The second of the Borderline AWARE conversations relates to Weighting (Diagnosis, Course, Social Causation - how these factors may influence the weighting that we put on a person's suicidality). The conversation is named Empowerment vs Containment. The episode builds on the Advice vs Action conversation and goes a step further providing the listener a thorough understanding of the different approaches to take and when to take those approaches.
Based on whether the presentation is acute, chronic or acute on chronic the professional needs to make an informed and mindful approach regarding the focus of therapeutic action. Essentially they need to answer the question, is this a situation that needs containment or is it one where my focus needs to be on empowering the person to believe that these suicidal urges can be navigated.
Connect with Assoc Prof Manaan Kar Ray at https://www.linkedin.com/in/drmanaankarray/
Follow us on www.progress.guide
The second of the Borderline AWARE conversations relates to Weighting (Diagnosis, Course, Social Causation - how these factors may influence the weighting that we put on a person's suicidality). The conversation is named Empowerment vs Containment. The episode builds on the Advice vs Action conversation and goes a step further providing the listener a thorough understanding of the different approaches to take and when to take those approaches.
Based on whether the presentation is acute, chronic or acute on chronic the professional needs to make an informed and mindful approach regarding the focus of therapeutic action. Essentially they need to answer the question, is this a situation that needs containment or is it one where my focus needs to be on empowering the person to believe that these suicidal urges can be navigated.
Connect with Assoc Prof Manaan Kar Ray at https://www.linkedin.com/in/drmanaankarray/
Follow us on www.progress.guide
Host: Good day, this is Mahi, your host, we are on to episode 24, in the last four academic episodes we have been discussing Personality Disorder. In Episode 20 Manaan provided and overview of all the Personality Disorders, we then started our indepth journey in Borderline Personality Disorder, spending time in episode 21 on the psychological phenomenon of splitting, in episode 22 we went through the diagnostic criterion and then shared Jill’s story. We discussed how the AWARE factors influence different aspects of clinical decision making. And in the last episode we began to discuss fairly nuanced conversations that may be necessary with someone in suicidal crisis with a diagnosis of borderline personality disorder. The specific conversation was related to how we navigate anxiety. The conversation itself was called advice vs action. Manaan do you want to provide a quick recap of what the conversation entailed.
Expert: Sure in its simplest form, the conversation or reflection is all about asking the question, am I following my own advice, the advice that we give to people with BPD in crisis is to hang in there and to face their fears, the anxiety can be mastered and part of the therapeutic process is to learn to do that, not to give in to the urge to self harm and regulate one’s emotions and everytime one successfully does that the brain learns that suicidal urges can be mastered, I don’t need to be hospitalised to stay safe, that is the advice we give, but the advice in itself is fairly anxiety provoking for the practitioner as we worry about all the what ifs…
Host: What ifs like what if Jill cant keep herself safe
Expert: Yes what if she does end up taking her life, what if I get blamed for it, what if an investigation found me to be negligent as she is clearly voicing suicidal thoughts and I am not admitting her.
Host: And you made the point that the anxiety generated by self doubt in the practitioner may result in the practitioner not facing their own fears and giving in to the urge to admit.
Expert: Yes many professionals operate with the mindset, better be safe than sorry, one has to ask better for whom, better for the patient or better for the professional. Admissions may be indicated but generally are not that helpful. When the anxiety can be navigated with appropriate positive risk taking, it is actually harmful for the person in distress, if the professional does not follow their own advice in their actions.
Host: So to cut a long story short, your suggestion was that professionals need to role-model their advice, if you the main therapeutic intervention in the treatment of BPD is to face your fears, the professional needs to do the same.
Expert: That’s correct.
Host: This is a nice segue way into the next conversation empowerment vs containment, but before that a recap of Jill’s story so you can put the conversation into context, Jill is 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.
Expert: Following the assessment you call the on call consultant to discuss Jill’s presentation. 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 you that Jill should engage with community team and avoid admission if possible. You were concerned about Jill getting highly dysregulated when she is told that she will be send back home. You have opened the conversation with Jill using the in-parts technique, sharing with Jill your thoughts and your dilemma. You have put yours cards on the table saying part of you is worried about Jill maintaining her safety in the community but the other part knows that that is what recovery entails, Jill has to face her fears and learn that the anxiety of feeling unsafe can be mastered.
Host: Jill is gobsmacked, and tells you that she cant believe that she is telling you that she is worried about keeping herself safe and you just don’t care and are sending her home.
Expert: This is where the next conversation comes in containment vs empowerment and it relates to the second AWARE factor weighting. Jill is looking for containment and you are talking of about empowerment. There is a clear dissonance between the two positions and somehow common ground has to be established for relational safety to be restored.
Host: Do you actually think that any practitioner will take risks of this magnitude when a person is clearly feeling suicidal.
Expert: I don’t disagree with what you are saying, this is a highly anxiety provoking situation for all concerned and that’s why we discussed the whole advice vs action episode. I also do understand the drive for self preservation in a practitioner, but that’s why the right training, reflective practice and supervision comes in, to enable you to do right by the person, not just in the here and now but also in the longer term, we pick that up in a later conversation, short term vs long term.
Host: You mentioned that this conversation relates to weighting, will you just remind our listeners about what is weighting in the AWARE framework.
Expert: Weighting is on page 52 of the Guidebook. It is the second factor in AWARE and 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, in comparison Depression’s SMR is 19.7, so the diagnosis increases risk doesn’t decrease it.
Host: SMR is standardised mortality ratio, it is the ratio between the number of observed suicides in people with a specific diagnosis compared to the expected number of suicide in a matched standard population.
Expert: So for every suicide that happens in the general population one can expect almost 20 suicides in those with a diagnosis of Depression and 45 in those with a diagnosis of BPD.
Host: I should have mentioned earlier that in the workbook the worksheet that these conversations relate to are on pages 20 and 21, worksheet 6.4, so three subthemes in the weighting AWARE factor, diagnosis, course and social causation.
Expert: Yes, it is really important to remember that a diagnosis of BPD with repeat crisis presentations does not mean that your clinical input will be lower, if anything it will be more because of the higher SMR.
Host: We have talked about this in Episode 16, I am assuming it is the different approach to therapeutic risk management that you are talking about when you say containment vs empowerment.
Expert: Yes Containment will be our response to a sudden peak in risk, in terms of course, what we would consider to be an acute presentation, their has been a step change in the person’s presentation, now our response to this needs to be like a response to someone having a myocardial infarction or a stroke.
Host: I remember this discussion, you talked about taking definitive steps, like in a patient with chest pain having a heart attack where the professionals take control of the situation
Expert: Yes, so jump in and do what needs to be done. The mental health comparator will be someone presenting in acute suicidal distress, a distinct development from their baseline mental health. Here containment is what is needed and one may take more restrictive measures like an inpatient admission.
Host: Essentially by containment you are saying where the professional takes charge of safety.
Expert: Yes that would be an appropriate response. The inpatient setting may be much more restrictive than treatment at home, but it is justified in that situation as there is a clear escalation from the baseline.
Host: So that is for acute risk, tell us about the approach to chronic risk.
Expert: In chronic risk for someone like Jill with a personality disorder remember those with BPD may also have comorbid or chronic depression too, there battle with suicidality may be a daily event, essentially their baseline is elevated and the risk has daily or even hourly minor fluctuations going in between ideation and intention sometimes peaking into action with self harm to release the in-built tension rather than with the intent to take their life.
Host: In the online safety planning courses at PROGRESS Guide I have seen videos where you talk about the concept of acquired capability, I am assuming this repeated self harm or living with suicidal thoughts and plans is a good example of that.
Expert: Actually, that is a very insightful observation, those who self harm repeatedly are desensitised to pain and the idea of death by suicide, very similar to soldiers and health professionals who are exposed to pain and death fairly regularly. This acquired capability may explain the high standardised mortality ratio of 45.1 in people with BPD.
Host: So you were saying the baseline risk is elevated in someone with BPD fluctuating between ideation and intention.
Expert: Yes, now every time Jill presents in crisis it will be inadvisable and also impractical to admit her.
Host: But doesn’t the high SMR mean that you should
Expert: It means that Jill needs help and active support, rather than an admission. Jill does not need containment, Jill needs empowerment, the goal has to be help Jill understand that she can navigate through this period of heightened suicidality.
Host: So this is where the containment vs empowerment theme arisis from.
Expert: Yes, but please remember the response to Jill needs to be equally thorough if not more than to someone with acute suicidality due to depression. It is qualitatively different to the one of a patient having a heart attack. I have mentioned in episode 16 of how I think of the Jills as patients who have a severe diabetic illness and they need rigorous support to help them stay on top of their diabetes, a lot of that is self-monitoring and self-regulation, taking adequate insulin, eating appropriately, avoiding hypoglycemic states, getting adequate wound care if they get a cut and so on.
Host: So, for chronic risk, rigorous support like in severe diabetes, but care that is primarily led by the person and the person has to take charge of their recovery, an empowered Jill is the outcome one is hoping for.
Expert: Yes, so we draw on Jill’s internal coping strategies, help them understand, that suicidal urges come in waves, every time they can use an internal coping strategy successfully, they learn that these urges can be mastered, so the focus is very much on learning distress tolerance.
Host: In the Guide book coping strategies are discussed on page 143 and 156, but we will cover them later when we do episodes on the ASPIRE module, specifically the safety planning chapters. So what you are saying about Jill is that a lot of work has to be done following an assessment and in many ways admitting will be the easier thing to do and will defeat the treatment objective of supporting Jill’s journey into an empowered space.
Expert: Absolutely and there may be a temptation to rationalize Jill’s risk away as low or non-existent as not much has changed but people with chronic risk need rigorous safety planning, particularly as it is more likely that they would be managed in the community. So a lot of work, and maybe even more work needs to go into chronic risk management than acute risk management where you step in and take control and just contain the situation. Empowerment is a much harder route.
Host: And this additional work is to prevent people with chronic risk tipping into suicidal action, assuming if you are in that ideation – intention tier of the STEPS model it will not take much to tip one over into a full blown crisis.
Expert: That is exactly correct, understanding triggers, early warning signs, when to use internal coping strategies, when to use external coping strategies, when has it become a crisis, when is it an emergency, so clarity over what to do when and with whom is essential. So, a lot of work involved in mitigating chronic risk, just like in supporting people with severe diabetes.
Host: So, for acute risk, deliver care like you would for someone having a heart attack and for chronic risk, deliver care for someone with severe diabetes, this whole containment vs empowerment discussion is reminiscent of the Care Compass.
Expert: That is an extremely insightful comment and will help the listener connect the dots. Care Compass is Chapter 2 in the Guidebook, page 10. If you don’t know what we are talking about my recommendation will be to listen to episodes 3 and 4. In brief, the Care Compass has two axes: x represents resilience in the distressed individual, East or the right end of the axis is resilient; rated at +5 and West or the left end is fragile rated at -5, and y represents the principal focus of care delivery for the professional; North or the top end relates to self-reliance rated at +5 and South or the bottom end relates to safety rated at -5. The numbers + or – 5 does not indicate right or wrong, it is just to graphically demonstrate the degree of resilience in the person on the x axis and the clinician’s primary focus on the y axis. This is much easier to follow if you have the diagram in front of you on page 10
Host: The two axes gives rise to four care quadrants, bottom left or south west: Prudent Care, top right or north east: Permissive Care, bottom right or south east: Prescriptive care and top left or North West: Precarious Care.
Expert: We have described in detail how recovery entails movement from prudent care which is the bottom left quadrant to permissive care which is top right. With Jill if you only focus on containment and hospital admissions every time she presents in crisis, then we will be pushing her care trajectory into prescriptive care which is bottom left. Your own ceiling of expectation from Jill becomes Jill’s ceiling of expectation of herself. If you cannot come around to believing that Jill cannot manage her safety than nor can Jill.
Host: A verbal description without the Care Compass may be confusing, remember you can get the images and the show notes at www.progress.guide. So a practitioner’s goal is to keep Jill in the top right permissive care quadrant where the focus is on empowerment, creating longer term resilience and recovery. Are there times when this may not be the case.
Expert: Yes, there are times when actually care for Jill needs to be in the prudent care quadrant where the clinician’s focus is primarily on safety and not on creating longer term resilience and they relate to scenarios where the risk is acute on chronic? Put simply when you have an acute on chronic situation it is like caring for those with a severe diabetes in the midst of a heart attack. So they really should be the top of your response list but unfortunately if you are not able to differentiate acute on chronic risk from chronic risk one is bound to take the wrong approach. In care quadrant terms if you mistake acute on chronic as chronic can focus on empowerment rather than containment you will be pushing Jill into the top left precarious carfe quadrant.
Host: So Jill is so fragile that she is not able to manage her safety and the clinician’s focus has prematurely shifted to resilience.
Expert: Yes, you all will remember from the nautical metaphor of Navigating Rocky Waters, if prematurely a person is asked to take charge of their recovery, it may be like pushing someone out into open waters on a raft with very few sea survival skills. That is why it is so important to predefine in a person centered way for each individual what does acute on chronic look for them, so for someone who self harms it might be that their frequency of self harming goes up from once or twice a week to daily or they go from self-harming on the concealed parts of their body to on their neck and face or their cuts are getting quite deep and are no longer superficial. This discussion needs to be undertaken when the person is calm and it operates best when you conceptualise these discussions with Jill almost like an advanced directive, preplanning care for these situations, so even if you take restrictive measures focused primarily on containment, Jill has had a say in it and it does not destroy her self belief in managing her safety longer term, if anything it enhances it, as she begins to believe that she can proactively identify such risky scenarios and contribute meaningfully to her safety. In my experience designing this safety net actually decreases the frequency of such crisis.
Host: This is very relevant for community care coordinators or case managers and community based psychologists and psychiatrists but you do spent a lot of time talking about this kind of ultra high risk scenarios in the suicide prevention training for GPs and primary care professionals.
Expert: Yes, it’s a training program called LIFE, designed for primary care folk, they are the ones who deal with a lot of chronic ongoing risk and doing this work up when the going is good provides clear trigger points of when to escalate to secondary care for short term intensive crisis support for the difficult period to subside and for them to return back to primary care. Most secondary care mental health professionals struggle to support people with Personality Disorder, so you can imagine how difficult it is in primary care with 10 minute appointments, but remember it can be a sequence of 10 minute appointments, that is what management of chronic risk involves and if one or two of those 10 minute appointments are utilized for forward planning a lot of risk can be managed.
Host: Sounds like the escalation from primary to secondary care will be the equivalent of containment and ongoing management in primary care the equivalent of empowerment if the starting point is in primary care.
Expert: That is spot on, in secondary by containment we tend to think of an admission and empowerment will be community management. In the next episode we will pick up the next conversation inpatient vs community and some practical examples in terms of words to use when talking to Jill or to Jill’s family.
Host: Actually I just noticed that we haven’t provided specific techniques like the in parts technique we discussed in the previous session and we have run out of time.
Expert: Most of these conversations are related and I would request listeners to go back to epsiodes 3 and 4 as the visual prop of the care compass can be very helpful in having some of these discussions with Jill. Just drawing out the two axes and drawing Jill into a conversation about where she believes she is and where you as the professional believe you are and the reason why the focus on empowerment is essential to recovery. You may actually have to say like I mentioned in the previous episode “Jill the easiest thing I can do for you is to admit you and we will all sleep better tonight knowing your immediate safety needs have been met, but I know if I did that I am being negligent towards my responsibilities to you and am not doing the harder but essential work that relates to relicense through empowerment.”
Host: Resilience through empowerment, that has a nice ring to it.
Expert: I am the master of my fate: I am the captain of my soul.
Host: Beautiful words by William Ernest Henley to end this episode on, I am the master of my fate: I am the captain of my soul. The goal of every mental health professional when supporting a person in suicidal distress is to capture hope, reconnect he person with their strengths and re-create self-belief and agency and in the process make themselves irrelevant in the person’s life so that they can remain the master of their fate and the captain of their soul. Containment vs Empowerment is a critical consideration in supporting people with BPD on their road to recovery. When communicating a difficult decision if you have the theoretical foundations of why you are making the decision you are making, it becomes so much easier to open up a window into your own mind so that the person in distress can clearly see your reasoning. If you are able to get across your role you will heal any ruptures in relational safety, remember that is the essence of all these conversations. Have you had a scenario like Jill’s where you have explained your role and how through your decisions you are trying to empower her and reconnect her with her self-belief that she can master these suicidal urges. Based on what you have heard what changes will you make to such interactions? 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. Next week we will go deeper into inpatient care vs community care and certain innovative approaches that combine both. Challenges in supporting people with Borderline Personality Disorder is a common knowledge and skills deficits. Given severe borderline personality disorder has a standardised mortality ratio 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. Thank you for joining us today and keep spreading the word.