Excerpts from "Borderline Personality Disorder: Struggling, Understanding, Succeeding"
Chapter 5: The Struggle to Stay Alive
This is a tough chapter - there's a lot of good, important information here, but I'm not up to transcribing it all and it's been difficult to pull out the most salient parts... So let's go back to the beginning... [Remember this book is written by a clinician for clinicians...]
For many Borderlines, one of the biggest struggles is chronic thoughts of suicide or other self harm. It is difficult to focus on other goals in life when one is chronically overwhelmed with urges to hurt oneself. Likewise for many clinicians one of the biggest struggles is dealing with the client's chronic parasuicidal behavior. It is difficult to focus on other therapeutic goals or set limits when one is worried about the client's safety. This anxiety can often lead to countertransference reactions in the clinicians including feelings of hopelessness, helplessness, anger, and resentment. (45)
...
Studies consistently estimate the percentage of Borderlines who complete suicide at 3 to 10% and most completed suicides happen later in the course of the illness. This reiterates the importance of clinicians dealing with borderlines having adequate understanding of risk assessment, intervention and documentation techniques. In short, Borderlines are more likely to self injure than other psychiatric populations but not necessarily more likely to complete suicide.
FUNCTIONS OF PARASUICIDAL BEHAVIOR
One of the most critical points to understand in dealing with parasuicidal behavior is that while helping professionals and others tend to view parasuicidal behavior as a "problem," borderlines view it as a "solution." This is extremely important because unless clinician and client agree on what the "problem" is, they will often be working at cross purposes. Most often, professionals simply want the client with BPD to stop the self-injurious behavior and become frustrated when the client seems unable or even unwilling to do so. Often this is misinterpreted to mean they "enjoy" the behavior.
Invariably if one explores this sufficiently one finds that the reason they are unable or unwilling ti stop self injury is not that they truly or completely believe self injury is in their best interest, but because they view it as the only or the most efficient means to meeting some need. If one explores the thoughts, urges, and feelings associated with the parasuicidal behavior sufficiently one can identify what functions it serves (i.e. what the "problem" is for the client) and can then teach the client less damaging strategies to serve that function of meet that need.
Notice I use the term "less damaging" and not "more efficient" or "more effective." This choice of words is intentional as part of what the client may have to learn is that they may need to use other strategies that in face are more difficult or take longer to be effective than self injury. Part of the intervention then is to convince them to choose a strategy that ultimately may be more difficult but is less damaging.
So how does parasuicidal behavior serve to solve problems? Parasuicidal behavior has multiple purposes but I have found it usually tends to serve one of the following five functions: 1) Emotion Regulation; 2) Communication; 3) Relief from dissociation; 4) Relief from racing or obsessive thoughts; and 5) Maintaining a sense of control (especially control of pain or of their bodies). These functions are summarized in Table 3...
Table 3 Functions of Parasuicidal Behavior
1) Emotion Regulation - "I feel better afterward."
2) Communication - "They wouldn't listen so I decided to show them."
3) Relief from dissociation - "It's the only way I feel real."
4) Relief from racing or obsessive thoughts - "I have all these thoughts going through my head and it's the only way to make them stop."
5) Maintaining a sense of control - "I can't control the feelings, but I can control that."
(46-48)
...
While I have found these five functions of parasuicidal behavior most common, there may be other functions as well. Parasuicidal behavior may serve any or all of these functions at various points in the client's life, but I have found that for most clients parasuicidal behavior tends to have one or two primary functions. If one can identify which of these functions the behavior serves, one then has a strong clue as to where to start in terms of intervention. Again, clients are not likely to give up the parasuicidal behaviors unless they develop other skills and options for addressing those functions.(54)
The chapter continues on to discuss assessing parasuicidal behavior, but I think I'll tackle that later. There's enough here to digest.
This is a tough chapter - there's a lot of good, important information here, but I'm not up to transcribing it all and it's been difficult to pull out the most salient parts... So let's go back to the beginning... [Remember this book is written by a clinician for clinicians...]
For many Borderlines, one of the biggest struggles is chronic thoughts of suicide or other self harm. It is difficult to focus on other goals in life when one is chronically overwhelmed with urges to hurt oneself. Likewise for many clinicians one of the biggest struggles is dealing with the client's chronic parasuicidal behavior. It is difficult to focus on other therapeutic goals or set limits when one is worried about the client's safety. This anxiety can often lead to countertransference reactions in the clinicians including feelings of hopelessness, helplessness, anger, and resentment. (45)
...
Studies consistently estimate the percentage of Borderlines who complete suicide at 3 to 10% and most completed suicides happen later in the course of the illness. This reiterates the importance of clinicians dealing with borderlines having adequate understanding of risk assessment, intervention and documentation techniques. In short, Borderlines are more likely to self injure than other psychiatric populations but not necessarily more likely to complete suicide.
FUNCTIONS OF PARASUICIDAL BEHAVIOR
One of the most critical points to understand in dealing with parasuicidal behavior is that while helping professionals and others tend to view parasuicidal behavior as a "problem," borderlines view it as a "solution." This is extremely important because unless clinician and client agree on what the "problem" is, they will often be working at cross purposes. Most often, professionals simply want the client with BPD to stop the self-injurious behavior and become frustrated when the client seems unable or even unwilling to do so. Often this is misinterpreted to mean they "enjoy" the behavior.
Invariably if one explores this sufficiently one finds that the reason they are unable or unwilling ti stop self injury is not that they truly or completely believe self injury is in their best interest, but because they view it as the only or the most efficient means to meeting some need. If one explores the thoughts, urges, and feelings associated with the parasuicidal behavior sufficiently one can identify what functions it serves (i.e. what the "problem" is for the client) and can then teach the client less damaging strategies to serve that function of meet that need.
Notice I use the term "less damaging" and not "more efficient" or "more effective." This choice of words is intentional as part of what the client may have to learn is that they may need to use other strategies that in face are more difficult or take longer to be effective than self injury. Part of the intervention then is to convince them to choose a strategy that ultimately may be more difficult but is less damaging.
So how does parasuicidal behavior serve to solve problems? Parasuicidal behavior has multiple purposes but I have found it usually tends to serve one of the following five functions: 1) Emotion Regulation; 2) Communication; 3) Relief from dissociation; 4) Relief from racing or obsessive thoughts; and 5) Maintaining a sense of control (especially control of pain or of their bodies). These functions are summarized in Table 3...
Table 3 Functions of Parasuicidal Behavior
1) Emotion Regulation - "I feel better afterward."
2) Communication - "They wouldn't listen so I decided to show them."
3) Relief from dissociation - "It's the only way I feel real."
4) Relief from racing or obsessive thoughts - "I have all these thoughts going through my head and it's the only way to make them stop."
5) Maintaining a sense of control - "I can't control the feelings, but I can control that."
(46-48)
...
While I have found these five functions of parasuicidal behavior most common, there may be other functions as well. Parasuicidal behavior may serve any or all of these functions at various points in the client's life, but I have found that for most clients parasuicidal behavior tends to have one or two primary functions. If one can identify which of these functions the behavior serves, one then has a strong clue as to where to start in terms of intervention. Again, clients are not likely to give up the parasuicidal behaviors unless they develop other skills and options for addressing those functions.(54)
The chapter continues on to discuss assessing parasuicidal behavior, but I think I'll tackle that later. There's enough here to digest.