Borderline personality disorder and suicidal attempts : how to calm an uprising dilemma

Patients with Borderline Personality Disorder (BPD) are more likely than patients with any other personality disorder to commit suicide. Many programs have been found successful in helping these patients control their thoughts. Using the Behavioral Activation Treatment for Depression (BATD) with a cathartic journal process in addition to the treatment, instead of hospitalization, it is hypothesized that BPD patients will reduce thoughts and attempts of suicide. This is a five year program that will be implicated to see how a patients progress through the treatment. There will be a pretest-posttest control group design used in this research. With adding a journaling process, the patients will be able to release their emotional burdens which will then decrease their time dwelling on those thoughts. Therefore, this will help to decrease the thoughts and attempts of suicide within people with BPD. Introduction and Literature Review Numerous research studies have shown that there is a strong correlation between Borderline Personality Disorder and suicidal behavior. Suicidal behavior has been stated to occur in up to 84 % of patients who have Borderline Personality Disorder (Black et al. , 2004). Borderline Personality Disorder, or BPD, symptoms include seeing things in extremes, believing that something is one of only two possible things, and ignoring any possible "in-betweens". There are also disturbances in one' s self image and BPD creates instability in relationships with others. These major symptoms cause for a patient to see problems in a different light (Grava, 2006). Due to these symptoms, patients begin believing that suicide is one of their only options to solving their problem (Rietdijk et al, 2001 ). Once they have the idea of suicide it is difficult to change their thought process. Borderline Personality Disorder and Suicidal Attempts 4 Thus a dilemma is created due to the seriousness of suicide gestures. The suicide gestures occur from the ongoing pattern of self demeaning activities. Patients with BPD have more thoughts about suicide, are more likely to attempt suicide, and are more likely to make multiple attempts compared to any other patient with or without mental impairment (Hopko et al, 2003). However, longitudinal studies have showed that, suicide is not as frequently completed by patients with BPD as it is with rest of the population. Ninety percent of people diagnosed with BPD who threaten or attempted suicide, never complete it (Paris, 2004). Yet these thoughts still occur and the attempts are still being made. Hospitalization of a BPD person is a frequent choice made by physicians when these patients come in with suicidal attempts but this may not be the best solution (Reynolds et al , 2006). Hospitalization does nothing for their BPD but rather attempts to calm the patient's suicidal thoughts (Reynolds et al, 2006). The item that is rarely considered is that these thoughts will reoccur since it is part of their mental impairment. This means that the patient will return to the hospital time and time again with no effective use of a treatment. (Paris, 2004; Brodsky et al , 2006) Since hospitalization is not as effective as one may believe, another treatment needs to be looked at. One such treatment that has been proposed for patients is Behavioral Activation Treatment for Depression combined with a cathartic journal; patients with BPD will have reduced thoughts of suicide leading Borderline Personality Disorder and Suicidal Attempts 5 to less suicidal attempts. The other treatments that have been tested will be discussed to why they are not as effective as BATD. Lastly, BATD with a cathartic journal will be explained as to why this is a better solution for patients with Borderline Personality Disorder and how this treatment could help them reduce suicidal thoughts. Other treatments that have failed to meet their goals include hospitalization, as discussed briefly before, contracts, family intervention, and group therapy (Reynolds et al, 2006; Sansone, 2004). Hospitalization has been shown effective only if the patient can help determine a goal that is realistic with the therapist or family. Sansone (2004) used a study where he reviewed what the hospital asked of these patients. They asked the patients to within three days come to a goal that would help benefit the patients themselves. However, since the behaviors of patients with BPD are constantly changing, they could be sent to the hospital numerous times and continually making the same goals and breaking them. Thus leaving the patient back at step one and not meeting the needs of how to stop suicidal thoughts (Sansone, 2004). The patients could also try and access or "work the system" whenever they feel that they are not secure in their thoughts. Therefore, using hospitalization as just a cushion and not something they can use for assistance (Paris, 2004). Paris (2004) found that by leaving the patient as uncomfortable and short as possible in hospitalization that they are less likely to use it as a crutch and is more likely to search for actual assistance. Borderline Personality Disorder and Suicidal Attempts 6 Contracts can help find a defining boundary for the treatment with the therapist (Sansone, 2004). On the other hand, they could be broken very easily with little to no consequences. The consequences that may occur may be sending the patient back into hospitalization which would push them further away from finding a way to reduce their suicidal thoughts (Sansone, 2004). Brodsky et al (2006) found that even though these contracts may have some sort of effect on how the patient may view suicide; there may be ways to sneak around the contract by inflicting self harm only with no intent on death. This causes a whole different dilemma to whether or not the patient is taking the contract seriously or not. Family intervention is a difficult treatment to impose because it involves educating the family on the matters of how to help the patient with BPD (Sansone, 2004). There could be added stresses to the families ' lives if the patient did decide to complete suicide. There can also be a burden left on the families of wonderment to whether or not it was their fault. This could be stressful and highly dangerous to the relationships the family already has as well. The patient may believe that the family is trying to control them and the patient may push them away, leaving the BPD patient with little to no support (Sansone, 2004). Black et al (2004) found that impulsivity is the leading cause for suicide attempts. Consequently, if a patient loses their family ties it could put them at a higher risk of an attempt. Borderline Personality Disorder and Suicidal Attempts 7 Lastly, group therapy may also be a dangerous situation. If a person were to make attempts while in the group therapy treatment, others in the group may seem to think that the treatment is not working and start to doubt their own progress. This would leave them more vulnerable to regress into a suicidal state (Reynolds et al., 2006). Reynolds et al (2006) stated that there was a thirty percent increase in suicidal thoughts after interviewing the patients after group sessions (Reynolds et al. 2006). Behavioral Activation Treatment for Depression is based on the idea that behavior is maintained and conceptualized by a choice. Every choice has a consequence either negative or positive that will make an alternative behavior occur. Therefore, this treatment also realizes that with little activity, thoughts of suicide become more prevalent and acts on this threat by creating more activity for the patients (Hopko et al 2003). This has been used in patients with BPD already and has been showing positive results (Hopko et al, 2003). Hopko (2003) summarized a patient's journey through BA TD who made tremendous progress with reducing suicidal thoughts and attempts. However, there are also many complications to the treatment that include resistance to the activities and problems when patients are left to be on their own (Hopko et al, 2003). This is where the cathartic journal would help benefit the patients because they would be able to write down their thoughts whenever they felt them (Lester, 2004; Sansone, 2004). A cathartic journal is a way to let Borderline Personality Disorder and Suicidal Attempts 8 emotional baggage off in a positive direction. The patient would be instructed to write in the journal but not allowed to go back and reread it. This way, they are able to express their suicidal thoughts on paper and not dwell on them (Lester, 2004). As a result, being able to write down thoughts has been effective in helping to re-channel fears and ideas to be observed to try to benefit the patient (Sansone, 2004). BATD with a cathartic journal includes a one on one session with a therapist and time to evaluate your own thoughts. Lester (2004) discussed that the life of a girl named "Katie" would have been immensely different if her journal writing were to be cathartic and not looked over repeatedly. Lester (2004) believes that she would have had less suicidal thoughts and would have had less of a risk of completing suicide. As seen through the different treatments listed above, there have been many treatments that have not been effective to BPD patients. They have hindered them from progressing to find a way to control and reduce their suicidal thoughts. BATD with an accurate journaling process is a proposed method with the best chances of helping these patients. With BPD being one of the most lethal of all psychiatric disorders with an average of three lifetime attempts per patients, something different needs to be done to help them (Soloff et al 2005). By allowing patients to meet with a therapist in a one on one session, the patient will be able to release the emotions and thoughts of suicide and starting new with a clean slate. The clean slate would occur because the counselor would