In the third of the 5 Critical Crisis Conversations, Manaan explores how the person's agenda of ensuring short term safety through admission may be quite different to the long term focus of resilience for the professional.
Both want safety but the route to it is different. Being able to show the similarity of the overarching goal amidst the dissimilarity of the immediate outcome is a critical conversation to have with the person in distress. If they are able to understand that the professional is not rejecting their needs or abandoning them and on the contrary is selecting a much longer harder route to walk with them one can bring the person on board for safety planning and taking charge of maintaining their safety. Or else a person with BPD will feel the pressure to prove the professional that they are in deep distress and the risk will escalate as the threats to harm oneself intensifies.
Connect with Assoc Prof Manaan Kar Ray at https://www.linkedin.com/in/drmanaankarray/
Follow us on www.progress.guide
In the third of the 5 Critical Crisis Conversations, Manaan explores how the person's agenda of ensuring short term safety through admission may be quite different to the long term focus of resilience for the professional.
Both want safety but the route to it is different. Being able to show the similarity of the overarching goal amidst the dissimilarity of the immediate outcome is a critical conversation to have with the person in distress. If they are able to understand that the professional is not rejecting their needs or abandoning them and on the contrary is selecting a much longer harder route to walk with them one can bring the person on board for safety planning and taking charge of maintaining their safety. Or else a person with BPD will feel the pressure to prove the professional that they are in deep distress and the risk will escalate as the threats to harm oneself intensifies.
Connect with Assoc Prof Manaan Kar Ray at https://www.linkedin.com/in/drmanaankarray/
Follow us on www.progress.guide
Host: Good day and welcome to episode 25, I am Mahi your host and with me is Manaan, head of faculty for Progress Guide. Today we will discuss the third of the five borderline conversations short term vs long term, how does your care decision impact each time window? We ended the last episode with the beautiful words of William Ernest Henley, I am the master of my fate: I am the captain of my soul. Fitting words to end an episode in which we discussed the dilemma of empowerment vs containment. Empowerment - The goal of every mental health professional when supporting a person in suicidal distress is to capture hope, reconnect the 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. This can be easier said than done particularly in the face of the intense suicidal distress of a person in a borderline crisis.
Expert: It is the intensity of distress that is often projected on to the professional that causes immense anxiety in care providers. Something we have covered in detail on the first of the five conversations advice vs actions. If our advice to a person in borderline crisis is, face your fears, you can navigate through this difficult time, suicidal urges do subside and you need to learn to overcome the anxiety by going through it, there is no other way, if that is your advice, then you need to role model it in the decision you make and the actions you take or else your advice is just empty words. This led to the discussion about empowerment and containment. If you operate from the principle of better be safe than sorry lean more towards containment, one has to ask, better for whom, you as the professional or the patient. Containment may be necessary at times, but surely the goal is to empower the person to manage the trials and tribulations of living a life that is meaningful despite their borderline personality disorder.
Host: I am assuming today’s episode short term vs long term builds on these two previous discussions.
Expert: Yes, it does
Host: And it relates to the 3rd AWARE factor Agenda?
Expert: Exactly, remember we have discussed Agenda in detail in episode 17, as an assessor we asked you to pause and think HOW OFTEN ARE YOU RESPONDING TO AN AGENDA that you have perceived IN AN ASSESSMENT that may be skewing the clinical decision or the outcome. Remember an agenda is a desire or motivation to achieve a particular outcome. Sometimes they are clearly stated and other times its implied or perceived by the assessor. What we found in the AWARE study was that once you pick up an agenda it begins to influence information processing which needless to say impacts the decision you make.
Host: And that wasn’t specific to borderline personality disorder?
Expert: No, it wasn’t assessors as I said perceive agendas all the time, in fact that is one of the key clinical skills that a practitioner needs to develop, to establish what is it that will meet the needs of the person in front of them, why are they here. What we did see was that assessors seemed to look more kindly on agendas that were out in the open, things that they could discuss honestly and candidly, but the stance often became less compassionate and in some cases adversarial if the assessors felt that they were being somehow forced into a corner to meet an unstated agenda.
Host: Like someone angling for an admission?
Expert: Yes, and that is where the whole discussion regarding BPD becomes relevant. Clearly they are angling for an admission because they believe that is where they will be safe and they cannot trust themselves to navigate their distress without putting themselves in harms way, however it is hardly ever spoken of in this way, the so called angling takes expression as statements which sound like, if I am discharged I am going to walk into traffic and sometimes, you will be responsible if I end up going back to the bridge again and jumping off.
Host: The clinical interaction sounds like a power struggle.
Expert:This is not unusual for the conversations to pan out in this fashion. In your thought bubble if you have got ‘Jill is angling for an admission, I need to keep her out of hospital’. This will rapidly become adversarial in nature. The assessor may not even be consciously aware of their mental stance. But Jill quickly perceives this stance, remember people with borderline personality are hyperaware of abandonment and rejection. So when they perceive this stance in a clinician who is discounting how unsafe they are currently feeling, they feel a pressure to prove their suicidal distress, and this escalates the risk in the situation.
Host: This reminds me that for our new listeners we should do a quick recap of Jill.
Expert: Yes, we should.
Host: So, Jill is a 30 year old female who has presented to ED in suicidal crisis. 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. Jill is aghast, 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. You then go on to elaborate the different approaches to providing support, you use the care compass to draw out the two axes¸ the x axis for Jill’s fragility and resilience and the y axis for your clinical focus which stretches from safety at one end to self reliance at the other end. You attempt to draw Jill into a conversation about containment and empowerment and help Jill understand why those whose struggles with suicidality are chronic, a large part of their recovery entails learning that suicidal urges can be mastered through one’s internal coping strategies.
Host: This is where we are, you are using the care compass to help Jill get on board for the journey ahead, so Manaan how might you go about it.
Expert: First things first, for a full description of the care compass please listen to episodes 3 and 4, if you don’t know what the care compass is none of this will make any sense. In the guide book the Care Compass is on page 10 and you can also see the image online at www.progress.guide on the podcast blog. When supporting someone who is feeling extremely fragile and may have presented to the ED or AnE, your initial focus has to be on maintaining safety, i.e. on the bottom left quadrant of prudent care, that does not mean that you admit everyone into an inpatient setting, yes some will need an admission because there risks are so high that crisis management and containment will take priority over empowerment, but the hope is that through the process of assessment and safety planning that follows each and every assessment you will be able to help the person shift from the bottom left quadrant of prudent care, where the focus is on re-discovery of hope and one’s strengths to the top right quadrant of permissive care where the focus is on recovery.
Host: In terms of movements across quadrants, that is what you describe as positive risk taking
Expert: Yes that’s correct, for some the initial focus may end up being containment and they might need a short 3 day inpatient stay to move them from prudent care i.e. focus on safety and rediscovery to permissive care i.e. focus on resilience and recovery, but for most your skills as an assessor and engager will need to be drawn on to help the person make the same move in a much shorter time window say 3 - 4 hours that will involve a thorough assessment, some brief interventions, decisions on the level of monitoring and who does the monitoring and then step down into the community.
Host: And that is what you call the AIMS approach
Expert: Yes, I guess at a later date when we talk about designing suicide prevention pathways we will talk about AIMS in details, AIMS stands for A for assessment, I for intervention, M for monitoring and S for Step up or Step down meaning transitions of care. We expect every practitioner to answer those four questions:
1. What further assessment is needed
2. What interventions need to be delivered
3. What monitoring is required
4. What actions need to be successfully undertaken before a step down or what would indicate that a step up is needed.
When I use the word what that is also a proxy for who does it, where is it best done, when should it be done etc, if all those four questions are reasonably answered one will find that they can begin to address the high levels of anxiety that is present in any crisis situation. I have a feeling I have digressed from the original question and have side tracked into AIMS, What were we talking about
Host: Positive risks, moving from Prudent care where the focus is on safety and rediscovery of hope and strengths to Permissive care where the focus is on resilience building and moving forward with one’s recovery
Expert: Of course, so yes, answering the four AIMS questions is the way in which you can operationalise this whole idea of positive risks, for example if you have not fully formulated or articulated those 4 answers you will find that the level of anxiety in Jill and her family would still be very high and it will be akin to a move from prudent care to precarious care, where the care feels rushed, the patient does not feel ready and is not on board and relational safety breaks down.
Host: So, that is the move from prudent care which is bottom left to top left precarious care, what you described in episodes 3 and 4 as risk prone clinical decision making.
Expert: It is quite interesting, the same decision can be positive risk or risk prone based on the quality of the dialogue and the interaction with the person, essentially are you able to bring the person on board and get them and their family to play the part that they need to play to maintain safety.
Host: There is also the move from prudent care, bottom left to bottom right into prescriptive care, something you have described as risk averse clinical decision making
Expert: Yes this is the opposite scenario to risk prone decision making where the person feels they are ready, the family feels that they are ready, but the professional does not share that belief and feels that the focus still needs to be on safety, under those circumstances care could become prescriptive and Jill might spend an awful lot of energy fighting the system to get out, please do remember that there may be very good reasons why the clinician may feel that way due to past experience with Jill or patients similar to Jill.
Host: So, there are 3 different clinical decisions, those that involve positive risks, those that are risk prone and those that are risk averse, clearly you don’t want to be risk prone.
Expert: True, so you have to get the person on board, but you also don’t want to be risk averse, if the focus is just on containment then you are stifling the person’s grown and self belief, that is why it is so important to have the conversation with Jill in which you open up a window into your thinking to help Jill see why you are choosing community over inpatient, this by the way is the fourth borderline crisis conversation which will pick up in the next episode which relates to the AWARE factor of resources.
Host: So when you say open up a window into your thinking, what does that mean, what will you actually tell someone like Jill?
Expert: With Jill it is slightly easier as you have specific examples to draw on due to her known past history of previous admissions, so you can describe how care got restrictive with escalation in self harming prior to discharge and the admissions stretched out with very little therapeutic benefit, if anything those short crisis admissions destroyed her trust in her self, trust in the system, and the seclusion and restrains resulted in retraumatising.
Host: So you will be articulating the case for not admitting?
Expert: I tend to think of this part as a two step process, first you need to put the competing agendas on the table, make the implicit, explicit, state the obvious. And make Jill and her family see that we are on different hills, clearly Jill you want an admission and containment and to feel safe and I feel that what you need is enhanced community support to support you to believe in your self that these suicidal urges can be navigated, you have what it takes to get through these and once you get through them your confidence in your self will grow.
Host: So, the different hills is the containment vs empowerment discussion
Expert: Yes, you are building on it, you are making obvious the different agendas, Jill wants to be safe you want her to be self-reliant. Jill wants inpatient care you want community care. This initial first steps of shining a light on the different hills is essential to move to the next step of showing that the hills share overlapping grounds, that there is a shared objective.
Host: Ok you have put it to Jill that the two of you are pulling in different directions
Expert: Well we want to avoid that, but it has to be done with honesty and candour, you might seem to be pulling in different directions but actually you are not, both hills stand on the same grounds, Jill wants safety, in the here and now, you want safety in the here and now too, but you know that every time if Jill presents in crisis and you admit her Jill will never develop the internal and external coping strategies she needs to regulate her emotions and affect, so you are talking about taking positive risks and make it safer in the longer run by focusing on resilience.
Host: So, Jill’s focus or agenda is short term safety and your agenda is long term safety.
Expert: Exactly but it is a difficult one for Jill to grasp, cause her anxiety is overwhelming her at the moment, so you will need some time to have this supportive sensitive conversation to help Jill see that if we keep admitting you Jill, every single time you present you are learning that in order to feel safe I have to take risks, I have to self harm, I have to cut more frequently or I have to cut deeper or I have to take or threaten to take bigger risks, so although an admission reduces the risk in the short term, it is actually increasing the risk in the longer term.
Host: This must be a very difficult conversation to have if Jill is feeling overwhelmed.
Expert: Yes it is that is why I keep saying use the in-parts technique to help Jill see that part of me does want to take the easy route and admit, you feel safe, I feel safe, everyone goes home happy other than you who ends up in hospital, but I know Jill that the easy way will be the wrong way, cause that is a short term solution, like a band aid, my responsibility to you is much harder than just saying admit, my responsibility to you involves helping see and believe that you can overcome these moments of crisis and I want to work with you to figure out what further assessment, intervention, monitoring is needed and what is the best option in the community that can help you through your crisis as well as identify when might we need to step up for an inpatient admission. I know you believe that it is now, but I need you to work with our community teams to test out whether we can support you to stay at home.
Host: Admission might contain the risks in the short run but will escalate risks in the long run as the person’s risk taking is reinforced through the desired consequence of hospitalisation.
Expert: Wow that is an excellent summary.
Host: Well, I have just regurgitated your words from the workbook on page 20
Expert: Ha ha, and for a moment I thought gosh you absolutely nailed this one
Host: Well, I have got it, cause I have put in my own flavour, I added in the word desired making it the desired consequence of hospitalisation, maybe you should add the word desired in the next edition of the workbook.
Expert: Actually, that’s a good point, yes it is Jill’s desired outcome but not yours and your two step challenge is step 1 that the desired outcome of the assessment she has and you have are different in terms of admission, and step 2 highlight that the desire for safety is the same, just that she is thinking short term you are thinking long term.
Host: Just a thought because I know you talk a lot in your courses about moving from top to tap, is there a risk that you might come across as a bit condescending, you are the expert so you are thinking long term and poor Jill is only the patient so she is thinking short term.
Expert: Well, you are dramatizing it a bit when you say poor Jill is only the patient, but I get the point you are making, there is always the risk that you might come across as condescending or you come across patronising, it depends on how big a window you open into your mind, cause it is the words you use. You can go a step further in your validation by explaining, Jill given your extreme anxiety, it does not surprise me that your focus is on surviving the here and now, just making it through today so you are forced to think short term, where as I am a step removed from you, I am walking with you but am not in your shoes, so will never be able to feel the anxiety in the way you do so I am able to think a bit longer term and think through how my decisions today can either be enabling for you in the longer run or actually disabling for you, how my decisions can make it safe in the short term but unsafe in the long term as you take more and more risks to express your distress and seek containment through admission, or I can take positive risks today, it will feel unsafe in the short term but in the longer run you will learn that you can survive these anxious moments by drawing on your strengths and natural circle of support.
Host: That is a long winded answer to a simple question Manaan so in short you can come across as condescending.
Expert: Ha ha stop scoring points, you are right these are extremely nuanced conversations, that’s why it is so important to practice them in simulation workshops, you learn through your mistakes.
Host: This is the Critical Crisis Conversations Course for BPD
Expert: Yes, we get professional actors and facilitators to repeatedly practice these conversations, very similar to the 7 SAFE Steps Program, of course this much more advanced and much more expensive so for experienced professionals looking to fine tune their skills, we do the AWARE factors in detail, understand Creep Crash Crawl and through evolving scenarios practice each of these conversations and the actors give you real time feedback as to what worked well and even better if, it is done in a very supportive way to build up a professionals confidence.
Host: How expensive it is?
Expert: It is quite expensive, depends on a number of factors, face to face or online, how many students, that dictates the number of actors and facilitators, a standard one day program for 24 – 28 participants with four actors and four facilitators, depending on one or two days will cost between 30,000 to 50,000 Aussie dollars, of course train the trainer programs in which we hand a licence to an organisation with our intellectual property rights are much more expensive. The sum taken in isolation may seem large, but you know what if each professional who attends manages to avoid one 2 month admission, at a bare minimum 1000$s a night that’s 60,000 dollars for an admission, so the course can save you 50 times the figure, if you have 24-25 participants in the very first month or two. It is money well spent not to mention the impact on people’s lives and how do you put a figure to a life that may be saved through a critical conversation. Well that one is for the managers to mull over as they think about pushing quality up and brining costs down.
Host: Yes, how do you put a price on the life of a loved one, that’s a poignant note to pull this episode to an end. Short term vs long term. The two can feel like competing demands but if through one of the critical conversations that we have been discussing we can get Jill to see that your goal is aligned to hers, that you want to create safety in the longer term by taking positive risks in the here and now you may be able to heal any ruptures in relational safety.
Expert: The critical issue with the agenda factor in AWARE is how quickly patients with BPD perceive rejection and abandonment and that then plays into their risk taking as they attempt to prove that they do need containment now, they need to be kept safe, you have to keep me safe or else you are responsible, this conversation about short term and long term pre-empts the other one about who is going to be responsible for my death, one that involves an unhelpful power struggle over resources, something we will pick up in the next episode. There is a quote by Garrison Wynn that I love, he is an author and motivational speaker, he says Long-term success is the result of relationships built on a foundation of trust. People get more value from those they trust. And relational safety is all about trust, of course he was speaking in a different context, whatever be the conversation, it has to be genuine, in Empathy in action we talk about the 3 components, cognitive empathy, emotional empathy and empathic concern, the third component, that is the bit around the genuine desire to help, if you have it will shine through.
Host: These conversations are all about building relationships, relationships as the foundation of long term safety and through the conversation helping the person see that you are genuine in your desire to help them overcome the challenges life is posing both in the here and now but also in the longer term future. Short vs long term is one of those critical conversations where you can help a person with BPD see your genuine commitment to them, if you can get this across you will win them over for the short term, as well as help them play their part in managing their safety and it all depends on whether they feel rejected or supported. Have you had a scenario like Jill’s where you have needed to explain what you are doing and why? How did it pan out? Did you win the person over and help them see your commitment to supporting them? 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, something we had thought we might have been able to tackle today, but we did not get around to it, so we will do it in the next episode. 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.