'Safe from Harm' first appeared in Mental Health Today in March 2011. To subscribe to the magazine click here.

Self-harm and borderline personality disorder are often closely linked, and clinicians often make assumptions about these, but what helps and what hinders service users? Susie Marriott reports.

 

Self-harm is one of the top causes of acute medical admissions each year and the UK has the highest rates in Europe. Despite this, service users who self-harm - inflict injury on their own body - often describe a lack of understanding and care when they come into contact with clinicians, something that service users diagnosed with borderline personality disorder (BPD) also say. There is no doubt that much controversy exists with these two topics.

 

BPDThe use of BPD as a diagnosis is becoming all too prevalent (Shulkes & Shaw, 2010) and the National Institute for Health and Clinical Excellence (NICE) has produced practice guidance for its treatment (National Collaborating Centre for Mental Health, 2009). The guidance itself confesses that BPD is one of the most contentious subtypes of personality disorder, a view that is widely accepted.
The term 'personality disorder' has been used to describe people who have "an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual's culture…" (APA, 1994). A person has to have at least five of the following 'symptoms':

- Intense interpersonal relationships

 - Affective instability and mood reactivity

 - Impulsive behaviours

 - Inappropriate intense anger or difficulty controlling anger

 - Frantic efforts to avoid real or imagined abandonment

 - Unstable self-image or sense of self

 - Recurrent suicidal and self-mutilating behaviours

 - Chronic feelings of emptiness

 - Transient paranoia or dissociative symptoms.  

Affective and anxiety disorders, psychosis, substance use disorder, or the occurrence of an acute medical or surgical condition, can all mimic symptoms of BPD (National Collaborating Centre for Mental Health, 2009). This further complicates the diagnostic picture and maybe gives more weight to viewing people in terms 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 to BPD and this can be extremely damaging (Shulkes & Shaw, 2010). Service users learn that although it might seem positive initially to be given a diagnosis, the way they are treated afterwards, as having both 'madness' and 'badness' (Johnson, 2010), means they quickly become aware of the stigma, often coming from within services themselves.

Survivors describe how they no longer 'fitted' into a category, acquiring a 'dustbin' label, where services could not do anything for them (Shulkes & Shaw, 2010) except reject or exclude them. This can set off a negative pattern of care, perpetuating the cycle of rejection and damage where service users only have contact with services when they are in crisis. They often report being judged and seen as a troublemaker and too difficult to work with at these times. 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 a psychological formulation'. This is drawn up collaboratively with the service user, over time, with planned interventions and is subject to revision and reformation.

This is an interesting idea and challenges the existing medical model of diagnosing symptoms and treating an illness, turning a person with problems into a patient with an illness. This is food for thought so it might be helpful to reframe BPD to complex post-traumatic stress disorder (PTSD).

Self-harm - what hinders

Self-harm has remained a controversial issue that few clinicians seem to understand. Terms like 'deliberate' and 'intentional' are still used synonymously with self-injury. It implies the person could stop if they wanted to or they were able to exercise control over what they were doing. These are common misconceptions (Jellicoe-Jones et al, 2009).

It is unhelpful to see self-injury as attention-seeking behaviour; it is about needing care and attention. It is not an attempt at manipulation, more a way of expressing what is unbearable and painful (Pembroke, 2000).

Self-harm - what helps

So what can clinicians do that is helpful? A moving account is provided by Tate (2010), where she awarded three gold stars during a positive encounter at the emergency department. One to the receptionist, the second to the triage nurse and the third to the emergency doctor - when they all treated her with care and respect.

She says that because the first two contacts were positive she became more relaxed and was able to tell the doctor why she had injured herself, something she had not done before. In fact, this was the first time she was able to tell any healthcare professional the truth about the circumstances of her self-harming, which in turn had a huge impact on her.

A study which asked women about their self-injury and treatments they had found helpful also highlighted that positive contact with the person providing the service was the important element to how the individuals rated a service as 'good' or 'helpful' and not necessarily the service itself (Marriott, 2001).

The first contact, at the point when the person has self-harmed and accesses acute medical care, is crucial and can lay down the map for future encounters. This can be when the person is at their most vulnerable and desperate.

It is therefore crucial to show concern for the injuries themselves and always describe what you are doing. Explanations about the related anatomy and physiology can involve the person in caring for the damage to promote self-care and knowledge of their own bodies (Pembroke, 2010).

Ensure the person is not experiencing too much pain and ask about their preference for pain relief (National Collaborating Centre for Mental Health, 2004).

It is important to see and care for the person in pain behind the self-injury (BCSW, 2010) and not to criticise them or their behaviour; this is the last thing they need. Criticism can feed into the person's already low self-esteem and reinforce what they already feel and that is bad. It can intensify their feelings of guilt and shame and quicken the path to self-disgust and build-up of tension, which can precipitate the repetition of the behaviour.

Do not take responsibility for the injury, because you are not. If one can keep this in my mind while working with someone, it may help deal with the moral conflict between safety and care.

Risk and safety discussions should be ongoing through the short and long-term

Professionals need to make the person aware of this, be honest and negotiate and take the person's views and opinions onboard.

Offer compassion and respect - this may be something different from what he or she may be used to receiving (BSCW, 2010).

It is important to 'stay in sync' (LivingWorks, 2004) with the person; this is about noticing the interaction between you and reading their nonverbal cues and not moving on too fast. Take things at the person's pace, notice when it seems too difficult to talk and acknowledge their pain and distress.

If you listen to enough reasons as to why a person feels this way they will feel understood, and it will be easier to talk about safety. It is useful to be aware that the person wants to be safe too.

Always involve the person in decisions about their care and assessing/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 talk about what led to the self-inflicted injury. But it is best to be guided by the person and to ask them about it sensitively.

One of the most important ways to help is to not make assumptions.

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 notice this

It may take a long time for a person to be ready to give up self-injury so it is best to acknowledge this (RCP, 2010). By doing so you can begin to support the person to think of living without self-injury in the future.

Conclusion

There is no doubt about the devastating impact receiving a diagnosis of BPD can have on a person and their future life. It might therefore be more helpful to consider reframing BPD to complex PTSD, or simply use the sign that you are encountering the person that something is wrong and support is needed.

Regardless of diagnosis, clinicians must be caring, show compassion and be supportive and non-judgmental. Clinicians must always be professional, but should not forget to show human responses, as this is what has the greatest impact of all.

Post uploaded March 2011 by Susie Marriott