I run a Suicide Crisis Centre in Gloucestershire where we provide face to face support to anyone who is at risk of suicide. In recent months we have seen increasing numbers of clients who have a diagnosis of Emotionally Unstable Personality Disorder, also known as Borderline Personality Disorder (BPD).
In a two-week period in November, 78% of the clients who accessed our services had a diagnosis of personality disorder (PD). This is a particularly high number, but the percentage of clients with BPD has been high for months.
We have looked for reasons why so many need to access our crisis services.
In our county there is no specialist personality disorders service, despite NICE guidelines stating that mental health trusts should develop such services. Plans for a specialist PD service were disbanded last year after a decision was made to divert the money to a different department instead. Our clients were devastated at this news and felt it reflected a lack of prioritisation of their needs.
NICE guidelines state that there is no recommended medication specifically for BPD. That makes the provision of other types of treatment even more important, particularly psychological therapies. Dialectical Behaviour Therapy is recommended in the NICE guidelines as an evidence-based treatment for people with BPD who self-injure frequently, especially where the self-injury is severe. DBT is a type of therapy which is carried out in a combination of group and individual sessions with psychologists. In our county, our clients report having been given "DBT skills" instead. When they go for their fortnightly appointment with their care coordinator, they work together from a book about DBT.
If DBT is delivered in the way that was intended (a type of therapy provided by psychologists) it is expensive. Doing it from a book with a care coordinator is much cheaper. Our clients have spoken extremely negatively about it - understandably so, since they have not actually received any therapy. There are other forms of therapy that can help people with BPD, too, and clients report equal difficulty in accessing these.
Many of our clients with BPD tell us that when they are in crisis, there seems to be an expectation on the part of mental health professionals that they should be actively seeking to resolve the crisis themselves and find solutions. Indeed, in the NICE guidelines it states that "when a person with BPD presents during a crisis" professionals should "seek to stimulate reflection about solutions". However, if a person with BPD is clearly in crisis, having strong suicidal thoughts, and is highly distressed, "reflection" may be difficult. Reflection is usually associated with calm, considered thought - the very opposite of how a person may be thinking, when in crisis.
Our clients feel that clinicians are giving them much of the responsibility for resolving their own crisis, without having given them the NICE-recommended services and treatments which might help them to do this (or which might have helped prevent crisis in the first place).
In terms of psychiatric hospital admissions, our clients with BPD tell us that they are usually offered short stays of around 5 to 7 days. They feel that decisions about the length of admission are made based on their diagnosis, rather than on their unique needs. There appears to be a perception on the part of clinicians that they will become dependent on the service if they remain there longer than this. That's if they get offered psychiatric admission at all. One of our clients with BPD reports that she was told by a mental health professional: "People with your diagnosis don't do well in hospital."
Everyone who comes to us with a diagnosis of BPD is different and unique. We don't have "an approach" for working with people with BPD (or any other diagnosis). Knowing their diagnosis is helpful - it can help us to understand better how to help them. But it is getting to know them as individuals, which helps even more. The way we work with each client is different, especially in terms of the type of help they receive. Every client has individualised care, which is tailored to them. The frequency with which we see them and the length of time we support them is different for everyone.
When they are in crisis and at risk of suicide, we support and care for them, as we do for all our clients. We do not place any greater responsibility on people with certain diagnoses to manage their own crisis when they are at risk of suicide. We are tenacious in the way that we support them, as we are with all our clients.
"Julia" is one of our clients who has BPD. Her view is: "People with BPD are treated as a label, not as people. We need to be taken seriously. Our illness needs to be taken as seriously as bipolar or schizophrenia. The afore-mentioned illnesses would not be offered psychiatric hospital admissions of only 5 days - it is just another generalisation."
Recently a BBC 6 O'Clock News crew accompanied and filmed us as we visited clients in crisis. "Sarah", who is featured in the BBC online video (http://www.bbc.co.uk/news/health-38152562), first came to us in 2014. Her self-harm was so serious that it frequently put her life at risk. She was in her twenties but had already suffered a heart attack, and had undergone major surgery. We advocated for her to be referred to specialist PD services outside our county, and she was told that this would happen. When she came back to us in November 2016, it still hadn't happened.
NICE guidelines confirm that people with BPD "are particularly at risk of suicide". It seems incomprehensible that their needs are not being prioritised, and that mental health trusts are failing to provide the specialist services which they need.
The term BPD is used by many of our clients, including Julia and Sarah. However, we recognise and respect the fact that that many people find it an inaccurate and unhelpful term. We hope the term will be dropped soon. Please note that it is unusual for us to take a client to A&E. Sarah wanted to be admitted to psychiatric hospital and this was our only route to it, as the crisis team (the usual team who admit people to psychiatric hospital) was "closed".
For information about the Suicide Crisis Centre: http://www.suicidecrisis.co.uk