either facilitate the exercise of control or, conversely, present a barrier to free action;

2. the extent to which individuals actually possess competencies and skills that enable them to control some aspects of their lives and to perhaps overcome environmental barriers;

3. the extent to which individuals believe themselves to be in control; and

4. various emotional states or traits that typically accompany different beliefs about control such as feelings of helplessness and depression, or feelings of self-worth. Self-esteem and locus of control are two important personality characteristics central to the process of self-empowerment.

Inspired-personal-development (2015) defines self-empowerment as implying self-belief, trust and self-leadership. Being self-empowered means that you have an active role in creating the future of your dreams. Wright (2013) explains that self-empowerment begins with what you think about and what you say to yourself. It means being the person you want to be and following the path you want to follow.

Self-empowerment means taking charge of your own life, in your workplace, with your colleagues, with your subordinated, with your superiors, with your body, with your illness and for caring for yourself (Jordaan, 2015).

Self-empowered people reflect within themselves a feeling of self-confidence that is demonstrated by having self-knowledge, self-appreciation, vision, power of purpose, commitment and contribution. Self-empowerment means to gain knowledge and understanding. Shah (2015, p. 1) describes the meaning of self-empowerment as taking control of your own life, setting goals and making positive choices. It further means to understand your strengths and weaknesses and to believe in yourself.

Self-empowerment involves people constantly challenging their own beliefs and what they are capable of undertaking (Jase, 2013). To develop self-empowerment, one must develop trust, must understand one's own strengths, weakness and limits, and must develop confidence and self-esteem. Self-empowerment is about looking at who you are and becoming more aware of yourself as a unique individual.

4.1.5. Model case

The researcher developed a model from the identified essential criteria. To create conceptual meaning is to create a model case that will represent the central concept, namely facilitation of self-empowerment of women living with borderline personality disorder, in order to promote their mental health. Applying such a model will assist in clarifying the central concept. This process is drawn from nursing practice (Chinn & Kramer, 2011, p. 166).

Sr Tshidi is a 26-year old psychiatric nurse practitioner who is currently working in the psychotherapy unit. Her duties entail rendering nursing care to women living with borderline personality disorder. Sr Tshidi admits Jenny who is 20-year old women diagnosed with borderline personality disorder. Jenny mentions to Sr Tshidi that she was abused as a child and that she feels a great deal of emptiness inside herself. Jenny also mentions that she has a very strained relationship with her boyfriend, as he is emotionally abusive towards her. Jenny tells Sr Tshidi that she feels depressed most of the times and that she has resorted to cutting herself in an attempt to numb her pain. Jenny says that she has had enough of the life she is living and that she would like to be helped since she is not coping anymore. Sr Tshidi collaboratively decides, with Jenny, that she will assist Jenny's progress until Jenny can manage on her own. Jenny will engage in an interactive and dynamic process by creating a positive environment through establishing a nurse-patient relationship, ensuring a safe environment in the psychotherapy unit and ensuring effective communication occurs with Jenny. Sr Tshidi will mobilise resources such as individual therapy, group therapy, mental health education and life skills training. Sr Tshidi will assist Jenny to take charge of her own life. Jenny would take charge of her own life by taking responsibility for her own actions, naming her feelings that she is currently experiencing, learning to sit with an emotion without reacting to it, Jenny to allow to work through the dynamics between her and Sr Tshidi and to use symptom relief skills such as meditation taught by Sr Tshidi. At the end of this admission, Jenny will begin to play an active role in her own life by creating the future of her own dreams, feeling secure, connecting and developing a sense of meaning and coherence. Jenny will start to feel that she can develop her potential as a person and that she is able to make choices about desired actions because she knows what is best for her.

 

5. Findings

5.1. Synthesis

Concept synthesis is the process of describing and naming a previously unrecognised concept (Burns & Grove, 2011, p. 122). It also refers to a process whereby isolated pieces of information are connected in a manner that it has not previously been connected (Walker & Avant, 2011, p. 63). This process involves organising more than one interrelated concept in the description of the structure and process of the model in order to assist psychiatric nurse practitioners in facilitating the mental health of women living with borderline personality disorder (Walker & Avant, 2011, p. 63). The aim of concept synthesis is to generate new ideas and to provide a method of examining data for new insights that can add to theoretical development. In this study, newly defined concept is "facilitation of self-empowerment".

Firstly the new definition of the concept "facilitation" will be formulated, then the definition of self-empowerment will be formulated, and lastly "facilitation of self-empowerment" will be defined.

5.1.1. Definition of "facilitation"

The dictionary definition of "facilitation" is to assist, assist the progress of a person, or act of assisting.

The literature definition of the concept "facilitation" is described as a dynamic, interactive process by creating a positive environment, mobilisation of resources for promotion of health.

5.1.2. Definition of "self-empowerment"

A summary of the dictionary definition of the concept "self-empowerment" is knowing what is best for yourself by taking charge of your own life.

The literature definitions describe the concept "self-empowerment" as taking charge of your life and knowing what is best for you by playing an active role in creating the future of your dreams in order to feel secure, connected and to develop a sense of meaning and coherence.

5.1.3. Definition of "facilitation of self-empowerment"

The psychiatric nurse practitioner's facilitation of self-empowerment entails assisting the progress of a woman living with borderline personality disorder through a dynamic, interactive process by creating a positive environment and mobilising resources in order to promote mental health in women living with borderline personality disorder. Self-empowerment is achieved when the women living with borderline personality disorder know what is best for them and take charge of their own lives, by playing an active role in creating the future of their own dreams.

They achieve this by feeling secure and connected, and by developing a sense of meaning and coherence.

 

6. Discussion

The researcher used both the dictionary and subject definitions to define the concept of "facilitation of self-empowerment". The concept "facilitation of self-empowerment" is a relatively new concept in this specific context. Defining the concept was thus very crucial. Developing the concept "facilitation of self-empowerment" was also important, as the researcher's aim was to make the definition more accessible and easy to understand since it is a new concept. The concept needs to be understood easily, especially by the psychiatric nurse practitioner who will act as the agent in facilitating self-empowerment of women living with borderline personality disorder. The definition of the concept "facilitation of self-empowerment" was derived and analysed in a South African context. The definition of facilitation has similar components as the Theory of Health Promotion in Nursing (University of Johannesburg, 2011). The central concept's components will be used in developing a model to assist psychiatric nurse practitioners in facilitating the mental health of women living with borderline personality disorder. The model case demonstrates that psychiatric nurse practitioners need to assist women living with borderline personality disorder in taking charge of their lives. This process was limited in the sense that mostly the psychological literature was used for creating the subject meaning of the concept facilitation. The dictionary definitions of self-empowerment were limited in that only two definitions of the concept could be found. With regard to the subject definitions of the concept self-empowerment, the literature examined was more online articles than researched articles. These limitations emphasise the gap in the concept analysis of the concept self-empowerment.

 

7. Conclusion

This paper contributes to the nursing profession by defining a concept that has not been defined previously. This paper highlights the role of the psychiatric nurse practitioner that is current lacking in the South African scope of practice for psychiatric nurse practitioners. South Africa has no clear legislation that defines the scope of practice for psychiatric nurse practitioners (Temane, Poggenpoel, & Myburgh, 2014, p. 2). Such legislation will certainly not only empower women living with borderline personality disorder, but will also make the work of psychiatric nurse practitioner working with women living with borderline personality disorder more manageable. The researcher has consequently made recommendations for nursing practice, nursing education and nursing research.

 

8. Recommendations

8.1. Nursing practice

Defining the "facilitation of self-empowerment" is important in the psychiatric nursing context, especially in the psychotherapy units to which women living with borderline personality disorder are admitted. The psychiatric nurse practitioner must be knowledgeable about this concept, since they feel a great need to empower women living with borderline personality disorder. It would be crucial for the psychiatric nurse practitioner to understand this concept in order for implementation to be effective. This would require in-service training about self-empowering women living with borderline personality disorder. Once this concept is applied, often it would generate discussions that could further increase knowledge in the psychiatric nursing field; not only in South Africa but also internationally. This would also a have great impact on improving women living with borderline personality disorder's understanding in the facilitation process led by psychiatric nursing practitioners. Ultimately the women living with borderline personality disorder will gain facilitated mental health, which in turn will ultimately have greater benefits for mental health practice.

8.2. Nursing education

Defining the central concepts can assist in teaching psychiatric nursing students at undergraduate level, as well as post-graduate level, about borderline personality disorder and in exploring what women living with borderline personality disorder can achieve. Such knowledge will empower the psychiatric nursing student. Currently nurses are working towards an unachievable goal. The psychiatric student nurse will be taught what it is to truly facilitate self-empowerment and how to achieve it in their patients. This would ultimately make the work of psychiatric nurse practitioner satisfying, as the nurse would now understand what the "facilitation of self-empowerment" entails and how to deal with the challenges of borderline personality disorder.

8.3. Nursing research

The concept analysis process lays a foundation for the development of a model to facilitate the mental health of women living with borderline personality disorder. This already creates a need for further research to be done. Psychiatric nurse practitioners can evaluate the implementation of the facilitation of self-empowerment on the grounds of how they experience the process.

 

Acknowledgements

Marina van der Merwe for the language editing.

 

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Received 22 September 2015
Accepted 5 September 2016
Available online 18 October 2016

 

 

E-mail address: mpumin@uj.ac.za (N. Ntshingila).
Peer review under responsibility of Johannesburg University.
* Corresponding author. Fax: +27 115592257.