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Saturday, April 30, 2011

How to Disarm a Borderline, Part VII: Suicide Threats

Before reading this post, particularly if you are going to try this at home with a real adult family member with borderline personality disorder (BPD) (which is not recommended without the help of a therapist), please read my previous posts Part I (October 6), Part II (October 29), Part III (November 24), Part IV (December 8), and Part V (January 12), and Part VI (March 2). The countermeasures described in this post do not work in isolation but must be part of a complex, consistent, and ongoing strategy.

In this post, I will discuss the most dangerous and difficult problem of all, suicide and parasuicidal behavior. Parasuicidality includes suicide attempts, gestures, threats and non-suicidal self-injurious behavior (SIB) such as cutting or burning oneself.  In my opinion, self-induced vomiting and drug or alcohol binging are also SIB.  In some cases, also in my opinion, excessive body piercing and tatooing may also be.

***Important caveat:  In cases in which a family member engages in suicidal or parasuicidal behavior, strong efforts should be made to get that person to a mental health professional who has experience with, or even specializes in, borderline personality disorder.  No one should attempt to deal with such a person all by themselves.  However, getting an oppositional individual to seek help is often in itself no simple feat.

Having said that, I can still discuss some things that are helpful for anyone dealing with such a person to know.

First of all, it is important to be aware that just because a person has make a lot of idle suicide threats in the past, this does not mean that they will not kill themselves in the future.  Follow-up studies have shown that individuals with BPD have a 10% rate of completed suicides over the long term.  That is nothing to sneeze at.  Of course, that means that the good news is that about 90% of persons with BPD will not kill themselves.

So one does have to take suicide threats seriously.  On the other hand, if a relative goes into hypercontrol mode every time a person talks about suicide, and tries over and over again to get the person committed to a mental hospital, this may actually make things worse rather than better. Remember, making others feel helpless is part of what persons with BPD try hard to do, while secretly hoping that they fail at it.

There is no evidence that psychiatric hospitalizations reduce the long term risk of suicide in patients with BPD.  Hospitalization should only be used occasionally to buy time during an unusual acute crisis so that the unusual circumstances pass.  This may reduce an imminent risk. 

Furthermore, individuals with BPD can use parasuicidal behavior to make others look foolish.

I learned this the hard way.  When I first started practicing in the late 1970's, a time when BPD was far less prevalent than it is today - it wasn't even in the DSM until 1980 - I was providing back up coverage for another psychiatrist.  I got a call from one of his patients. 

The woman immediately started making wild suicide threats.  I found out where she was at and called the police to go out to her house.  By the time they got there, she was calmly knitting away like Madame DeFarge and sweetly telling the police, "I don't know what Dr. Allen is so excited about; I never said anything about killing myself."

 
So what else should a lay person know that might be helpful in negotiating this minefield?
 
First of all, if an individual with BPD says that they are thinking about suicide, this is usually not a suicide threat.  People with BPD frequently think about suicide.  Doing so is actually one of the criteria for the condition.  If, on the other hand, the patient says, "I am going to kill myself," then the threat should be taken more seriously.
 
Second, if a person is dead set on killing himself, pardon the pun, then there is literally nothing you can do about it. You are helpless.  As mentioned, hospitalizations can only buy time.  We cannot lock such people in a hospital room and throw away the key.  They will be out eventually.  Fortunately, most individuals with BPD are highly ambivalent about dying.
 
Third, most SIB is not meant to lead to death.  People hurt themselves because it makes them feel better when they are overwhelmed and highly anxious, not because they wish to die.  "Pulling your hair out" is a common expression concerning this feeling, so the urge is not exactly unknown to non-BPD individuals.  Otherwise normal people often slap themselves in the head or pound their fist into a wall when frustrated.  So, while witnessing or hearing about a loved one engaging in SIB is very distressing, one usually does not have to worry about actual suicide.
 
Suicide gestures are usually impulsive, non-lethal reactions to an episode of an interpersonal conflict that are meant to manipulate the other person, and likewise do not often lead to death.  People in this situation will cut their wrists or take a handful of pills that they know will not kill them.  Obviously, if a person takes a handful of pills one should probably call 911 anyway.  Sometimes suicide gestures accidentally lead to death.  One can choke to death on the pills, for example.  Several rock stars apparently met their demise in this fashion.
 
Another important clue as to the seriousness of a suicide threat is the tone of voice and the choice of words made by the threatener.  If someone says that they may kill themselves at some point and are being coy about exactly when and where, that usually means that they are not imminently suicidal but are trying to make you feel helpless.  Another clue is when their tone sounds something like, "Nyah, Nyah, Nyah - Nyah, Nyah, I'm going to kill myself and there's nothing you can do about it." The threat may not be a serious one.
 
For example, the very first patient with BPD I saw as a resident, which coincidentally was the first patient I ever had in psychotherapy, started making such threats.  We were in an outpatient office late on a Friday afternoon.  I picked up the phone to call security.  She calmly reacted with, "You know if you call security, I'll run out of the room and I'll be gone before they get here."  Zing, she had me.  I was in a total panic as she indeed quickly left the office.

In the cell phone age, things are even worse.  Threateners can phone in a suicide threat, knowing that there is no way they can even be located. 
 
I spoke to a faculty member about the patient I just mentioned.  He suggested I could have said, "You really want me to worry about you, don't you?" 

Had she then replied, "Oh, bull! You don't care about me," I could have replied, "Well, I am going to be worried about you all weekend."  Good advice.

I could have also said, in a sincere tone, "I sure hope you don't do that."

By the way, that patient showed up on time for our next regularly scheduled visit as if nothing had happened.

I do have one other intervention I frequently use called the paradoxical offer to hospitalize.  It's paradoxical because it is meant to keep people out of the hospital.  It is not really appropriate for a lay person to use, so I won't describe it here (Therapists can find it in my book, Psychotherapy with Borderline Patients: An Integrated Approach).  Besides, I don't want potential patients to know all of my secrets.

9 comments:

  1. Would a "hunger strike" in a frail elderly woman qualify as self-injurious behavior?

    a fan and a frequent reader, in Milwaukee, Wisconsin

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  2. "Fortunately, most individuals with BPD are highly ambivalent about dying."

    Although I won't claim to speak for "most" of any arbitrary group, I can offer the perspective that, as someone raised as the family scapegoat, I am alive because it turns my stomach to think of proving the family right. Nice dance, eh? My existence is the official excuse for their unhappiness, but ending it would only reinforce their convictions and provide a built-in excuse for all their future miseries. I've extricated myself just enough from the unit that I have to stay alive for as long as other people matter. Cute! And RIDICULOUS. Grrr....

    That is way oversimplified and may not be as clear as I'd like it to be. (I'm not quite ignoring "with BPD," but I'd suppose people with any number of issues are ambivalent about dying.)

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  3. I have BPD and I have NEVER wanted or tried to make anyone feel helpless. I am not manipulative. You over-generalize doctor.

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    1. Never 'wanted or tried' is not the same thing as never having done so.

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    2. Wow, talk about an invalidating response right there! I think it's very reasonable for anyone, BPD or not, to wonder aloud why "the other" would feel so sure about their generalizations even in the face of conflicting information. Also, since we've moved on from the 80's, most in the field seem to have realized that BPD is a syndrome, not a single disease, the permutations of which yield at least 256 different clinical presentations of what is now termed simply "BPD."

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  4. I am a BPD and I never use suicide as a threat. It really really hurts when people make fun of the word in front of me. It feels like discrimination - kicking you because you feel bad.

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  5. I'd be very grateful if you could reply. I've found this series of blogposts very helpful.

    A close friend of mine has BPD. Her behaviour has been particularly bad since a bad break-up three years ago. During that period, I have found through trial and error that patience and kindness are very effective. However, I find it hard to cope when she threatens to kill herself, which has happened probably four times now. At this point, I feel furious with her. Yesterday, after finding out that, contrary to her email, she was not about to kill herself (she was instead informing her friends that if things turn out a certain way, she will kill herself), I snapped and told her she was being selfish and manipulative. I might need to not be in contact with her for some weeks now. I'm not sure. Maybe I'll feel differently in a few days.

    But what I want to know is, should I tell her how emotionally shocking and traumatic it is to get these threats and tell her there is a boundary in friendship and she is crossing it when she does things like that? But could that reinforce her desire to make me feel that way in future? Is it somehow counter-productive to try and make her think about the effect of what she's done?

    Or should I somehow pretend it didn't get to me as much as it did and try to move on and be calm and kind? I just feel that doing so wouldn't be human. I'm not her shrink. I'm her friend.

    More broadly, do you think it's crazy to try and maintain a friendship with a person with BPD? Fundamentally, I don't really believe there's anything wrong with her. I mean, I believe she's been in pain and depression, but she's mostly a sensible and very intelligent person. It's just... she winds herself into these fits, collateral damage be damned. And I get sick of being collateral damage at times.

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    1. Hi Anonymous,

      Unfortunately what works for one person may not work for another, and individuals with the disorder vary widely as to how serious their suicide threats can be, so I cannot really give you any specific advice.

      More generally, I absolutely do not think it's crazy to maintain a friendship with someone with the disorder if you usually enjoy their company, so long as you are aware of your own limitations and communicate these limits to them clearly.

      In general, when the relationship is in a calm state and no threats are being made, one should let that person know what those limits are in an almost apologetic tone of voice but without backing down on them. For example, saying something like, "I'm sorry, I want to be there for you when you feel bad, but it's too upsetting for me when you talk like that and I'll have to back away." If she can't accept that, (even though she is probably already aware of it), or tries to guilt trip you and won't stop, then you probably cannot remain friends with her. (Even Marsha Linehan won't talk to patient for at least 24 hours after they self-injure).

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  6. Thanks for your response.

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