*Please note that this lesson contains several references to self-harm and suicide, if you need to stop at any time please take a break, and talk to someone you trust or call Samaritans anytime on 116 123*

Self-harm and suicidal thoughts or attempts are sadly common in BPD. In this lesson we will look a little at what we mean by self-harm and suicidal ideation.

What is self-harm?

Self-harm can take many forms. We often associate it with cutting, which is the most common form of self-harm, but it can also include things like scratching or burning skin, pulling hair, hitting yourself or picking at damaging skin.

People who self-harm are usually trying to alleviate intense emotional pain, and self-harm is not necessarily associated with the intention to complete suicide. It’s a method of changing emotional pain for physical – we can temporarily use the physical pain to block out the emotional distress.

Self-harm can also make people feel more in control of themselves and their bodies, or can be part of self-destructive behaviours such as binging/purging or substance misuse. The sense of relief or control is temporary however, and creates a destructive circle of repeated self-harm.

While self-harm is common in BPD, it also occurs in a range of other mental illnesses including depression, and panic or anxiety disorders.

There is a certain stigma attached to self-harm – some people think it’s just manipulation or attention-seeking. In some people, this may be true, it may be a way to attract attention or seek someone to care for them. But for the majority of people, it’s likely they are seeking help, letting others know they are not ok, despite what it looks like on the outside.

What is suicidal ideation?

Suicidal ideation is a wide term for thinking or contemplating about death and suicide, or a preoccupation with suicide. There are two types of suicidal ideation:

• passive – a person wishes they were dead, or that they could die, but don’t plan to take their own life
• active – thinking about it, but also having the intent to take their own life, including planning how to do it

Suicidal ideation is common in BPD, more so than other mental illnesses. People with BPD suffer from intense emotional pain, and feel emotions so deeply that it can feel overwhelming. Alongside mood swings, panic, depression, dissociation and other symptoms, it can trigger suicidal thoughts.

People affected by BPD can feel alone, frightened and confused – they may feel there is no other way than to take their own life. For most people, these thoughts are a cry from help – they don’t want their life to end, they want the pain to end.

How can DBT help?

Not too long ago, people who attempted to take their own life were hospitalised for long periods, or even for the rest of their life. Even in recent years, there have been cases of people being kept in psychiatric facilities for months or even years after suicide attempts.

DBT was developed for the purpose of supporting people who self-harmed or had suicidal ideation. In DBT, the focus is on you – after all, you are the most important person in your care plan, and right at the centre of treatment.

It’s a solution-based therapy, helping you to identify unhealthy behaviours, recognise and accept them, and learn new health behaviours in their place. All four of the main skills – mindfulness, distress tolerance, interpersonal effectiveness and emotional regulation – are essential tools for overcoming self-harm and developing healthier coping strategies.

Mindfulness is about being in the moment, learning to notice your throughts and feelings as they arise and accept them without judgment. Self-harm is often an impulsive reactional behaviour, and mindfulness works by putting a pause between the intense emotions and the impulsive behaviour (self-harm).

Distress tolerance teaches you to tolerate your heightened emotions, and to learn how to react to them without harming yourself. Distress tolerance is a second, or alternative, method of putting a pause between the intense thought or feeling and the coping mechanism.

Difficulties with communication can be a factor in people who self-harm – we don’t always know how to talk to others about how we are feeling, we may not know what to say, or we may fear the reaction from the person we talk to.

Interpersonal effectiveness focuses on building your communication skills, teaching you how to express your needs instead of burying them in harmful behaviours. Interpersonal effectiveness can also teach you how to say no, learning healthy boundaries which can help with your sense of self, increased self-respect and healthier relationships with those in your life.

As self-harm occurs during moments of extreme emotions – whether highs or lows – learning to keep your emotions on an even level is vital. Emotional regulation is the most important skill here. It helps you to understand that emotions aren’t permanent, what you are feeling is fleeting and it will change. It helps you develop better control of your emotions, and helps reduce the impulse to react inappropriately.

Hospitalisation

Historically, patients with BPD who displayed symptoms of self-harm and suicidal ideation were hospitalised. Sometimes these enforced hospital stays went on for months, if not years.

Thankfully, the general belief in DBT is that hospitalisation interferes with effective treatment, and many professionals agree that it should be kept only for extreme cases (when the patient is at serious risk of harm), and for short stays wherever possible. Being treated as an outpatient means that you can continue to function in society, with an experienced treatment and support team around you.

Studies have shown that patients receiving DBT in outpatients are better able to continue working, have stable relationships and live full lives.