A life worth living: Clients with borderline personality disorder find hope

CrossCurrents

By Karen Shenfeld

“Once you try to commit suicide, you open a door that you fear you will never be able to shut.” Skye* is speaking about a subject she knows only too well. As a young woman in her 20s, she tried to die by suicide so many times she can’t really remember. “I think it was somewhere between six and 12. Once or twice I slashed my wrists. Mostly I took overdoses of painkillers.”

Now, at 45, Skye, who works as a secretary, has matured into an athletic-looking woman with eyes that reflect her sparkling intelligence. Although it has been many years since she actually took an overdose, she says she still must resist the urge to harm herself.With complete frankness, she rolls up her sleeves and pant legs to reveal dozens of scars, bearing testimony to the numerous times she has cut herself with knives and scissors and burned herself with cigarette lighters and irons.

Skye has borderline personality disorder (BPD), which affects about two per cent of the population, and is characterized by disturbed relationships, mood swings, impulsivity and chronic suicidality and self-harming behaviours. But mental health professionals have historically underestimated the lethality of suicidal behaviour in clients with BPD. They may dismiss suicide attempts as willful or manipulative, or as non-deadly calls for help. Statistics, however, tell a different story: About one in 10 people with BPD actually die by suicide – a 60 per cent greater risk of dying by suicide than among the general population. This high risk for attempted and completed suicide has been linked to the disorder’s lack of response to antidepressants and to the impulsivity that characterizes BPD.

But there is hope. “It’s been more than nine months since I last harmed myself,” says Skye with visible pride. “And I feel certain I won’t cut or burn myself or try to commit suicide again.” Skye says her confidence has come from having recently completed a year-long course of dialectical behaviour therapy (DBT).

DBT is a modification of cognitive behavioural therapy (CBT) developed in the early 1990s by Dr. Marsha Linehan, director of the Behavioral Research and Therapy Clinics at the University of Washington in Seattle. The concept of dialectics expresses the idea that opposites can be integrated to understand the nature of reality. DBT reflects Linehan’s findings that treatment for chronically suicidal clients must focus not only on helping them change their behaviour, but also “on helping them to accept the reality of their own lives – to accept what happened in their past, for example – and to tolerate their present.”

As well as offering clients radical validation, therapists practising DBT sometimes take what seems to be an irreverent approach. A client, for example, might express a desire to die because treatment is coming to an end. The therapist might then ask, “Well, why not die?” “Therapists use out-of-the-ordinary statements to ensure that new information will be processed,” Linehan explains.

DBT is carefully structured and broken down into four stages, the first of which focuses on suicidal behaviours because, as Linehan says, “therapy doesn’t work with a dead person.” Clients attend weekly individual and group therapy sessions; during the latter, they learn skills to build their core mindfulness (ability to focus on the present moment), interpersonal effectiveness, emotion modulation and distress tolerance. Clients also fill out diary cards and have access to around-the-clock telephone support.

“Therapists might fear being available to their clients 24/7 because they believe they’ll be taking calls all day,” says psychologist Dr. Shelley McMain, head of the Borderline Personality Disorder Clinic at the Centre for Addiction and Mental Health (CAMH) in Toronto. “But the truth is, clients with BPD often don’t call, partly because they don’t know how to ask for help.”

Since 2002, McMain has been conducting the largest study to date to evaluate the clinical and cost effectiveness of DBT for chronically suicidal individuals with BPD. “DBT is being widely adopted in treatment, due to promising results from research,”McMain says. In the course of this study, 180 participants have been randomly assigned to be treated either by DBT or with general psychiatric management (GPM), which consists of medication plus psychosocial support. The 90 participants receiving DBT are being treated at the CAMH clinic; the other group is receiving outpatient treatment at Toronto’s St. Michael’s Hospital. Eighty-six percent of participants are female, reflecting the fact that in clinical samples, BPD is more common among women than men.

Following guidelines set forth by the American Psychiatric Association, clients being treated with GPM attend weekly hour-long therapy sessions that take a psychodynamic approach: “A client may begin a session by saying she had an upsetting interaction with a boyfriend,” explains says Dr. Paul Links, the Arthur Sommer Rotenberg Chair in Suicide Studies and a psychiatry professor at the University of Toronto, who is leading the treatment team at St. Michael’s. “We try to help the client identify and understand what she is feeling, and then to express and process the feeling in a way that is not self-harming, by journaling, for example.”

The main difference between DBT and GPM in terms of how they address suicidal behaviour is the extent to which therapists explicitly and directly target self-harm and suicidal behaviours. DBT’s top priority is to target suicidal behaviours and to analyze factors that lead to and follow the behaviours, such as problem emotions, contingency problems and skills deficits. GPM focuses less directly on the suicidal behaviour, targetting instead the factors assumed to underlie the behaviour, such as problem emotions.

The general management approach to BPD also calls for pharmacotherapy. At St.Michael’s, clients are prescribed a combination of medications, including selective serotonin reuptake inhibitors, mood stabilizers and anti-psychotics, to help them cope with some of the disorder’s symptoms. In contrast with the views held by Linehan and others, Links says there is good evidence that medications can play a role in helping clients deal with impulsivity,mood swings and intense anger.

DBT and GPM also differ in their attitudes toward hospitalization. While both agree that hospitalization may be necessary when suicide risk is acute, DBT has a bias toward treating people on an outpatient basis. In fact, DBT views hospitalization as having limited value with BPD clients and even as being counterproductive. “Hospitalization often inadvertently reinforces suicidal behaviours in the long run,” says McMain. “For example, a client who has difficulty communicating may express herself through suicidal behaviours. People responding to her with increased contact and support through hospitalization can inadvertently positively reinforce the suicidal behaviour. So the client learns that the only way to be taken seriously by others is through suicidal behaviour.” The goal of DBT is to help solve the problem that underlies the suicidal behavior. For example, it may involve teaching the client how to communicate effectively without escalating through suicidal behaviour.

Regardless of the approach, dealing with chronically suicidal clients can be stressful for therapists. “It’s important for therapists to have colleagues with whom they can discuss their emotions,” says Links. In fact, as developed by Linehan, DBT must be practised in teams and therapists meet for scheduled weekly support sessions. Although the results of the BPD study aren’t expected until October 2007, existing evidence suggests that most people with BPD do recover. Suicidality often subsides when they find meaningful work and a reliable network of relationships. In recent months, Skye, a talented artist, has taken up painting. She has had her art work exhibited at a CAMH show and has attended a week-long artists’ retreat. She is considering art classes, as well as looking for more gratifying work. She is on the road to discovering what Marsha Linehan calls “a life worth living.”

*not her real name

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