HOW DO MENTAL HEALTH PROFESSIONALS EXPERIENCE AND MAKE
SENSE OF MANAGING RISK IN SELF-HARM AND SUICIDE WITH PATIENTS
DIAGNOSED WITH BORDERLINE PERSONALITY DISORDER? A STUDY
USING INTERPRETATIVE PHENOMENOLOGICAL ANALYSIS.
DR.VICTORIA MORAN
A THESIS SUBMITTED IN THE PARTIAL FULFILMENT OF THE
REQUIREMENT FOR THE AWARD OF THE DEGREE OF THE DOCTORATE
IN CLINICAL PSYCHOLOGY
ACKNOWLEDGMENTS TO TEESSIDE UNIVERSITY, DR.T PRESCOTT & DR. S
MITCHELL
Overview
 Summary of literature
 Research design
 Findings
Summary of super-ordinate & sub-ordinate
themes
 Discussion
Limitations
Implementation
 Conclusions
Literature Summary
‘BPD’
“A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and
marked impulsivity beginning by early adulthood and present in a variety of contexts as
indicated by five (or more) traits”.
 Diagnostic process for PD can be problematic for some of the following reasons:
 Overlap and co-morbidity with other mental health diagnoses (NICE, 2009; Zanarini,
Frankenburg, Hennen, Reich & Silk, 2004; Zimmerman & Mattia, 1999)
 Breadth of individual presentations that diagnostic criteria can generate (Cooper, Balsis &
Zimmerman, 2010)
 No single cause attributed to development (Kupfer, First & Regier, 2002; Pilgrim, 2001)
 Lack of biological evidence (Paris, 2008)
 Debate transcends from a theoretical research framework into the working clinical world. The
key features which define personality disorder are necessary and allow clinicians to assess and
provide interventions.
 Additionally, diagnosis enables individuals who have intense interpersonal difficulties to be
identified and receive appropriate therapeutic input (Paris, 2008).
Attitudes towards BPD
 Aversion to working with this group
 Individuals who receive a diagnosis of PD can feel overcome with
powerful emotions which may influence the emotional experience of
clinicians (Aviram et al., 2006).
 The self-destructive behaviours that individuals with BPD demonstrate
can evoke feelings of incompetence within teams (Cleary et al., 2002).
 Subsequently, negative attitudes may reflect an underlying fear staff have
when working with individuals that are both impulsive and chronically
risky.
 Murphy and McVey (2003) reviewed the challenges of nurses working
with personality disordered patients. Noted that lack of personal
qualities and appropriate skills intensified the difficulties nurses
experienced in comparison to other psychiatric diagnosis.
Risk & BPD
 Managing suicidal patients is one of the most stressful tasks undertaken by clinicians
(Jobes, 1995).
 Literature is beginning to emerge that considers healthcare professionals experiences
of managing risk, self-harm and suicide
 (Lindgren, Oster, Aström, Hällgren & Graneheim, 2011; McAllister, Creedy, Moyle & Farrugia, 2002;
Thompson, Powis & Carradice, 2008; Wilstrand, Lindgren, Gilje & Olofsson, 2007).
 No research specifically with explicit links on professionals experience of managing
risk of self-harm and suicide in BPD.
 Suicide risk in BPD individuals across their lifetime is approximately 8- 10% (APA,
2001).
 Within a hospital based sample, 45.9% of patients with personality disorder have
deliberately self-harmed ([DSH], Haws, Hawton, Houston & Townsend, 2001).
Risk & BPD
 Fowler (2012) comments that when assessing suicide and
self-harm, focusing on meaning and understanding
collaboratively with patients can contribute towards the
avoidance of aversive outcomes.
 However, building such a collaborative relationship can be
problematic with individuals diagnosed with BPD (Nehls,
2000), particularly if they continuously engage in selfharming or suicidal behaviours (Commons Treloar & Lewis,
2008).
 So how do mental health professionals experience such a
dynamic and challenging aspect of their work with BPD?
Clinical Context
 Two main policy drivers exist that have substantially shaped the
experience that clinical staff can have with patients with BPD.
 Personality Disorder: No longer a diagnosis of exclusion (National Institute of Mental Health
[NIMHE], 2003).
 National Suicide Prevention Strategy for England (Department of Health [DoH], 2003) &
updated Preventing suicide in England: A cross-government outcomes strategy (DoH, 2012)
 Drivers create a context of inclusion and reduction.
 So what is this like for clinicians when trying to manage risk with a
complex patient group?
Rationale
 Literature captures feelings of difficulty and incompetence in staff who
work with BPD (Cleary, Siegfried & Waters, 2002; James & Cowman, 2007; Lewis & Appleby, 1988).
 There is no published research that clearly highlights how mental
health professionals make sense or experience aspects of risk
management explicitly with BPD.
 This gap is particularly pertinent with BPD because a primary feature
of the disorder is self-harm and suicidal behaviours.
 National drivers highlight a tension between inclusion and suicide
reduction.
 Clinicians are faced with systemic and organisational pressure in
addition to working with a complex client group.
Current Research
 The research question posed is:
 How do mental health professionals experience and make sense of managing
risk in self-harm and suicide with patients diagnosed with borderline
personality disorder?
 A qualitative approach was adopted to answer this question.
 Aim was to develop a coherent narrative of an explorative nature into
what it is like to manage risk with individuals diagnosed with BPD.
 The researcher is seeking to explore participants’ lived experience of
managing suicide and self-harm in patients diagnosed with BPD and
therefore the participants’ working environment and context is
important.
Current Research Design
 The use of Interpretative Phenomenological Analysis (IPA) allows for
some psychological insight into the experience of managing risk with
patients with a diagnosis of BPD.
 Qualitative approaches are suitable when considering individuals’
experiences in depth, particularly when the research is undertaken in
novel areas (Barker, Pistring & Elliot, 2002)
 Both collective and idiographic experiences of the mental healthcare
professionals considered.
Participants
Participant
Gender
Age
P1
Female
50
P2
Female
46
P3
Male
26
P4
Male
39
P5
Female
37
P6
Male
49
P7
Female
51
Backgrounds and Professions included:
Occupational Therapy, Nursing, Psychology, Social Work
Research Design
 Interpretative Phenomenological Analysis (IPA)
1. Researchers initial encounter with the text
2. Identification of themes
3. Clustering of themes
4. Production of summary
5. Integration of cases
6. Write up
 (Willig, 2008, pp. 60 - 63)
Findings
Superordinate
Themes
Sub-ordinate Themes
Clinicians’
experiences
with self
Clinicians’
experiences with the
patient
Power, Control,
and Uncertainty
World of Conflicts,
Paradox, and
Unpredictability
Recognising
limitations to role
Positive regard and bond with
the patient
Attempts to gain control
through a conscious process
‘You’ve got to be prepared
to say, yeah okay, I know
what my limits are, lets go’
P5: 570 - 571
‘I do like the patients, I do like my
patients, I like hanging out with them’
P5: 150 - 152
‘Formulation and a really good
understanding of where they’ve
come from. So all that background
history’. P3: 161 – 162
Multifaceted,
incongruent emotional
experience
Rejection of assumptions,
stigma, and labels associated
to patient
Patient and risk as powerful
and uncertain
‘I don’t know what a normal
personality is so I don’t know what a
disordered personality is’ P6: 8 - 9
‘Everything’s got to stop now
because I do have to go out and
react to this because I can’t not
react to this’ P2: 355 - 356
Personal self as part
of the professional
self
‘It’s a bit of a maternally,
parentally thing where you
can be a bit tough but this
kind of compassion, erm,
professional tolerance’ P2:
124 – 126
Coping utilised with the
patient in the working role
Searching for meaning in
risky behaviour
‘You’re rubbish and you’re a social worker
so you don’t know anything. Just the
normal things you get told’. P1: 363 –
365.
‘It is a way of expressing emotions
erm, when you cannot think of
other ways to do it I suppose’. P7:
70 – 71
‘Ahhhh, well sometimes anxious,
sometimes I have a bit of doubt,
sometimes feel sad, sometimes feel
angry’. P6: 365 – 366.
Clinicians’ experience
within a system as
conflicting and
ambiguous
‘There is no policy that says at
this point is when you do this,
right, so it is all kind of, down to
judgement’ P1: 397 – 398
Key Findings
 The super-ordinate themes demonstrated a level of shared understanding and commonality
amongst participants in how they experience risk of self-harm and suicide in BPD.
 However, the detail within the sub-ordinate themes highlighted the differences and individual
experiences amongst participants
 Multi-faceted and complex experience:
On one hand, participants
feel a bond and relationship
with the patient that can be
shaped by and influence their
own experience as a mental
health professional.
On the other hand, participants
recognise the power that risks hold
with regard to the wider systemic
influences.
 Participants therefore experience incongruence in their work and can often utilise
personal coping, defences and conscious cognitive processes to manage the work they
carry out with suicide and self-harm in BPD.
Key Findings
Participants alluded to a divide within their work managing risk of self-harm and suicide.
 This was shared between their work with the patient and their work within the system.


However negative or emotionally difficult the work with the patient was, participants were able to
find a positive regard and view of the patient. Participants quite strongly and actively rejected the
labels and stigma associated with individuals diagnosed with BPD.

However, in some experiences, there was the propensity for boundaries to be weakened in the
relationship with the patient when risk was present. This left the participants caught with their
professional roles and responsibilities spilling into their personal worlds in the form of anxiety,
worry and fear.
Super-ordinate Theme 4 - World of
Conflicts, Paradox and Unpredictability
 Sub-ordinate themes:
 Multifaceted, incongruent emotional experience
 ‘Ahhhh, well sometimes anxious, sometimes I have a bit of doubt, sometimes
feel sad, sometimes feel angry’. P6: 365 – 366.
 Clinicians’ experience within a system as conflicting and
ambiguous
 ‘There is no policy that says at this point is when you do this, right, so it is
all kind of, down to judgement’ P1: 397 – 398
Sub-ordinate Theme 1 - Multifaceted,
incongruent emotional experience
 It emerged from all participants that the working environment
was often emotionally charged.
 All participants talked about the emotional impact of managing
risk of self-harm and suicide with patients diagnosed with BPD.
 The power of emotions experiences extended into participants
home environment.
 Paradoxes featured in the experiences of participants such as a
reward – punishment paradigm.
Multifaceted, incongruent emotional
experience
 The relentlessness of erm, if someone is in constant crisis it can feel like
you're not making much progress, but then it can be very rewarding if you
do, erm, discharge and if they get what they want, they get their life
worth living type thing (P3: 387-390).
 Ahhhh, well sometimes anxious, sometimes I have a bit of doubt,
sometimes feel sad, sometimes feel angry (P6: 365-366).
 Erm, so I certainly had a lot of sympathy for him but, erm, erm, and you
know I could see that he was, he was trying, he was trying to improve the
situation. Erm, but then he would do things which would quite annoying
me as well actually (P4: 125-128).
Sub-ordinate Theme 2 - Clinicians experience
within a system as conflicting and ambiguous
 All participants talked about struggles relating to the
management of self-harm and suicide with individuals diagnosed
with BPD.
 Generally, this was associated with ambiguity and conflict in the
system in which they work.
 Attention drawn by some participants to a lack of guidance when
making decisions about self-harm and suicide.
 A sense of isolation and blame stemmed from systems in which
participants worked.
Clinicians experience within a system as
conflicting and ambiguous
 I mean there is no policy that says at this point is when you do this, right, so it is
all, kind of, down to judgement. At the same time, you can't kind of be rushing in
with the, you know, erm, you can't be rushing in with every mental health act
assessment every time somebody cuts themselves. So I think making that judgement
is quite difficult. And [sigh], I think if you err on the side of caution it takes the
responsibility away from the patient and I don't think that that is always helpful
(P1: 396-404).
 Powers that be would have it, that there is plenty of support out there, but I think
when you’re sat in somebody’s home making individual judgments erm, there
isn’t…it doesn’t always feel that supported (P2: 289-292).
 In that people are saying, you know, we need to take lots of risk, we need to, you
know, allow people a bit more freedom.When there is an SUI it’s ohh who’s going
to get it, take the rap for this. So I think again people, erm, what they say just
isn’t congruent with the organisation policies (P6: 471-475).
Discussion
 At present theoretical literature that is specific to suicide and BPD is
sparse (Chance, Bakeman, Kaslow, Farber & Burge-Callaway, 2000).
 A psycho-dynamic theoretical framework was used to discuss and
make sense of the experiences captured across the super-ordinate
themes.
 Super-ordinate theme 4: World of Conflicts, Paradox and
Unpredictability
 From the emergent themes it is recognised that there is
incongruence between clinical work and managerial drivers with risk
in BPD.
 There was a level of awareness to some of the conflict experienced in
the working world.
Unconscious Dynamics
 The super-ordinate theme of power, control, and uncertainty also demonstrated elements of less
conscious influence.
 Malan’s (1995) ‘triangle of conflict’ provides a theoretical framework to understand the
dynamics that can unconsciously emerge in the professionals’ world.
Defence:
Splitting
Projection
Denial
Anxiety:
Conflict/Turmoil,
Incongruent & multifaceted emotions
Hidden Feeling:
Questioning of ‘caring’ integrity
Anger
Dislike of patient / Want them to be harmed
Triangle of conflict…
 Healthcare professionals may experience strong, negative and intense




yet hidden feelings towards the patient.
Such hidden feelings remain elusive because bringing them into
consciousness is an unbearable, intolerable experience for
professionals who are employed to ‘care’ for others.
These feelings can create a level of anxiety which needs to be managed
and defended against.
To defend against such tension professionals can evade the thoughts
becoming conscious by disregarding the internal conflict or tension.
The participants were conscious of power, control and uncertainty
associated with risk. By discussing the impact of risk, healthcare
professionals are displacing the internal conflict that stems from the
interaction with the patient and are therefore maintaining their
personal and professional integrity.
‘Splitting’
 Less conscious aspects of ‘splitting’ emerged within this theme.
 In psycho-dynamic terms the defensive practice of ‘splitting’ allows
individuals to keep apart two conflicting, uncertain or opposing
worlds (Klein, 1952).
 The defence of splitting has historically and commonly been associated
with individuals diagnosed with BPD (Kernberg, 1967; Lichtenberg & Slap, 1973;
Zanarini, Weingeroff & Frankenburg, 2009).
 Professionals may mirror aspects of the patient’s experiences through
counter-transference interactions.
 Therefore, participants may naturally split their world of work with
the patient and system into ‘good’ and ‘bad’ facets (Klein, 1952).
‘Splitting’
 Working with the patient and within the system is difficult for the
participant to integrate resulting in a projection of negativity towards
the system and a positive regard for the patient.
 When integration was attempted participants talked about bringing the
two opposing areas of inclusion and risk reduction.
 Participants wanted to take short term risks therapeutically in order to
benefit the patient in the longer term.
 This is an area supported theoretically with BPD (Krawitz, Jackson, Allen,
Connell, Argyle, Benesemann, Mileshikin, 2004; Paris, 2005) and self-harm (NICE, 2004 & 2012).
 If there is a drive to reduce risk in a service and give inclusivity to
those with a PD diagnosis, it appears that something has to give in
order for clinicians to be able to achieve this.
Limitations
 Qualitative research specifically in BPD and suicide and self-
harm management is still sparse and so current study only
adds to a small body of literature.
 Purposive sampling, aimed at three groups within Adult MH.
However, no individuals participated from Crisis team.
 Only one Mental Health Trust recruited from.
Implications
 Contribution to under researcher area.
 Evidence that participants are striving to care whilst endeavouring to
maintain a professional boundary.
 Promotion of supervision weighted in evidence.
 Supervision should focus on the emotional impact of working with
self-harm. Provides space to share the difficult multi-faceted
experiences of risk in BPD.
 Supervision can also focus on counter-transference and relational
dynamics.
 Promoting of risk-tolerant approach in wider systems.
 Support and education for managers who are not clinically trained to
work with PD may be beneficial in the development of shared
understanding of patients with BPD.
Conclusions
 The emergent themes highlighted that the experience of
managing self-harm and suicide with patients diagnosed with
BPD is multi-faceted and complex.
 A divide emerged were participants felt a bond and relationship
with the patient that can be shaped by and influence their own
experience as a mental health professional.
 However, participants also recognised the power that risks hold
in regards to the wider systemic influences. Participants
experienced incongruence in their work and utilised personal
defences and conscious cognitive processes to manage the work
they carry out with suicide and self-harm in BPD.
References

American Psychiatric Association (2001). Practice guideline for the treatment of patients with
borderline personality disorder. American Journal of Psychiatry, 158, 1–52.

Aviram, R. B., Brodsky, B. S., & Stanley, B. (2006). Borderline personality disorder, stigma and treatment
implications. Harvard Review of Psychiatry, 14, 249-256.

Barker, C., Pistrang, N. & Elliott, R. (2002). Research methods in clinical psychology: An introduction for
students and practitioners (2nd ed.). Chichester: Wiley.

Bernstein, D. P., Iscan, C., Maser, J., (2007). Opinions of personality disorder experts regarding the
DSM-IV personality disorder classification system. Journal of Personality Disorders, 21(5), 536551.

Cleary, M., Siegfried, N., & Walter, G. (2002). Experience, knowledge and attitudes of mental health
staff regarding clients with a borderline personality disorder. International Journal of
Mental
Health Nursing,11(3), 186–191.

Commons Treloar, A. J., & Lewis, A. J. (2008). Professional attitudes towards deliberate self-harm I
n patients with borderline personality disorder. Australian and New Zealand Journal of Psychiatry,
42, 578-584.

Cooper, L. D., Balsis, S., & Zimmerman, M. (2010). Challenges associated with a polythetic
diagnostic system: Criteria combinations in the personality disorders. Journal of Abnormal
Psychology, 119(4), 886-895.

Chance, S. E., Bakeman, R., Kaslow, N. J., Farber, E., & Burge-Callaway, K. (2000). Core
conflictual relationship themes in patients diagnosed with borderline personality disorder who
attempted, or did not attempt suicide. Psychotherapy Research, 10(3), 337-355.
References










Department of Health (2003) . National Suicide Prevention Strategy for England. London: Department of Health. Retrieved
from http://www.nmhdu.org.uk/silo/files/national-suicide-prevention-strategy- for-england.pdf
Department of Health (2012). Preventing suicide in England: A cross-government outcomes strategy. London: HM Government /
Department of Health. Retrieved from
https://www.gov.uk/government/uploads/system/uploads/attachment_dat
a/file/156153/Preventing-Suicide-in-England-A-cross-government-outcomes-strategy-to-savelives.pdf.pdf
Evans, M. (2007). Being driven mad: Towards understanding borderline and other disturbed states of mind through the
use of the countertransference. Psychoanalytic Psychotherapy, 21(3), 216-232.
Fowler, J. C. (2012). Suicide risk assessment in the clinical practice: Pragmatic guidelines for imperfect
assessments. Psychotherapy, 49(1), 81–90.
Haws, C., Hawton, K., Houston, K., & Townsend, E. (2001). Psychiatric and personality disorders in deliberate selfharm patients. British Journal of Psychiatry, 178, 48–54.
James, P. D., & Cowman, S. (2007). Psychiatric nurses’ knowledge, experience and attitudes towards clients with
borderline personality disorder. Journal of Psychiatric and Mental Health Nursing, 14, 670-678.
Jobes, D. A. (1995). The challenge and the promise of clinical suicdology. Suicide and life-threatening behaviours, 25, 437–
449.
Kernberg, O. (1967). Borderline personality organization. Journal of the American Psychoanalytic Association. 15, 641–684.
Klein, M. (1952/1975). Some theoretical conclusions regarding the emotional life of the infant. In M. Klein (Eds.), Envy
and Gratitude and OtherWorks, (pp. 61 – 93). London: Hogarth.
Krawitz, R., Jackson, W., Allen, R., Connell, A., Argyle, N., Bensemann, C., & Milshkin, C. (2004).
Professionally indicated short-term risk-taking in the treatment of borderline personality disorder. Australasian
Psychiatry, 12(1), 11-17.
References











Kupfer, D. J., First, M. B., Regier, D. A. (2002). A research agenda for DSM-V. Washington, DC: American
Psychiatric Press.
Lewis, G., & Appleby, L. (1988). Personality disorder: the patient’s psychiatrists dislike. British Journal of
Psychiatry,153, 44–49.
National Institute for Health and Clinical Excellence (2012). Self-harm longer term management (Clinical
Guideline 133). Retrieved from
http://www.nice.org.uk/nicemedia/live/13619/57205/57205.pdf
Nehls, N. (2000). Being a case manager for persons with borderline personality disorder: Perspectives of
community mental health center clinicians. Archives of Psychiatric Nursing, 14(1), 12-18.
New, A. S., Triebwasser, J., Charney, D. S. (2008). The case for shifting borderline personality disorder to
Axis I. Biological Psychiatry, 64, 653–59.
Paris, J. (2005). Borderline personality disorder. Canadian Medical Association, 172(12), 1579-1583.
Paris, J. (2008). Treatment of Borderline Personality Disorder: A Guide to Evidence-based practice.
Guildford Press: New York.
Pilgrim, D. (2001). Disordered personalities and disordered concepts. Journal of Mental Health, 10, 253265.
Raven, C. (2009). Borderline personality disorder; still a diagnosis of exclusion? Mental Health Today. June,
27-31.
Thompson, A. R., Powis, J., & Carradice, A. (2008). Community psychiatric nurses’ experience of
working with people who engage in deliberate self-harm. International Journal of Mental Health
Nursing,
17, 153–161.
Willig, C. (2008). Introducing Qualitative Research in Psychology (2nd ed.). Maidenhead: McGraw Hill/Open
University Press.
References

Wilstrand, C., Lindgren, B. M., Gilje, F., & Olofsson, B. (2007). Being burdened and balancing
boundaries: a qualitative study of nurses’ experiences caring for patients who selfharm. Journal of Psychiatric and Mental Health Nursing, 14, 72–78.

Zanarini, M. C., Frankenburg, F. R., Hennen, J., Reich, D. B., & Silk, K. R. (2004). Axis I
comorbidity in patients with borderline personality disorder: a 6-year follow-up and
prediction of time to remission. American Journal of Psychiatry, 161(11), 2108–2114.

Zanarini, M. C., Weingeroff, J. L., & Frankenburg, F. R. (2009). Defence mechanisms associated
with borderline personality disorder. Journal of Personality Disorders, 23(2), 113-121.

Zimmerman, M. & Mattia J. I. (1999). Axis I diagnostic comorbidity and borderline personality
disorder. Comprehensive Psychiatry, 40, 245–252.
Thank you
victoria.moran@nhs.net