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26 June 2009 mentalhealth today

Referring to people as PDs simply depersonalises them, and terms such as manipulative and attention seeking are often derisive, and usually inaccurate, says Christopher Raven

Borderline personality disorder: still a diagnosis of exclusion?

espite recent initiatives and positive guidance from the government, borderline personality disorder remains a diagnosis that seems to evoke extremes of emotional response from practitioners, such as annoyance, frustration, anxiety, helplessness and sometimes apathy. As a result, people diagnosed with borderline personality disorder often receive limited and inconsistent care, which can often mimic their own internal turmoil. Service provision for people diagnosed with personality disorder is sparse, with exclusionary practice still operating in many mental health services (Department of Health, 2006). One reason for this could be the controversial nature of the diagnosis, in that many clinicians feel that it is impossible to treat a persons personality, and therefore people with this personality type only really receive treatment for their acute symptoms in times of crisis, rather then for the disorder as a whole (Flory, 2007). As a crisis often appears brief although it can be frequent in times of particular stress the time span in which professionals intervene is often short, so the opportunities for making any real difference to the service users life is very limited. This reinforces the professional view that the condition is untreatable, and strengthens the stigma attached to it. Many service users diagnosed with personality disorder do indeed feel stigmatised by services, and feel they are viewed as difficult, manipulative, and attention seeking. Many feel blamed by services for their

condition, when all they seek is legitimacy and basic acceptance (NIMHE, 2003). After many years working in mental health, I have come to the conclusion that, because of the stigma attached to the diagnosis and how it is described in many professional texts, people diagnosed with borderline personalities are not always adequately informed about their diagnosis. Practitioners can become cautious about giving information due to this stigma, and an alternative diagnosis is often applied. I believe that the stigma associated with personality disorder is actually created by services feeling powerless to help, and we perpetuate this stigma when we avoid labelling people with such a stigmatising diagnosis as this reduces the opportunities for individuals to learn about themselves, and receive appropriate treatment. I have also found that professionals can also become cautious about offering support in case it opens up cans of worms, and many feel ill equipped to deal with the raw emotion that can sometimes manifest. Conversely, other practitioners often seem unwilling to believe that the service user is feeling any real emotion at all, giving way to the view that they are attention seeking or manipulating services in some way. More often then not, ineffective support and information provision is due to practitioners not understanding the diagnosis particularly well. I hope to challenge the view that people with borderline personalities are beyond help, or somehow not in need of support from mental health services by exploring what the condition really means for the

KEY WORDS Personality disorder Stigma Community mental health Assertive outreach A&E department

AUTHOR Christopher Raven has worked in mental health since 1990. He qualified as a social worker in 2000 and has worked in many roles (including management and tenant participation), and various settings, both in the voluntary and statutory sectors. These include residential care, inpatient settings, community mental health teams and assertive outreach. He currently works in Tower Hamlets home treatment team. Contact: chris. raven@hotmail.com

Target audience
This article provides an alternative and optimistic approach to working with people who are diagnosed with borderline personality disorder and should be of particular interest to care co-ordinators as well as practitioners in acute care and crisis settings.

Take-home messages
Photo credit: spfoto, iStock

Regardless of your setting, professional background or role, a more individualised and optimistic approach to working with people with a borderline personality disorder should go a long way to relieving the distress and discontent in both service user and practitioner alike.

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Personality disorder
people who experience it. I also hope to offer positive advice, and argue that working with, or even having a borderline personality type, though at times distressing and difficult, can at other times be very positive and rewarding. services should have no involvement in trying to cure a person of their personality. Your personality is what makes you who you are, and like all personality types, the components that make up your personality can be both positive and negative. However, this does seem to be the root of the difficulties that services have in working with borderline personality disorder, in that by its very nature, health services are in the business of treating illnesses, and health practitioners become very frustrated when they feel unable to do this (Perkins et al, 1996). Nevertheless, I would argue that mental health services have a clear and important role in supporting people with borderline personalities, and can make very real and significant changes in how people perceive themselves and manage distress. Also, people with borderline personalities can also be prone to legitimate illnesses such as depression, post-traumatic stress disorder, and anxiety due to the impact of their personality on their lives, and the life events that possibly contributed to the development of the personality type in the first place (Chapman & Gratz, 2007). The ICD-10 and DSM-IV definitions describe two main features of borderline personality, the first being impulsivity and emotional instability, and the second being feelings of emptiness and an undefined or uncertain sense of self. Issues such as being unable to plan ahead, having emotional outbursts, self-harm, and a fear of abandonment are, in my opinion, less to do with symptoms, and more to do with how individuals react to the two features of borderline personality. This is quite a useful point of view, as it opens up opportunities to:  i dentify the positives and negatives that the personality features present, allowing service users to amplify the positives and manage the negatives  i dentify behaviours or habits that are adversely affecting the service user, and support them to understand them within the concept of their personality, thereby developing effective coping strategies to either remove, replace, or reconceptualise them, or at least minimise their impact. This approach does, however, rely on open, optimistic, and positive communication with the service user, which is difficult with existing definitions. I have found the Chapman and Gratz (2007) definition of borderline personality disorder clear and accessible, and have found it useful when explaining the diagnosis to service users. BPD (borderline personality disorder) is a disorder of instability and problems with emotions. People with BPD are unstable in their emotions, their thinking, their relationships, their identity, and their behaviour. People with BPD have rocky relationships and are often afraid of being abandoned. Emotionally, people with BPD feel like they are on a roller coaster, with their emotions going up and down at the drop of a hat. They may also have trouble with anger (either having anger outbursts or being so scared of anger that they avoid it entirely). People with BPD act impulsively (they act quickly without thinking)

The diagnosis

According to the ICD-10 Classification of Mental and Behavioural Disorders (WHO, 1994), emotionally unstable personality disorder is a condition in which there is a marked tendency to act impulsively, and without consideration of the consequences, together with affective instability. The ability to plan ahead may be minimal, and outbursts of extreme anger may often lead to violence, or behavioural explosions (p204). The ICD-10 identifies two variants of emotionally unstable personality disorder, the impulsive personality type, and the borderline personality type. People with impulsive personalities are described as having emotional instability and poor impulse control, which can often result in outbursts of violence, or threatening behaviour, especially when criticised. People with borderline personalities are also characterised with emotional instability, along with unclear or disturbed self-image, aims and internal preferences (including sexual), as well as chronic feelings of emptiness. The ICD-10 also describes a tendency to become involved in intense and unstable relationships, resulting in repeated emotional crisis, associated with excessive efforts to avoid abandonment and a series of suicidal threats or acts of self-harm (WHO, 1994). The American Psychiatric Association (1994) defines borderline personality disorder in its DSM-IV classification of mental disorders. Here it is defined as a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity beginning in early adulthood and present in a variety of contexts, and goes on to list a number of diagnostic criteria, of which five or more should be present for at least a year.  F rantic efforts to avoid real, or imagined abandonment  A pattern of unstable and intense interpersonal relationships characterised by alternating between extremes of idealisation and devaluation  I dentity disturbance: markedly and persistently unstable self-image or sense of self  Impulsivity in at least two areas that are potentially self-damaging (for example, spending, sex, substance abuse, reckless driving, binge eating)  Recurrent suicidal behaviour, gestures, or threats, or self-mutilating behaviour  A ffective instability due to marked reactivity of mood, usually lasting a few hours and only rarely more then a few days Chronic feelings of emptiness  Inappropriate intense anger or difficulty controlling anger  Transient stress-related paranoid ideation or severe dissociative symptoms. Looking at these definitions, terms such as illness and symptoms are fairly obvious in their absence. This is quite correct, as I agree in principle that mental health

28 June 2009 mentalhealth today

Personality disorder
when they are upset, and they sometimes attempt suicide and engage in self-harm. Often people with BPD have trouble figuring out who they are, and they sometimes have trouble thinking clearly and staying grounded when they are stressed out. (Chapman & Gratz, 2007: 1617).

The guidance in practice

The causes

There are many theories as to why people develop personality disorders, including biological, psychological and social factors, which create in individuals a combination of difficulties with personal identity and with accurately interpreting the behaviour of others (Alwin, 2006). Chapman and Gratz (2007) suggest that people with borderline personality disorder are naturally sensitive and emotional people, and in that respect it is to some degree a physical condition, as emotionality is reliant on such factors as genes and brain function. For naturally emotional people to go on to develop a borderline personality, they have usually experienced a sustained invalidating environment or significantly traumatic events in their developmental years (usually in childhood). An invalidating environment is one in which people communicate that your thoughts or feelings are not valid, reasonable, understandable or true (Chapman & Gratz, 2007, 53). Unfortunately, service users with borderline personalities have often found mental health practitioners assuming that what they say, feel or do is somehow invalid, unreasonable, or untrue (NIMHE, 2003), which of course mirrors and perpetuates past abuses.

The official guidance

The NICE clinical guidance for working with borderline personality disorder sets out the following advice.  People with borderline personality disorder should not be excluded from any health or social care services because of their diagnosis, gender, or because they have self-harmed.  Health and social care professionals should work in partnership with people with borderline personality disorder with the aim of developing their autonomy and promote choice.  Health and social care professionals working with people with borderline personality disorder should:  explore treatment options in an atmosphere of hope and optimism, explaining that recovery is possible and attainable  build up a trusting relationship, work in an open, engaging and non-judgemental manner, and be consistent and reliable  be aware of sensitive issues, including rejection, possible abuse and trauma, and the stigma often associated with self-harm and borderline personality disorder.  Health and social care professionals should ensure that withdrawal and ending of treatments, and transition from one service to another, is discussed carefully and in advance with the person (and carers if appropriate) and anticipate that endings may evoke strong emotions and reactions for the person (NICE, 2009).

The first stage in adequately supporting people with borderline personalities is to recognise the role mental health services has had in perpetuating the stigma associated with the condition, and to develop a more positive and hopeful attitude. Being emotionally sensitive, with a fear of abandonment makes many people with borderline personalities very skilled at reading body language for signs of rejection. If you are a practitioner with negative views of borderline personality disorder, and are unwilling to reflect on this and change your opinion, the best way for you to support a person with borderline personality disorder is to keep away, as you may only succeed in alienating them and reinforcing their feelings of inadequacy and of being out of control. You may in fact, perpetuate and mirror the abusive relationships that created the personality disorder in the first place. If, on the other hand, you are willing to provide a supportive service, then try and understand the nature of the condition. People with borderline personalities, especially when in distress, are emotionally labile. This is actually a good thing if approached correctly, as the service user can be very responsive to the practitioners emotional state. If approached incorrectly, it does become a hindrance. I have found that two extremes of intervention are often carried out. Services will either under-support due to fears of creating dependency, opening cans of worms which will be difficult to close, or under-valuing the level of distress at the time. Under-supporting is problematic, because it can amplify the service users feelings of rejection and low self-worth. Alternatively, services can also over-react, with practitioners showing too much concern and entering into the crisis with the service user. Over-reaction is also problematic, as it amplifies the service users feelings of chaos and of being out of control. What people with borderline personalities need in times of crisis is firm ground. Coming from a strengths perspective (Morgan, 1996), I have found that offering measured, but supported and optimistic interventions has, in my experience, been very effective, and I have found people to respond very strongly and positively to not only reassurance, but also to my genuine trust in their ability to manage the situation. Be aware also that a single episode of distress can be short lived, but the underlining crisis can be lengthy if its cause is not addressed. People with borderline personalities manage their lives adequately most of the time, despite the difficulties their personalities present them. Occasionally, lifes events undermine their usual coping skills, and a crisis follows. The very nature of the personality type means that crisis can take the form of rapidly cycling periods of distress then calm. Avoid treating each episode of distress as a new event, as it may not be, it may be part of the current crisis still. Before getting frustrated and concerned about dependency, consider offering consistent support through each episode of distress, taking every opportunity to assist the service user in learning from their experience, and developing strategies, and the confidence to deal with any future distress.

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Take an interest when the service user is not in crisis, as this is the best time to educate, explore and develop strategies for coping with crisis, and adverse life events. Develop a true understanding of the individual and work together to form plans. Help them avoid stressful situations by recognising any issues they may have with forward planning. In other words, ensure that individuals remain actively involved in finding solutions to their problems, even during crisis, and encourage individuals to consider different treatment options and life choices, with consideration for any consequences these choices may have (NICE, 2009). Also, be aware of the stigma associated with the diagnosis, but avoid letting it prevent you from offering information about the condition. Be mindful of the language you use, not only with the service user, but also in the office, as the language you use, and which is used around you will affect your attitude towards your service users. Referring to people as PDs simply depersonalises them, and terms such as manipulative and attention seeking are often derisive, and usually inaccurate. For example, if someone were attention seeking, this would suggest that they are in need of some attention. It is not the service users responsibility to seek attention in a way that services find appropriate, but it is the practitioners responsibility to respond professionally and skilfully (Perkins & Repper, 1996). Manipulative behaviour can be considered a process in which a service user has learnt from years of being under-supported by services, to exaggerate their symptoms to receive the support they feel they need, however, I do not believe that this is always the case. Remember that when in distress a person with a borderline personality may be overwhelmed by strong emotions, feel out of control, and may be impulsive. Is it not then understandable, when someone approaches more than one source of support, is inconsistent regarding the support they want and can quickly become frustrated and reactive? Again, it is the services responsibility to respond to this professionally and skilfully, and not judge the service user for having the symptoms of their condition (Perkins & Repper, 1996). Finally, be aware of the impact of endings and that people with borderline personalities are particularly sensitive to feelings of abandonment and may have trouble not taking a change of practitioner or service personally. Consider whether an ending of a service should be structured and phased out over a period of time, and whether working with other care providers might be helpful over such transitions, and ensure systems are in place for managing any potential crisis over this time (NICE, 2009). concern due to the emotional liability and impulsivity associated with the condition. Chapman et al (2007) cites one study that found 75% of people diagnosed with borderline personality disorder saying they have made at least one attempt to end their life, and it is also estimated that between 5% and 10% of people with this diagnosis are actually successful (Chapman & Gratz, 2007). This risk of suicide, along with the associated impulsivity can raise serious concerns for mental health services, and in view of these risk potentials, it is no wonder that both services and service users prefer admission to hospital when safety is in any doubt. The National Institute for Health and Clinical Excellence (2009) gives the following advice in regards to formulating risk assessment for people with borderline personality disorder. Undertake within the context of a needs assessments. Differentiate between acute and long-term risks.  I dentify risks to self, and others (including the welfare of dependent children). Formulate assessments with the person concerned. Explicitly relate to long-term treatment strategies.  T ake into account any changes in personal relationships, including the therapeutic relationship. One of the long-term risks to service users is repeated admission to hospital when in emotional distress. This is problematic because it erodes the service users independence, self-esteem, and any opportunity to develop future, or try out existing coping strategies (Raven, 2007). It also increases the stigmatisation already present for that person due to their diagnosis, as practitioners in acute care settings become increasingly more frustrated at each identical presentation.

In summary

C  hallenge your own assumptions, attitudes and prejudices. Work towards autonomy, and choice.  B e optimistic, supportive, encouraging and consistent.

Messages for community mental health and assertive outreach teams


C  are co-ordinators are the most consistent and important health care professional in the service users life, so they should get to know the person behind the diagnosis.  F ocus on recovery and on developing coping strategies, rather than only being involved when it is a matter of risk management or crisis.  Consider the risks of dependency and institutionalisation when considering hospital admission or referral to home treatment, as you may well be the most effective person to support someone through crisis, due to your ongoing relationship.  F ormulate with the service user a user-led comprehensive multidisciplinary care plan that specifies potential triggers for that person, and identified the course of action to be taken when in distress (NICE, 2009).

Managing risk

As a diagnosis, borderline personality disorder is often associated with a number of self-harming and risk-taking behaviours, and may be a cause of anxiety and frustration in practitioners. Such behaviour can include repeated self-harm, severe risk taking and attempts at suicide. These issues are of particular

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Messages for accident and emergency departments, psychiatric liaison and inpatient services
H  ospital admissions may feel the safest option at times when a service user is expressing suicidal thoughts and beliefs, or is harming themselves, but is not always helpful in the long run, especially if there are repeated admissions.  A&E can be a safe haven when needed, even if it is for a short while, as can short hospital admissions.  You may need to spend some time reassuring the service user that the crisis will pass and that they have the past experience, the skills and the ability to get through what they are currently experiencing.  Waiting time targets may make it difficult to devote this amount of time in A&E.  Make sure that their established diagnosis is not masking another acute condition, such as depression.  H ome treatment is a less restrictive option than admission to hospital. others. Mental health practitioners need to develop compassionate and non-judgemental attitudes if they wish to successfully support people with borderline personalities, and should focus on helping people make positive changes to their lives. This seems very simple, but of course the most effective interventions are. n
Alwin N (2006) The causes of personality disorder. In: M Sampson, R McCubbin & P Tyrer (Eds) Personality Disorder and Community Mental Health Teams: A practitioners guide. Chichester: John Wiley and Sons Ltd. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Health (4th ed). Arlington, VA: American Psychiatric Association. Chapman AL & Gratz KL (2007) The Borderline Personality Disorder Survival Guide: Everything you need to know about living with BPD. Oakland, CA: New Harbinger Publications, Inc. Department of Health (2006) Personality Disorder Capacity Plans 2005 Summary. London: Department of Health. Flory L (2007) Understanding Borderline Personality Disorder. London: Mind. Morgan S (1996) Helping Relationships in Mental Health. London: Chapman and Hall. NICE (2009) Borderline Personality Disorder: Treatment and management: The National Institute for Health and Clinical Excellences clinical guideline 78. London: NICE. NIMHE (2003) Personality Disorder: No longer a diagnosis of exclusion. London: National Institute for Mental Health in England. Perkins E & Repper JM (1996) Working Alongside People with Long-term Mental Health Problems. Cheltenham: Nelson Thornes Publishers Ltd. Raven C (2007) Breaking the cycle of risk. OpenMind 146 July/ August. WHO (1994) The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: World Health Organization.

Messages for crisis resolution and home treatment teams


R  epeated referrals to home treatment are not always helpful, but there is definitely a role in supporting care co-ordinators and inpatient services to break the cycle of revolving door admissions, and a lot of good crisis management work can be achieved.

Conclusion

Borderline personality disorder is caused by a combination of being born particularly emotional, and then having those emotions invalidated by

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