Once again I feel compelled–because of some of the comments on these posts–to point out what should be rather obvious: The countermeasures described in the series are of course unnecessary when patients with the disorder are not in process of behaving in the manner described. Which is most of the time, by the way.
If it is you are initially acting in an antagonistic manner and someone with BPD gets angry with you, then the person with BPD may often not be engaging in what I call spoiling behavior. However, I must add that it is often difficult to ascertain exactly who started a given problematic interaction, since both members of any dyad who are intimate with one another often act out with one another simultaneously. This is an example of what I call mutual role function support.
Problematic behaviors of this sort are usually done habitually and without any thought, so, in order to ascertain what you are doing, stop and think about how you might be coming across.
A reminder from part III: Tone of voice is crucial. You can use the same, and exactly the right, words and sound as if you are indeed feeling helpless, guilty or hostile–or you can sound like you are at peace with yourself and with your own limitations.
In the last post in the series, Part VI, I discussed how to counter BPD provocation #3, their use of seemingly illogical statements and absurd arguments. In this post, I will discuss the most dangerous and difficult problem of all, #4, suicide threats 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, drug or alcohol binging, and compulsive gambling are also examples of 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 eventually kill themselves in the future. Follow-up studies have shown that individuals with BPD have about a 10 percent 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 percent 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 may be trying hard to do, while secretly hoping that they fail at it (some commenters here also seemed to have missed that part about their ambivalence).
As pointed out by Marsha Linehan, "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 acute crisis so that any unusual circumstances pass. Doing this may reduce an imminent but short-lived risk.
Furthermore, individuals with BPD may at times 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 statement should be taken much 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 functional people often slap themselves in the head or pound their fist into a wall when frustrated (the musician Tom Petty could not play guitar for a while because he injured his hand while doing this).
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 vacated the premises.
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 if they turn off the phone.
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 later learned I could have also said, in a sincere tone, "I sure hope you don't do that." Very effective.
By the way, that patient who ran out of the office showed up on time for our next regularly scheduled visit as if nothing had even 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.
In the next post in this series, Part VIII, I will discuss BPD provocation #5: How patients with BPD get two or more other people to fight with one another, and how to avoid getting sucked into such fights.