Chapter 14 Managing chronic risk
Chronic risk as a term is used predominantly to refer to a risk of suicide which remains present in a patient in a sub-acute form but which can become acute from time to time. It is also used for patients with repeated self-harming behaviour which at times is difficult to differentiate from acute suicidal risk. This behaviour is frequently linked to the diagnosis of borderline personality disorder (BPD) but is also seen in other personality disorders, dysthymia and chronic depression. The focus of this chapter is to look at the risk as it relates to patients with BPD although some of the techniques can be utilised in patients with other diagnoses when the same psychodynamic features are present.
• Bateman A, Fonagy P 2006 Mentalization-based Treatment for Borderline Personality Disorder: a Practical Guide. Oxford University Press, Oxford.
• Krawitz R et al 2004 Professionally indicated short-term risk-taking in the treatment of borderline personality disorder. Australasian Psychiatry, 12(1):11–22.
• Linehan MM 1993 Cognitive Behavioural Treatment of Borderline Personality Disorder. The Guilford Press, New York.
Professionally indicated short-term risk-taking
Before embarking on the development of a plan for managing chronic risk, it is timely to remember that a diagnosis of BPD should not be made lightly. It is likely that a patient will have been assessed and treated within a mental health service for some weeks or months before the diagnosis is made and detailed assessments and formulations will have been undertaken. The clinical picture needs to be clear before management approaches for chronic risk can be put in place.
The risks most frequently associated with the BPD diagnosis are self-damaging acts and suicide attempts. Between 70 and 75% of people with BPD have a history of at least one self-injurious act and estimates of suicide rates vary, but tend to be about 9%.1 Given the high frequency of suicide attempts, death by suicide is a genuine risk. This risk has been reported to be of the same magnitude as that noted in patients with schizophrenia or bipolar affective disorder (BPAD).2 This data highlights the risk clinicians face when working with BPD. Self-harm exists on a continuum with suicide for the patient with BPD.3 The behaviour is not necessarily seen as being risky by patients. It is often the clinician or family member who sees the danger. The dynamic which leads to either self-harming behaviour or attempted suicide is difficult to explain simply. Individuals with BPD can experience a sense of badness which can be overwhelming. Self-harm can be understood as a way of using a physical act to relieve unbearable emotional states. The similarities with entrapment, which is a risk factor for suicide, are clear. Subsequent to the event, the patient often feels relieved and experiences a greater sense of self-coherence. Suicide attempts often occur when the patient is temporarily unable to mentalise (see glossary). The patient often believes that one part of them will survive the suicide attempt and that an alien/bad part will be destroyed.4 Suicidality can vary from zero lethality and intent to un-ambivalent intent.5
For these patients, the behaviour is adaptive until such time that other ways of expressing distress are learned. For patients with BPD, the behaviour is likely to persist over time. This has substantial relevance to the issue of hospitalisation as it is unlikely to change the level of risk substantially. Paradoxically, hospitalisation can increase the risk.6, 7
There are two important factors to consider in deciding how active to be in response to a suicidal crisis:8
1. the short-term risk of suicide if staff do not actively intervene
2. the long-term risk of suicide and of a life not worth living, if staff do actively intervene.
The response to the patient in any given case requires a good knowledge of dynamic risk factors and of the functions of suicidal behaviour for the patient. These are more clearly identified in patients well known to the service. For patients less well known, treatment will be more conservative and active.
Certain responses may in the short term decrease the probability of suicide, but that response may actually increase the likelihood of future suicide.9 When suicidal ideation and threats are enacted because of the consequences they bring — that is, they function to get others actively involved (e.g. get help, solve problems, obtain admission to hospital, etc) — clinicians need to be careful that their response does not inadvertently reinforce the high-risk suicide behaviours they are trying to stop. Conversely when the suicidal behaviour is elicited in response to a situation or stimulus event, rather than by the consequences it brings, the behaviour will not be reinforced by responding to it. The nature of BPD is that the risk is likely to persist over time.
With a chronically suicidal patient, staff can expect a number of repeated suicidal behaviours before that behaviour comes under control. However, ‘it is ultimately essential that the behaviour comes under the patient’s control and not that of staff or of the community’.10 ‘Chronic suicide behaviour can be seen as being a mode of adaptation to life, an extremely common state among individuals with BPD.’11
If the patient is assessed to be an acute risk for suicide, then clinicians are ethically and legally required to take a directive role in preventing the patient from actually committing suicide — management of the short-term crisis is needed until the self-destructive phase passes. In contrast, chronic suicidal states driven by abnormal personality functioning represent a seriously disturbed yet consistent mode of relating to others and the environment by engaging others into assuming responsibility for suicidal behaviour and thus avoiding appropriate levels of personal responsibility for behaviour. Interventions for chronic suicide should assist and teach the patient to again assume realistic self-responsibility. Otherwise, traditional paternalistic and directive interventions may actually reinforce the destructive interpersonal dynamics of the individual with BPD and provoke further suicidal behaviour. ‘Reducing risk to people with personality disorder involves placing a high degree of choice and personal responsibility with the patient.’12
‘For both clinical and ethical/legal reasons, it is important that clinicians recognise the distinction between acute and chronic suicidal states.’13
