‘Safe from Harm’ first appeared in Mental Health Today inMarch 2011. To subscribe to the magazine click here.
Self-harm and borderline personality disorder are oftenclosely linked, and clinicians often make assumptions about these,but what helps and what hinders service users? Susie Marriottreports.
Self-harm is one of the top causes of acute medical admissionseach year and the UK has the highest rates in Europe. Despitethis, service users who self-harm – inflict injury on their ownbody – often describe a lack of understanding and care when theycome into contact with clinicians, something that service usersdiagnosed with borderline personality disorder (BPD) also say.There is no doubt that much controversy exists with these twotopics.
BPDThe use of BPD as a diagnosis is becoming all tooprevalent (Shulkes & Shaw, 2010) and the National Institute forHealth and Clinical Excellence (NICE) has produced practiceguidance for its treatment (National Collaborating Centre forMental Health, 2009). The guidance itself confesses that BPD is oneof the most contentious subtypes of personality disorder, a viewthat is widely accepted.
The term ‘personality disorder’ has been used to describe peoplewho have “an enduring pattern of inner experience and behaviourthat deviates markedly from the expectations of the individual’sculture…” (APA, 1994). A person has to have at least five of thefollowing ‘symptoms’:
– Intense interpersonal relationships
– Affective instability and moodreactivity
– Impulsive behaviours
– Inappropriate intense anger or difficultycontrolling anger
– Frantic efforts to avoid real or imaginedabandonment
– Unstable self-image or sense of self
– Recurrent suicidal and self-mutilatingbehaviours
– Chronic feelings of emptiness
– Transient paranoia or dissociative symptoms.
Affective and anxiety disorders, psychosis, substance usedisorder, or the occurrence of an acute medical or surgicalcondition, can all mimic symptoms of BPD (National CollaboratingCentre for Mental Health, 2009). This further complicates thediagnostic picture and maybe gives more weight to viewing people interms of their ‘experiences’ and their ‘needs’, and not their’deficits’ or ‘disorders’.
Receiving a diagnosis of BPD – what hinders
Terms like ‘untreatable’ are all too often used in relation toBPD and this can be extremely damaging (Shulkes & Shaw, 2010).Service users learn that although it might seem positive initiallyto be given a diagnosis, the way they are treated afterwards, ashaving both ‘madness’ and ‘badness’ (Johnson, 2010), means theyquickly become aware of the stigma, often coming from withinservices themselves.
Survivors describe how they no longer ‘fitted’ into a category,acquiring a ‘dustbin’ label, where services could not do anythingfor them (Shulkes & Shaw, 2010) except reject or exclude them.This can set off a negative pattern of care, perpetuating the cycleof rejection and damage where service users only have contact withservices when they are in crisis. They often report being judgedand seen as a troublemaker and too difficult to work with at thesetimes. A sense of hopelessness can prevail.
BPD – what helps
Johnson (2010) puts forward a powerful argument to replace’diagnosing’ in the conventional way with ‘developing apsychological formulation’. This is drawn up collaboratively withthe service user, over time, with planned interventions and issubject to revision and reformation.
This is an interesting idea and challenges the existing medicalmodel of diagnosing symptoms and treating an illness, turning aperson with problems into a patient with an illness. This is foodfor thought so it might be helpful to reframe BPD to complexpost-traumatic stress disorder (PTSD).
Self-harm – what hinders
Self-harm has remained a controversial issue that few cliniciansseem to understand. Terms like ‘deliberate’ and ‘intentional’ arestill used synonymously with self-injury. It implies the personcould stop if they wanted to or they were able to exercise controlover what they were doing. These are common misconceptions(Jellicoe-Jones et al, 2009).
It is unhelpful to see self-injury as attention-seekingbehaviour; it is about needing care and attention. It is not anattempt at manipulation, more a way of expressing what isunbearable and painful (Pembroke, 2000).
Self-harm – what helps
So what can clinicians do that is helpful? A moving account isprovided by Tate (2010), where she awarded three gold stars duringa positive encounter at the emergency department. One to thereceptionist, the second to the triage nurse and the third to theemergency doctor – when they all treated her with care andrespect.
She says that because the first two contacts were positive shebecame more relaxed and was able to tell the doctor why she hadinjured herself, something she had not done before. In fact, thiswas the first time she was able to tell any healthcare professionalthe truth about the circumstances of her self-harming, which inturn had a huge impact on her.
A study which asked women about their self-injury and treatmentsthey had found helpful also highlighted that positive contact withthe person providing the service was the important element to howthe individuals rated a service as ‘good’ or ‘helpful’ and notnecessarily the service itself (Marriott, 2001).
The first contact, at the point when the person has self-harmedand accesses acute medical care, is crucial and can lay down themap for future encounters. This can be when the person is at theirmost vulnerable and desperate.
It is therefore crucial to show concern for the injuriesthemselves and always describe what you are doing. Explanationsabout the related anatomy and physiology can involve the person incaring for the damage to promote self-care and knowledge of theirown bodies (Pembroke, 2010).
Ensure the person is not experiencing too much pain and askabout their preference for pain relief (National CollaboratingCentre for Mental Health, 2004).
It is important to see and care for the person in pain behindthe self-injury (BCSW, 2010) and not to criticise them or theirbehaviour; this is the last thing they need. Criticism can feedinto the person’s already low self-esteem and reinforce what theyalready feel and that is bad. It can intensify their feelings ofguilt and shame and quicken the path to self-disgust and build-upof tension, which can precipitate the repetition of thebehaviour.
Do not take responsibility for the injury, because you are not.If one can keep this in my mind while working with someone, it mayhelp deal with the moral conflict between safety and care.
Risk and safety discussions should be ongoing through the shortand long-term
Professionals need to make the person aware of this, be honestand negotiate and take the person’s views and opinions onboard.
Offer compassion and respect – this may be something differentfrom what he or she may be used to receiving (BSCW, 2010).
It is important to ‘stay in sync’ (LivingWorks, 2004) with theperson; this is about noticing the interaction between you andreading their nonverbal cues and not moving on too fast. Takethings at the person’s pace, notice when it seems too difficult totalk and acknowledge their pain and distress.
If you listen to enough reasons as to why a person feels thisway they will feel understood, and it will be easier to talk aboutsafety. It is useful to be aware that the person wants to be safetoo.
Always involve the person in decisions about their care andassessing/managing their risk – acknowledge that they are the’expert’ of their own condition and experiences (Waterhouse &Marriott, 2010).
If the injuries are old then it may well be appropriate to talkabout what led to the self-inflicted injury. But it is best to beguided by the person and to ask them about it sensitively.
One of the most important ways to help is to not makeassumptions.
You can define them by their behaviour, such as ‘self-harmer’but there is so much more to a person, so it is helpful to noticethis
It may take a long time for a person to be ready to give upself-injury so it is best to acknowledge this (RCP, 2010). By doingso you can begin to support the person to think of living withoutself-injury in the future.
Conclusion
There is no doubt about the devastating impact receiving adiagnosis of BPD can have on a person and their future life. Itmight therefore be more helpful to consider reframing BPD tocomplex PTSD, or simply use the sign that you are encountering theperson that something is wrong and support is needed.
Regardless of diagnosis, clinicians must be caring, showcompassion and be supportive and non-judgmental. Clinicians mustalways be professional, but should not forget to show humanresponses, as this is what has the greatest impact of all.
Post uploaded March 2011 by Susie Marriott
