TW: Suicide, Ableism (against people with BPD), Self-Injury, EDs: The following post talks about suicide, ableism against people with BPD, and Self-Injury in depth. Please be warned before you read it, and stay safe.
“Those who take a dismissive approach [towards suicide] make a mistake in the opposite direction. They become blase about suicidal behaviour, often attributing it to manipulation or gesturing on the part of the potentially suicidal person. This problem is acute when it comes to the often misunderstood borderline personality disorder, which is characterized by a long-standing pattern or out-of-control emotions, interpersonal storminess, feelings of emptiness, and impulsive behaviours, including impulses toward self-injury. Some clinicians take a dismissive attitude toward patients with this disorder because they believe that these patients merely “gesture” suicide. In other words, they engage in suicidal behaviours, such a cutting themselves, but do not really intend to kill themselves; instead, they only intend to provoke or manipulate others. I wish this were true, but it is not-approximately 10% of patients with this disorder end up dying from their suicidal gestures…The following quotation illustrates this misunderstanding:
The borderline patient is a therapist’s nightmare…because borderlines never really get better. The best you can do is help them coast, without getting sucked into their pathology…They’re the chronically depressed, the determinedly addictive, the compulsively divorced, living from one emotional disaster to the next. Bed hoppers, stomach pumpers, freeway jumpers, and sad-eyed bench-sitters with arms stitched up like footballs and psychic wounds that can never be sutured…Borderlines go from therapist to therapist, hoping to find a magic bullet for the crushing feelings of emptiness.
This characterization is demonstrably false. Patients with BPD do get better. A persuasive study found that 34.5% of a sample of BPD patients met the criteria for remission at two years, 49.4% at four years, 68.6% at six years, and 73.5% over the entire follow-up. Only around 6% of those who remitted then experienced a recurrence.
The dismissive attitude is dangerous for another reason. A main thesis of this book is that those who die by suicide work up to the act. They do this in various ways-for instance-, previous suicide attempts-and all of these various ways have the effect of insulating people from danger symbols. They get used to the pain and fear associated with self-harm, and thus gradually lose natural inhibitions against it. Clinitians’ dismissive attitudes have the potential to model a blase attitude about self-harm. If clinicians blithely get used to suicidal behaviour, their patients may vicariously do so as well.
…BPD and anorexia nervosa, are of particular interest, because they are among the most lethal of all psychiatric disorders, with the usual mechanism of death (including for anorexia nervosa) being suicide.
Unfortunately, in some clinical settings, patients with the disorder have the reputation for manipulation, including manipulating others through self-destructive behaviours (e.g., “gesturing suicide”), as well as for “splitting” (e.g., pitting people, including clinicians, against one another); some people roll their eyes about such patients, take a subtly or overtly demeaning tone about them, and make disparaging comments.
In some clinial settings, mental health professionals harbour demeaning attitudes toward people with BPD. I recently read a hospital progress note for a person with BPD that stated, “This patient is certainly not getting treatment from me.” One reason for sentiments like this is belief that these patients merely “gesture” suicide. In other words, they engage in suicidal behaviour…only…to provoke or manipulate others.
If only this were true. Those with BPD have a 10% lifetime rate of death by suicide; at least 50% of people with BPD have made a minimum of one very serious suicide attempt; and among those with this syndrome, an average of over three lifetime suicide attempts has been reported. Further, history of previous attempts among people with BPD is a stronger predictor of completed suicides than for any other diagnostic group (e.g., 65% of suicides among those with BPD have made a prior attempt; 33% of suicides among those with major depression have made a prior attempt). Through repeated self-injury, people with BPD become practiced regarding suicidal behaviour and may thus become…competant about suicide. Moreover, a common and pervasive sense of self-doubt and feelings of alienation and abandonment are very likely to instill perceptions of being a burden and create difficulty in belonging. As a consequence, suicide risk is usually elevated in patients with BPD.
-Why People Die of Suicide, Thomas Joiner, pp 20, 195-196
(Please forgive some of the repetition, it’s a bit choppy since I used two different parts of the book. I have BPD, and there’s a lot of stigma and falsehoods out there about this disorder, and both those factors have a direct human cost. People with BPD are already extremely vulnerable to suicide-I’ve attempted suicide, with degrees of severity up to very, 5 times-and we’re especially vulnerable to uncaring and dismissive treatment by mental health care professionals, as well as stigmatizing media about us that portrays us as violent, unhelpable, and abusive. Often people with BPD already have a distorted view of ourselves and of our relationships with others, and stigma can push us over the edge or prevent us from getting medical care we desperately need. There is a human cost.)