23 | Borderline Conversation AWARE - Advice vs Action

In this sequence of nuanced conversations, listeners will be guided through some of the most sensitive issues that they will have to navigate while supporting a person in suicidal distress. This episode captures the essence of Advice vs Action. The advice we give - face your fears, applies to us as well when we make decisions regarding whether we admit or not. We must role model the advice we provide to have credibility. 

Listeners will learn the in-parts conversation to put on the table the dilemma that the mental health practitioner is facing. This is part of the Borderline Conversation AWARE program that is taught as an advanced training for mental health practitioners.

Connect with Assoc Prof Manaan Kar Ray at https://www.linkedin.com/in/drmanaankarray/
Follow us on www.progress.guide

Transcript

Host: Good day, this is Mahi, your host, we are on to episode 23, in the last two episodes we have dived deep into the challenges in supporting people with a borderline personality disorder, particularly amidst a suicidal crisis. We spent time in episode 21 understanding splitting as a psychological phenomenon, in episode 22 we went through all the diagnostic criterion and then finally shared Jill’s story. Here is a recap of Jill, a 30 year old female who has presented to ED in suicidal crisis requesting admission. The background is that she was diagnosed with Borderline personality Disorder a few months back. She is case managed by the Mood Community Team and awaiting DBT. She has had multiple crisis admissions in the past that have been generally unhelpful with increasing self harm and aggression on the ward that requires constant observation and seclusion to manage safety. On assessment you establish that there is worsening suicidal ideation in the context of recent relationship conflict, she is feeling hopeless and wants to end it all, she is seeking safety and containment through admission. You are faced with a decision and we wanted you to think about the AWARE factors and how each one of them might impact your clinical decision. Manaan will you please provide a summary of how the AWARE factors play out amidst a borderline crisis.

Expert: Sure, the five AWARE factors are, anxiety, weighting, agenda, resources and experience. In a suicidal crisis there is intense anxiety, particularly so when the person has borderline personality disorder, this is because of how overwhelmed the person is feeling, they end up project their entire distress on to the assessor which is quite anxiety provoking for the assessor too, the automatic consequence of that is to prioritise containment of the situation over establishing the facts behind the presentation, so it may be very tempting not to delve too deep into Jill’s story particularly if an assessor has managed to elicit a blanket safety reassurance, which are incredibly shallow and we advice against using them, so remember that there are two purposes to an assessment, a stated one which is to assess and the other non-stated one which is to contain the crisis and capture hope, do not skip to the second without properly completing the first, however tempting it may be. Premature crisis resolution without thorough exploration of the presentation is a recipe for an error in judgement. The more we dig, the more we find, the more anxious you may feel, this might stop you from exploring and conducting a full assessment, be aware of your level of anxiety and stick to the task of establishing the facts with kindness and compassion and only then work towards the second goal, not before. The second factor weighting captures how suicidality in someone like Jill with BPD, gets diluted by their diagnosis, chronicity of repeat presentations and the nature of the crisis which is often social in origin following relationship conflicts, financial issues, accommodation problems, and sometimes alcohol and drug misuse as well. Remember that the standardised mortality rate of suicide in severe BPD is the highest 45.1, the diagnosis increases risk doesn’t decrease it. The third factor Agenda reminds us of how patients with BPD can sense rejection and abandonment from a long way, if as an assessor you perceive that they have an agenda to get admitted and your job is to keep them out, then beware they will perceive this feeling you have even before it enters your consciousness, this will be followed by their need to feel safe, their drive to prove that they are in crisis and need an admission and the risk will escalate, so be very aware of your internal state and make sure that you engage in candid conversation about what you are perceiving and get them on board with the discharge plan. We will discuss this in more detail today. The penultimate theme resources plays out in all presentations but particularly with patients with BPD because of the heavy usage of staffing and bed resources. Often patients end up in constant observations which is resource heavy, and admissions tend to stretch out as threats or self harming escalates at the mention of discharge due to the intense anxiety patients with BPD feel. Thus, assessors are often quite reluctant to support short crisis admissions even when they are indicated. And finally Experience, the experience of the same patient and how it had panned out before or different patients with a similar presentation has a huge impact on decisions that are made, remember that although it is important to stick to the plan that has been formulated it is also important to treat each presentation on its own merit cause a lot might change in between presentations. We will build on the discussion from the previous episode today as we progress Jill’s story.

Host: So this where we are with Jill at the moment, following the assessment the clinician calls the on call consultant. Given Jill’s past history of hospital admissions which were generally unhelpful where her self harming escalated, a decision is made to avoid admission. The Consultant strongly recommends to the assessor that Jill should engage with community team and avoid admission if possible. The assessing clinician is concerned about Jill getting highly dysregulated when she is told about the decision. So today’s podcast is primarily about how can this conversation be safely navigated and how Jill can be brought on board for the journey ahead. What are the different shapes this conversation could take. What topics could come up in discussion and how will you navigate them.

Expert: This is worksheet 6.4 in the PROTECT workbook, on pages 20 and 21. Remember that Jill has presented in crisis to the ED and we are about to send her home, she might have come looking for hope or had hope in her heart of receiving help and she is going to perceive this as rejection and abandonment which is invariably going to increase the risk. In this situation is there anyway in which the power of relational safety can be used to bolster safety, that is the fundamental challenge and we discussed in Episode 9 the concept of Empath in Action, in the guidebook it is page 40, how relational safety stems from the 3 components cognitive empathy, your thoughts in my mind, emotional empathy, your pain in my heart and empathic concern, my genuine desire to help. The communication that is about to happen with Jill is a fairly nuanced conversation that has to be done with sensitivity, paying attention to all 3 components.

Host: So in effect you are emphasising the need to look at the world from Jill’s point of view before you communicate the outcome of the assessment.

Expert: Absolutely, if you look at it from Jill’s point of view, she came looking for support with hope in her heart and at the surface of it we are about to send her home and nothing has changed for her, other than the fact that she feels even more helpless and whatever hope she had has evaporated.

Host: So are you saying the decision to send her home is the wrong decision.

Expert: No absolutely not, it may very well be the right decision to make, but from Jill’s perspective or the perspective of Jill’s family and loved ones it will be appear that seeking out help and looking for support has done more harm than good.

Host: This is confusing, so it maybe the right decision but the person feels more hopeless.

Expert: Once we go through the different conversations it will become more clear as to why this maybe the right decision, but you are correct when you say that unless we are able to have a deeply empathic connection and foster relational safety, it may feel that as the assessor you just don’t care whether they live or die.

Host: And this goes back to the discussion on abandonment and rejection which is heightened for people with BPD and even more so when they are distressed.

Expert: That’s correct.

Host: Does this apply only to the ED setting or others as well.

Expert: You just need to change a few specifics in Jill’s story and these reflections or conversation could end up being conversations that are needed to be had at the point of admission or during an inpatient stay or at discharge from inpatient or even when a crisis bubbling in the community or as part of psychoeducation with future planning in mind when someone is actually doing well in the community.

Host: And these conversations are about restoring relational safety if it is about to be ruptured when an assessor conveys the decision.

Expert: Yes rebuilding relational safety in the moment or proactively having conversations with someone with BPD that when a crisis happens they may not get admitted and these are the reasons why.

Host: So worksheet 6.4 has these 5 conversations, they are advice vs action, containment vs empowerment, short term vs long term, inpatient vs community and complicated vs complex. We will try and cover as many of these in episode 23 but some may spill over into the next episode.

Expert: Each of these conversations relate to a specific AWARE factors, for example advice vs action relates to anxiety, containment vs empowerment relates weighting, short term vs long term relates to agenda, inpatient vs community relates to resources, complicated vs complex relates to experience.

Host: Is there a unifying theme for these conversations?

Expert: The golden thread is one of relational safety, and that comes with trust, in order to reestablish trust one has to put their cards on the table. As Bren Brown would say that the path of courage goes through vulnerability. It takes courage to put ones cards on the table, open up one’s thinking to the person in distress and show them in no uncertain terms the rationale behind the decision, that does make the assessor vulnerable, practitioners worry about how they may be misquoted or quoted out of context if they are open, honest and candid with the person they are supporting around why they are doing what they are doing. However if you are not and Jill feels that there is more to the story than you are providing, rest assured you wont be able to establish trust and relational safety will stay ruptured.

Host: I remember you saying in the pain relief conversation from Chapter 3, Page 20 in the guidebook, how important it is to see the world from the person’s view before you try to show them the world from the practitioner’s view, the emphasis on empathy in action sounds similar to that.

Expert: Exactly, before you share what’s on your mind, be very clear about the kind of thoughts the person will have when you share the outcome that sorry I believe your needs are better met in the community, think if you were walking in their shoes what would you think, what would you feel and given we can never really step into someone else’s shoes for real as we just haven’t got the same life experiences you need to multiply the intensity of the pain 3 to 5 folds and then think would believe that this professional in front of me has got a genuine desire to help me. That is the challenge of relational safety. You are about to break bad news, something that the person in distress believes is in your locus of control and you are about to deny them access but you still want them to believe that you genuinely care for their safety and wellbeing. So saddle in that is the flavour of the conversation that you need to have.

Host: So shall we get started.

Expert: Sure

Host: The first one which relates to the Anxiety theme of the AWARE framework has got the title Advice vs Action. Will you start with a summary of this conversation.

Expert: It may be easier to think of this as a personal reflection rather than a conversation, this could be a conversation as well if a practitioner is feeling really confident and doesn’t mind being vulnerable in front of the person in distress and put their cards on the table. So to cut a long story short, patients with BPD are often told that the anxiety they are experiencing can be mastered. We call it distress tolerance training, or affect regulation training, different names but the same concept in terms of advice that we give – you can master whatever you are experiencing. The reflective question we want you to ask is the actions we take in terms of decisions we make regarding admitting or not, are they congruent with the advice we have given to the person.

Host: Do you mean practitioners give the advice – face the anxiety to patients, the same advice applies to the practitioners too. Will you elaborate.

Expert: That is spot on, if our therapeutic intervention is built on the premise face your fears, then we need to role model the advice we are giving in the decisions we make and the actions we take. Someone in the midst of a borderline crisis is scared and overwhelmed by thoughts that they are going to do some serious harm to themselves, and we talk about this in the next conversation containment vs empowerment, we tell them that recovery entails learning to persist with the plan in the community and face their fears or at least that is what we should be doing and communicating. Having to communicate hang in there although you are perilously close to let go off the cliff’s edge is very anxiety provoking for the Psychiatrist or Psychotherapist or the Assessing nurse or Allied Health. But that is what we need to communicate, in that situation if do not role model by facing our own anxieties and give in to the anxiety by not following the formulate plan or admitting them without through consideration of what might this mean in terms of the message we are sending the person then we haven’t role modelled our advice in our actions and through our actions have given a message very different to what we have been asking the person to do.

Host: But you also say that there will be times when a practitioner should listen to the anxiety in their gut and act accordingly.

Expert: Yes that’s true and that is what clinical decision making entails, it is the art of knowing when one should listen to the anxiety and perhaps admit and when one should listen to the anxiety and perhaps persist with the community plan with increased support.

Host: You did mention this was more of a reflective question, the advice that I give, is it role modelled in the decisions I make and the actions I take? Are there any circumstances when you might actually share this with someone like Jill.

Expert: There are actually, but as I said before one needs to be ready to put their cards on the table and be vulnerable.

Host: Can you say a little bit more about being vulnerable, cause its not very clear in my mind what that means or how does it apply.

Expert: Well if you as a practitioner are going to share this reflection in some shape or form you will be telling the person that you too are feeling anxious, now there is a societal expectation that as the health care provider you should be the one who is providing hope and somehow diffuse the anxiety not fuel it further. And sharing that you too are feeling anxious goes against the grain of that societal expectation, one may almost misinterpret it as you are not a good enough professional if you are anxious, but the reality is that you are, your are worried and concerned about the person’s safety and also in terms of if things were to go wrong what does it mean for you. That is the honest truth of the matter, but having the courage to be able to share that with a person puts the professional in a vulnerable spot regarding how they come across, how are they perceived, will they be misquoted or quoted out of context and so on. Bottom line it does take courage to be vulnerable.

Host: This is actually quite deep.

Expert: Yes deep and nuanced, conversations are two way streets, we are not just dealing with the anxiety of the person with BPD, we are also dealing with the anxiety of the practitioner who is supporting the person with BPD

Host: And your belief is that transparency creates trust and trust reinforces relational safety.

Expert: Spot on.

Host: So how might you share with Jill that you too as the assessor are feeling anxious

Expert: The choice of words becomes crucial, and practitioners need to be comfortable with what they chose, if sharing that they are feeling anxious makes them feel too vulnerable one can use words like worry and concern or discomfort about the decision that they are making.

Host: So you are talking about actually telling the patient that you are worried about the decision you have just made.

Expert: Yes what do you think I have said so far about being vulnerable, this is not an easy conversation, but in order to build or rebuild trust you really have to go that extra mile.

Host: How do you do that though, how do you actually tell a patient that I have just made a decision that even I am not confident in?

Expert: Clearly you don’t do it that way, one of the ways in which I tend to have delicate conversations is the “in parts” conversation. A part of me is feeling this but the other part is feeling that and I want to think this through with you.

Host: So you are sharing your thoughts with the person.

Expert: Yes its like a window into your own mind. You might say something like “Jill there is a part of me which feels quite confident that the right thing to do in this situation is to engage with community support but then there is the other part which is concerned about your wellbeing in the interim and that part is worried about your safety” 

Host: And then that becomes a segue way into a discussion about safety planning

Expert: Yes it could be safety planning or you could just generally invite the person using motivational interviewing strategies to collaborate on how to make it safer or why it is important to engage with community support. It really depends on the situation at hand and the level of rapport you have with Jill as to how you frame the in parts conversation, you can say there is a part of me which feels confident that you will be able to understand why I am not keen for you to be admitted and why community supports are better, and then there is this other part of me which is really worried that you are going to think that we do not care about your wellbeing and safety and feeling rejected by this current interaction you will end up rejecting the community supports that are on offer to you.

Host: I can see what you are doing here, in this statement you are trying to pre-empt all or none thinking, the kind of thinking that stems from splitting that we have previously discussed, so either I have an admission or I will have nothing at all and take nothing from you all and I might take my life cause no one really cares.

Expert: Yes it does do that, but it is important to be genuine, be intentional in the choice of your words, but not with any intent to manipulate the person, just with a genuine intent to share what you are thinking through. Sometimes when you use a statement like that the rapport deepens, its something you feel, it happens in the room, you feel it in your body, it’s the creation of relational safety through empathy in action, it shows that you are genuinely trying to think through that the person may be feeling rejected by services and you can go a step deeper by saying that – if you felt that we don’t care about you because we aren’t admitting you then why would you accept the help on offer. 

Host: Could the opposite happen as well?, Like the rapport becoming shallow?

Expert: Oh yes absolutely can happen and does happen cause you can get it wrong or the person feels offended when you tell that a part of you is worried that they may reject services just to prove a point. That is why in these situations, the tone of voice, a humble attitude and the correct body language is important. You may want to soften the statement by adding a phrase, like I may have got it all wrong but there is this part of me that is worried about this or end with saying I am really hoping that this part of me is wrong. And if you have put your cards on the table and the patient denies that, that is the case, say I am so sorry for getting that wrong but am also relieved to hear your what you have just said.

Host: I guess there is an easy way to manage the anxiety the practitioner is feeling which is to admit and the harder way to manage the anxiety which is not admit and then travel with the patient through the anxiety.

Expert: Easy and Hard, that’s another nice in parts conversation to have where you can put your cards on the table. So one can say, Jill there is this part of me which is so tempted to do the easiest thing to remedy this current crisis which is to admit, everyone sleeps better tonight, including me knowing you are safe, you will feel less anxious, your family will feel less anxious and I will feel less anxious but then there is the other part which is telling me that will be the easy way out and I am shying away from my responsibilities which is the much harder path to take and that is of supporting you through the crisis in the community, cause that is what is needed for you to learn that you can master the anxiety you are feeling regarding not being able to manage the anxiety that you are currently feeling and I really should be role modelling to you that I am prepared to share some of the anxiety that you are currently experiencing by choosing the harder path rather than the easy one.

Host: Gosh, these are really delicate conversations.

Expert: Yes they are but when staff have a template to work from, even if it feels artificial to work with they can develop the confidence gradually to connect in a meaningful fashion. If staff don’t have the skills, they actually make it worse, they make bland statements like “I understand that this is disappointing for you”, well you don’t, you are not in their shoes and they came with hope and you have just taken it away, they will actually tell you that you don’t understand or staff may seek safety reassurances, can you keep yourself safe, which are totally meaningless and responses to that vary I have told you I cant to someone saying they can because they have no more fight left in them to convince you that they are feeling unsafe. Worse still are confrontational statements which escalate risk, like saying that it seems like nothing I am saying is good enough, what do you suggest we should do. For starters, yes its not good enough because they were hoping to be admitted, secondly its not good enough because they have BPD and what is a central theme for them in terms of their personality difficulty – it is splitting, they split the good from the bad, so seeing shades of grey and ash is not their strength, its all good or all bad, and because you are rejecting them you are all bad and finally the bit around what do you think will help, well if they knew they would not be in emergency will they.

Host: So it is really important to build up the skills cause certain words, phrases and sentences may escalate the risk.

Expert: That’s right. We will cover each of the conversations in the future podcast episodes, so do stay tuned in but for the full exposure staff should attend our advanced AWARE program.

Host: The one in which you run simulations with professional actors.

Expert: Yes the professional actors make the course very expensive, but it is money well spent, you would much rather be having these conversations in a supportive setting where you get constructive feedback rather than out in the field. I guess you will still make mistakes as you learn through your mistakes but you at least have a foundation.

Host: So essentially you practice the conversations based on case studies?

Expert: Yes you learn by observing and by practicing and it is actually quite a fun interactive way of learning.

Host: We have run out of time today and seems like we have barely scratched the surface of these conversations. 

Expert: We have four more to go through, but because we have talked through the in parts technique the others might go a little bit faster.

Host: Sometimes you need to go slow to go fast and the nuances of this first conversational topic – Advice vs Action does make it sound like one of those where you need to give it time to digest. Rarely does just saying something makes it better, what makes it better is connection and through the words that you are offering you are hoping to reconnect with the person whey relational safety is ruptured by a decision that has been made, the decision is in the patient’s best interest but still feels in the patient’s mind as rejection and abandonment. This is a challenging scenario, one that most practitioners will face. So pause and think about your clinical practice and what challenging conversations have you faced with Borderline Personality Disorders. Have you had a scenario like Jill’s where they do not want to go back home as they feel unsafe but you are tasked with communicating the decision. You may be the Consultant Psychiatrist yourself, doing the heavy lifting or actually a registrar or an Emergency Department Mental Health Nurse. What changes will you make to such interactions based on what you have heard today. If you have specific questions please do email us at admin@progress.guide. Share your musings with us. Tweet your thoughts and tag #GuideProgress. It helps get the word out about the podcast to more professionals and support progress to practice. You can access all the transcripts at www.progress.guide. You can connect with Manaan on Linked in, or follow our linkedin page by searching on linked in for progress.guide. We are also on twitter and YouTube. Our twitter handle is @GuideProgress. As usual please do follow the podcast, there will be weekly episodes every Friday and share it with your colleagues. Your ratings will help get the word out so please don’t forget to rate us on Spotify, apple podcasts or audible or whichever channel you are listening on. Challenges in supporting people with Borderline Personality Disorder is a common knowledge and skills deficits. Given severe borderline personality disorder has a standardised mortality rate of 45.1 it is a critical area for suicide prevention. Helping healthcare professionals fine tune their practice in this area is an essential step in creating a workforce that delivers high quality care for people in suicidal distress. Remember together we can make a difference. Tune in next Friday and we will explore some of the other critical conversations with Jill. Thank you for joining us today and keep spreading the word.