Sunday 31 March 2013

what it's like to be me

i walk along  path like this all the time...



but all it takes is sometimes the littlest gust of wind and i have a split-second to choose to drop and cling to the ridge and hope for the best or i can choose to jump to the left or the right...


and sometimes, the gust of wind blind-sides me on an already ridiculously narrow bit...



and i don't get any choice at all...

Thursday 28 March 2013

Greater Glasgow & Clyde Mental Health Crisis Service Information


Greater Glasgow and Clyde

What is Greater Glasgow & Clyde Mental Health Crisis Service?

Crisis Services work closely with both community mental health teams and hospital in-patient services.
The crisis service works with people who are experiencing increased distress in terms of their mental health and are at risk of admission to a psychiatric hospital.
We also support people while in hospital and on discharge as required.
Following initial assessment the team can offer packages of care to suit the needs of the individual at that time as appropriate.

These can include:
•A full assessment of your mental health needs.
•If required, increased contact when you are unwell.
•Visiting you at home when you are on pass from hospital.
•Visiting you at home when you have been recently discharged from hospital.
•We will continue to maintain close links with your key worker and/or GP whilst you are involved with our service.

The service is available to people who live in the following post code areas:
G11, G12, G13, G14, G15, G61, G62

Service Availability:
24hrs 7 days a week based at 

Riverside Resource Centre
12 Sandy Road,
Partick
G11 6HE
Tel: 0141 211 1430
Fax: 0141 211 1444
Mon - Fri 9:00am - 8:00pm
Sat/Sun and Public Holidays 9:00 - 5:00pm.

and
Arndale Resource Centre
80-90 Kinfauns Drive
Drumchapel
G15 7TS
Tel: 0141 211 6184
Fax: 0141 211 6185
Mon- Fri 9:00am- 5:00pm
Out of Hours Crisis Service
Tel: 0845 650 1730
Mon - Fri 7:30pm - 8:30am
Sat/Sun/Public Holidays 4:30pm - 8:30am

Data Protection

In order to assess your needs properly and to ensure you receive the most suitable treatment, the crisis team will gather information from yourself, other people and agencies involved in your care. Everyone working within the organisation has a legal duty to keep information about you confidential.

Sharing Information

Patient care often involves health and social services and you may be receiving care from others, e.g. social workers, as well as NHS staff.
It is now routine practice for health and social care staff to share information about people they are working with.
You also have the right of access to the information we hold about you.
A leaflet “Protecting Information about you” gives more details and is available at each resource centre, or speak to the person in charge of your care.

Equality & Diversity

Recent legislation stipulates that NHS Scotland must now promote equality and diversity as part of its core services. As part of our service we are committed to equality by ensuring that all of our services are impact assessed in order to eliminate any forms of discrimination. You can be assured that you will be treated as an individual and with respect and dignity. If you would like to find out more on
how we are promoting this, please visit www.equalityscot.nhs.uk

OTHER USEFUL NUMBERS

General Emergency Medical Services
0141 616 6200
Glasgow NHS Advice Line
0800 22 44 88
NHS 24
08454 24 24 24
Breathing Space
0800 838587
Carer’s National Association
0141 221 9141
S.A.N.E
0345 6700000
Advocacy Matters
0141 204 2270
Samaritans (24 hours)
0141 248 4488
Social Work Out of Hours
0141 276 3100

Wednesday 27 March 2013

i have gone beyond my darkest darkness i think...


not good
arm is burned a lot
i set my hair on fire in a haze but snapped straight back to 'reality' with the smell
i'm pretty sure my smoke alarm doesn't work
not been my best
no words
not
doing
ok

feels like i'm having a heart-attack in my brain
not a physical, painful brain/heart-attack...an emotional one...

can't stop rocking
samh worker this morning just informed me that would be the last time i'll see her as she's being moved to one of the branches closer to her home...i keep getting workers assigned, to whom i become attached and then they get punted...it feels like they're all doing it on purpose...but they couldn't be?...right?...that'd be giving 'the powers that be' too much credit...right??...why can't they keep folk where they are...why is it that i can't handle chance well?Why can't i just 'go with the flow'
i think it's just because i am me
i dont' know
i am desperate to vent -i am thankful to friends who let me offload on them -though i feel horrific afterwards because i know they have their own battles...

it...i just....aaargghhhh...

i pray every time i vent that it will get it out and away...
...but it doesn't always work like that... 
my friend asked if the problem was because of the build-up of thing over the last little while or if it was "just general life...-itis?" LOL -that made me smile for a minute...
life is ok
....it's living it that's hard
seeing all the injustice
and feeling all the pain
it makes my head reel

and that's only the wee bit of my brain that is seeing that

the rest of it's selfish and lost in blackness
and i am overwhelmed with nothing really when i think £11 can feed a kid a meal a day for a year and still leave some spare change...
who cares about what's gone on in my past -it's the past
i am so selfish

i'm getting out some stuff and i don't want to relive it again and again
i really do relive some things when i think about thinking about them
when i think about them?!!
...it's more than reliving; it's almost as though i could touch it...
and for some of the things i 'relive'...i could -and have..been sick
like, actually, physically sick
in the reality of the actual moment that is now, or then...
i haven't been sick just now...because right now, typing this...


am
a
shell



i am not in my head


i am thinking about thinking about thinking about things...

brain is off
i'm not thinking of thinking of anything...
i am looking at letters on a keyboard...
SAMH worker this morning just informed me that THAT would be the last time i'll see her as she's being moved to one of the branches closer to her home (immediately my brain went off in a zillion ways!AARRGH was one way; WHY ALWAYS ME, another; She'll be closer to her home don't be so selfish, another; WHY did you get attached AGAIN, you never learn, another...and countless many others)
...i keep getting workers assigned, to whom i become attached and then they get punted
...it feels like they're all doing it on purpose
...but they couldn't be?
...right?
...that'd be giving 'the powers that be' too much credit
...right??
...why can't they keep folk where they are
...why is it that i can't handle chance well?
Why can't i just 'go with the flow'
 
i had a nice time last night til the drive home and my mum went all jekyll n hyde
got in smashed old candle holders but stayed safe
why does our family always waste every nice moment we have together
it's always my fault though...i ALWAYS say or do something to ruin it...

ALWAYS...

Psychiatry Appointment Mix Up and Mixed Up

so...tonight...today...yesterday...all weekend...

tried2draw
can't
tried to blog
can't
tried to write
can't
can write on me though
trying to fight it
fighting
and knackered

...i wanna punch a wall...

i headered one at 4am yesterday morning...apparently this was not sufficient...

...i also set my hair on fire
was all very bizarre
am still a bit....
meh...



didn't sleep all night worrying about stupid appointment with psychiatrist because it feels like last chance saloon...incident with lighter apparently put me into complete auto-pilot and i went to the wrong place for appointment -they are named very very similarly and within a mile of each other...

...i then struggled for the rest of the day to NOT visit B&Q to buy a 'just incase' rope...

My arms are burnt (chemically) beyond belief!!



I DON'T WANT TO BE ME ANYMORE

i don't think i ever did...

i don't know that anyone hates me but i DO KNOW that if i hate me most and hurt me most -anything anyone else says or does pales into insignificance...

Tuesday 26 March 2013

Rainbow Journal

So someone asked if anyone knows what a Rainbow Journal is as it continually popped up on self help websites...

Well, yes I DO know what it is. In fact, I have finished 4 in the last 10 years!!!

I am now onto my 5th and it's nearly time to order another!!
they're £8 and can be bought from Bristol Crisis Service for Women

i've used these journals for over 10 years

...whats it like?....
...so theyre good then?...

Yes, they're fab for me -some pages have pictures drawn by self-harmers, some have empty pages where you can draw, some have lines for you to write plus there's a "how am i doing" scale every so often where you think about if you're taking care of you etc...
i couldn't be without mine
i possibly wouldn't be... (bit of a scary thought there!...i never really gave much thought as to how much i'd used it and how useful it had been!!)

maybe might'n've made it thus far -helped me feel less alone as a teen and made me much more able to express feelings and thoughts i would have otherwise kept bottled up as they were things  i felt i couldn't share with anyone...

and at uni...it was like a place where i could have a secret code and even if anyone found it it wouldn't have been readable!!ha!


Now i've learned to make even better use of it -i write smaller, draw more than one pic per space etc...



I love mine!!

Like I said -wouldn't be without it!!!

Saturday 23 March 2013

a wee update

oh a wee update by the way -SAMH now come out twice a week for 2 hours and we will combine the 2 lots of 2 hours once a month to go swimming -we hope...depends on all the 'usual' i guess for a lot of us...scarring, how folk react to that -including the support workers who, thus far, have been brill by the way...very accepting and non-judgemental...ow agoraphobia is that day and (for those of you who don't know, i have complex asthma and have had a broken ankle for over 3 years now...)..so it'll depend on pain levels too..and if i've slept blah blah blah...we'll see..
£19.58 per hour ...four hours a week...
that thought is making me a little...well, sick to the pit of my stomach really...

Thursday 21 March 2013

Positivities

Positiveness

 
Positive affirmations by definition is a technique used to program the subconscious mind to effect change by repeating (or meditating on) a key phrase to bring about the desired outcome.
So what does that mean exactly? A lot of people including myself have or had things about them they wanted to change. Some examples could be wanting more wealth, confidence, better health, good friendships, gaining success etc..  If you read the “my story” section of this website you will know that I struggled with confidence for a very long time.  Affirmations played a very critical role in the turnaround of that. I would jokingly say positive things out loud and over time I guess my subconscious cemented those thoughts and I started to believe the things I was saying. At this time I was in high school and didn’t realize what I had actually been doing was positive affirmations.   So the theory here is to program your mind just like you would program a computer! It works! At the very least the meditation process will definitely relax you and be beneficial for you in multiple ways.  Don’t believe me? Try it. I encourage it.  For those of you who can’t or don’t have the patience for meditation there is software that can be bought where your computer or music will play hidden subliminal messages.  This would make the work essentially effortless!

Some key tips to remember are:

*Prioritize your list! Focus on one thing at a time. Do not overwhelm yourself or expect things to happen over night. Be patient!

*Use the affirmations that match your goals in life

*Use your affirmations frequently to always refresh your "internal computer"

Below you will find some basic affirmations but keep in mind you can easily make up your own positive affirmation.
Positive Affirmations for Wealth
1. All the things I want and need come to me.
2. I always receive more than what I need.
3. I have a bank account with more than enough.
4. I am an abundant person.
5. I create abundance in all that I say and do.
6. I accept abundance.
7. I welcome, and am open to receive all abundance that comes.
8. I draw abundance to myself today and every day

9. My Financial abundance overflows today

10. Abundance surrounds me, today I claim my share

11. Money flows abundantly to me now and always
Positive Daily Affirmations For Success
1. I am successful.
2. Everything I do turns into success.
3. I am filled with success.
4. Success comes effortlessly to my direction.
5. My success is contagious, other people like it, seek it and respect it.
6. I attract positive-minded people to me; I draw all things positive to myself.
7. I am very fortunate to work at what I love to do.
8. I make powerful and enjoyable business relationships and many of my business contacts are now my friends.

9. I have the perfect job

10. My job satisfies me in every way.

11. Success is mine always
Positive Daily Affirmations For Relationships
1. I am a confident and positive person, and confident and positive persons gravitate toward me everyday.
2. I know who I obviously am and what I like in personal relationships.
3. I am attracting powerfully positive and healthy people into my life.
4. I am caring, smart, supportive, loyal, and fun to be with.
5. I feel completely at ease and comfortable with all types of people.
6. I am winning in all my relationships.
7. I am a positive and valuable contributor to my relationships.
8. I possess complete ability to articulate my thoughts and feelings to everyone, and I express myself wisely.

9. I am surrounded by love always

10. Those who are around me love me endlessly

11. Love comes easily to me


Positive Affirmations For Self Esteem/Confidence
1. I am sure of my ability to do what is necessary to improve my life.
2. If I make mistakes, I am able to give myself the benefit of the doubt.
3. I feel worthy as a person.
4. I am able to take risks and try new things without fear.
5. I feel good about the way I do my job.
6. I feel about myself pretty much what others think of me.
7. I have compassion for myself and the way my life has developed.
8. I am deserving of all the good things in my life.

9. I love myself and the thoughts of others don't matter

10. I am confident in every thing I do in life

11. I am great now and always
Positive Affirmations For Health
1. I am glowing with health and wholeness.

2. I behave in ways that promote my health more every day.
3. I deserve to be in perfect health.
4. I am highly motivated to exercise my body because I find exercise as fun.
5. I love nutritious healthy food, and I enjoy eating fresh fruits and vegetables.
6. I am healthy since my practices are healthy.
7. I let go of the past so I can create health now.
8. I create health by expressing love, understanding and compassion.

9. I am healthy now and always

10. Health is not a problem for me

11. I am free from any health issues forever more
 
(have found this on several sites, all 'claiming' it as theirs..so unsure of who to credit!LOL!)

Saturday 16 March 2013

Life is an echo

A son and his father were walking
on the mountains.
Suddenly, his son falls, hurts
himself and screams:
“AAAhhhhhhhhhhh!!!”

To his surprise, he hears the voice
repeating, somewhere in the
mountain:
“AAAhhhhhhhhhhh!!!
Curious, he yells: “Who are you?”
He receives the answer: “Who are
you?”
Angered at the response, he
screams: “Coward !”
He receives the answer: “Coward !”
He looks to his father and asks:
“What ’s going on?”
The father smiles and says: “My
son, pay attention.”
And then he screams to the
mountain: “I admire you!”
The voice answers: “I admire you!”
Again the man screams: “You are a
champion!”
The voice answers: “You are a
champion!”
The boy is surprised, but does not
understand.
Then the father explains: “People
call this ECHO, but really this is
LIFE. It gives you back everything
you say or do. Our life is simply a
reflection of our actions. If you
want more love in the world,
create more love in your heart. If
you want more competence in your
team, improve your competence.
This relationship applies to
everything, in all aspects of life; Life
will give you back everything you
have given to it.”

Monday 11 March 2013

the more that happens the less i can put it into words

my 10 year old niece just discovered yesterday that i self harm...


words cannot express how disgusted with myself i am...

we did, however, get 20 minutes COMPLETELY alone and i took the opportunity to explain that i do not wish her to view it as a good thing, a positive thing, a helpful thing...and that if she were to do it because she somehow thought it ok to do because she knows i do it -well, that would crush me...

she said she'd never do it because it wouldn't help anyone, least of all her and that she'd talk to someone instead....basically, she regirgitated what i'd said to her but she used her own words...

please, God, let that truly have sunk into her little head and heart...


please

Friday 8 March 2013

Emotional Freedom ~ Judith Orloff

4 Tips to Deal With Frustrating People

Four Tips for Communicating With Patience

"Have patience with all things, but chiefly have patience with yourself." —Saint Francis De Sales

Every day there are plenty of good reasons to be frustrated. Another long line. Telemarketers. A goal isn't materializing "fast enough." People don't do what they're supposed to. Rejection. Disappointment. How to deal with it all? You can drive yourself crazy, behave irritably, feel victimized, or try to force an outcome—all self-defeating reactions that alienate others and bring out the worst in them. Or, you can learn to transform frustration with patience.
As a psychiatrist, I help others see that patience doesn't mean passivity or resignation, but power. It's an emotionally freeing practice of waiting, watching, and knowing when to act. To many people, when you say, "Have patience," it feels unreasonable and inhibiting, an unfair stalling of goals. In contrast, I'm presenting patience as a form of compassion, a way to regain your center in a world filled with frustration.

In my new book on achieving emotional freedom, I discuss how to transform frustration with patience. To tame frustration, begin by evaluating its present role in your life, how much it limits your capacity to be happy. The following quiz will let you know where you are now so you can grow freer by developing patience.
Frustration Quiz: How Frustrated Am I?
To determine your success at coping with this emotion, ask yourself:
  • Am I often frustrated and irritable?
  • Do I typically respond to frustration by snapping at or blaming others?
  • Do I self-medicate letdowns with junk food, drugs or alcohol?
  • Do my reactions hurt other people's feelings?
  • When the frustration has passed, do I usually feel misunderstood?
  • During a hard day at work, do I tend to lose my cool?
  • When I'm disappointed, do I often feel unworthy or like giving up?
Answering "yes" to 5-7 questions indicates an extremely high level of frustration. 3-5 "yeses" indicates a high level. 2 "yeses" indicates a moderate level. 1 "yes" indicates a low level. Zero "yeses" suggests you're dealing successfully with this emotion.
Even if your frustrations are off the charts, patience is the cure. You'll have plenty of opportunities to cultivate this invaluable skill. Life teaches patience if you let it.


4 Tips for Dealing With Frustrating People (from "Emotional Freedom")

When someone frustrates you, always take a breath first before you react. Decide if you want to talk now or wait to calm down. If you're highly reactive and upset, have the discussion later when you're calmer. Then you'll be more persuasive and less threatening. At that time use this approach:

Tip #1. Focus on a specific issue—don't escalate or mount a personal attack.
For instance, "I feel frustrated when you promise to do something but there is no follow-through." No resorting to threats or insults. In an even, non-blaming tone, lead with how the behavior makes you feel rather than how you think the other person is wrong.

Tip #2. Listen non-defensively without reacting or interrupting.
It's a sign of respect to hear a person's point of view, even if you disagree. Avoid an aggressive tone or body language. Try not to squirm with discomfort or to judge.

Tip #3. Intuit the feelings behind the words.
When you can appreciate someone's motivation, it's easier to be patient. Try to sense if this person is frightened, insecure, up against a negative part of themselves they've never confronted. If so, realize this can be painful. See what change they're open to.

Tip #4. Respond with clarity and compassion.
This attitude takes others off the defensive so they're more comfortable admitting their part in causing frustration. Describe everything in terms of remedies to a specific task, rather then generalizing. State your needs. For instance, "I'd really appreciate you not shouting at me even if I disappoint you." If the person is willing to try, show how pleased you are. Validate their efforts: "Thanks for not yelling at me. I really value your understanding." See if the behavior improves. If not, you may have to minimize contact and/or expectations.
In communication, patience is a powerful emotional currency. As you're more able to tolerate the discomfort of frustration and not blow it by acting out, your relationships will function on a higher level. In any interchange, always define what you're after. Is it to resolve a specific frustrating behavior? To say "no" to participating in a dead-end pattern? Or is it to simply to convey your feelings without expectation of change? Even if the frustration is irresolvable, patience sets the right tone to treat others and yourself respectfully.

(http://www.psychologytoday.com/blog/emotional-freedom/201202/4-tips-deal-frustrating-people, accessed on 8/03/2013)

Frustration - 8 Ways to Deal With It ~Catherine Pratt

by www.Life-With-Confidence.com


A pessimist sees the difficulty in every opportunity; an optimist sees the opportunity in every difficulty. - Winston Churchill


The emotion you’re feeling is “Frustration”.
With a capital “F”. Maybe even add in some anger because you’ve been working really hard towards your goal or on a project and it just isn’t working. Or you feel like you’re stuck in a dead-end job and can’t find another one. And you may not even really know why. All you know is that you seem to be stuck and no matter how hard you try, you don’t seem to get anywhere. You’re just spinning your wheels in the mud and all you feel is pure frustration. Sound familiar?
This is the point where a lot of people will just say, “I Quit” and give up. Before you do though, here’s 8 ways you can blast through any frustration:

1. Ask Yourself, “What Is Working in This Situation?”
Even if feels like nothing is working, look closely and you will probably find at least something that is going right. So, that’s good. You’ve found something that’s working. Now, how do you improve it? By asking this question, you’ve taken yourself out of the negative mindset of “it’s hopeless” and are back to focusing on the positive.
There's something that’s working and that will give you a clue of what direction to focus on. You may find that even if your previous issues come up you’ll be able to resolve them in the process of concentrating on your improvements.

2. Keep an Accomplishments Log
Write down everything you accomplish in a log. If you do it in a monthly format you will be able to see all that you have accomplished in just one month. You may be surprised by how much you have done. If you realize there’s not much on the list, it may open your eyes to the fact that you may be procrastinating more than working or that you are using too much of your energy going in too many directions and that you need to focus more. Hopefully, you will have lots of items on your list then you can see that even though it may not feel like it, you are moving forwards. The log will also help to highlight where you were the most effective and where you need to work harder.

3. Focus On What You Want to Happen
Go back to the big picture. What is the desired outcome? Sometimes, we get so wrapped up in one problem and trying to solve it that we forget what we were originally trying to accomplish. Try not to ask yourself, “Why did this happen?” Asking questions like that will keep you rooted in the past. It doesn’t offer a solution to the problem. The important thing is knowing the answer to the following two questions:
- What do you want to happen differently this time?”
- What do you need to do in order to get there?

4. Remove the “Noise” and Simplify
When you’re trying to solve a problem, you can get so wrapped up in trying to find a solution that you add unnecessary clutter, noise, and tasks to a project because you thought they “might” be a solution.
Working on this website, I get bombarded by offer after offer of “easy ways to run your website”, “get more traffic”, “make more money” etc. They’re just noise though and usually a waste of my time even reading them. These people are just trying to make money off of me. They have no interest in whether I succeed or not. When people are frustrated by how slow the hard work process is taking, they get tempted by these “here’s what you’ve been missing” and “I’ll make it easy for you” offers. Usually, it ends up that if you do get tempted by the offers you discover 6 months down the road that if you had just stuck with your first plan and just kept working at it, you’d be a lot further ahead by now. Not to mention richer from not having spent money on the Get Rich Quick schemes. Believe in yourself. Simplify and go back to the basics. Determine what is really necessary and remove everything else. Anything that takes your time and effort that isn’t adding value, should be eliminated.

5. Multiple Solutions
You always have options. You just need to brainstorm and figure them out. Tell yourself you need to come up with 8 possible options to what you’re dealing with. Just knowing that you have lots of options will help to make you feel better. You won’t feel like you are trapped in one negative situation. From your list, figure out the best direction and go for it.

6. Take Action
When you get into serious frustration with a problem, you tend not to want to work on it anymore. It’s hard, it’s frustrating, and you’re not getting anywhere. So, anything to avoid having to be in that situation may be far more attractive. Procrastination may start to set in. If you can keep taking steps forwards, you will probably make it past this temporary hump. As Thomas Edison said, “Many of life's failures are people who did not realize how close they were to success when they gave up” and “Surprises and reverses can serve as an incentive for great accomplishment.”
The other thing that can happen is that you start to spend a lot of time worrying. Worrying is a definite waste of energy and does not move you in a forwards direction. Only taking action will. Once you start moving forwards again, you will most likely find that you worried for no reason.

7. Visualize a Positive Outcome to the Situation
A lot of times you can get stuck on focusing on what you don’t want to happen or fearing the absolute worst thing that could happen. The top athletes of the world will imagine themselves competing flawlessly over and over again. There is no room for failure in their minds. This is what you need to focus on as well. See yourself achieving your desired outcome. What will it look like? What will it feel like? What will you say? How will you feel? Take the time to visualize it and really feel it. It will inspire you to keep moving forwards.

8. Stay Positive
Things are usually not as bad as they first appear. Sometimes, things seem much worse simply because we’re tired or mentally drained. Taking a break and remembering to keep your sense of humour can also help. This time of frustration will pass. A positive mind is far more open to solutions and answers than a negative one that thinks it’s just “hopeless” and thinks “what’s the use?” A closed mind will not be able to see the possible solutions when they do come along. Stay positive.
As with any problem, the solution is to figure out what your options are, decide on a plan, focus, and then take action. By using the above 8 steps, you should find that you’re running into fewer problems and feeling less frustration. Instead, you may find that you’re running into opportunities and you know exactly how to take advantage of them.

(http://www.life-with-confidence.com/frustration.html, accessed 08/03/2013)

Recent Developments in BPD ~Anthony P. Winston

Patients with borderline personality disorder (BPD; known in ICD–10 (World Health Organization, 1992) as emotionally unstable personality disorder) pose some of the most difficult management problems facing the clinical psychiatrist. They frequently present in crisis, but are often difficult to engage in any form of treatment. Their behaviour causes considerable anxiety but their ambivalence about treatment often leaves professionals feeling frustrated and resentful. These feelings can all too easily be transformed into therapeutic nihilism. As well as being a significant problem in its own right, comorbid personality disturbance complicates the management of other psychiatric disorders and has a negative effect on their prognosis (Reich & Vasile, 1993).
Borderline personality disorder has an estimated prevalence of up to 2% in the community (Widiger & Weissman, 1991) and 15 % among psychiatric in-patients (Kroll et al, 1982). Yet, despite an extensive psychoanalytic literature and growing attention in the USA, BPD has until recently received relatively little attention in the British psychiatric literature. However, this situation is beginning to change as a result of recent developments in both research and treatment. Developmental research is shedding increasing light on the aetiology of BPD, new models of treatment have been developed and long-term research on outcome is helping to dispel some of the pessimism that has long surrounded the disorder. This paper will review some of these developments.
Box 1.

DSM–IV (American Psychiatric Association, 1994) diagnostic criteria for borderline personality disorder

At least five of:
Intense and unstable personal relationships
Frantic efforts to avoid real or imagined abandonment
Identity disturbance or problems with sense of self
Impulsivity that is potentially self-damaging
Recurrent suicidal or parasuicidal behaviour
Affective instability
Chronic feelings of emptiness
Inappropriate intense or uncontrollable anger
Transient stress-related paranoid ideation or severe dissociative symptoms

New perspectives on aetiology

Research over the past decade or so has emphasised the importance of childhood experiences in the aetiology of BPD. Ideas derived from psychoanalysis have received some empirical support and the central aetiological role of childhood trauma has become apparent. Attachment, identity and the ability to make sense of feelings are increasingly seen as interlinked and all are adversely affected by abuse or neglect in childhood.

Trauma, affect regulation and self-harm

Childhood abuse and neglect are extremely common among borderline patients: up to 87% have suffered childhood trauma of some sort, 40–71% have been sexually abused and 25–71% have been physically abused (Perry & Herman, 1993). The effect of abuse seems to depend on the stage of psychological development at which it takes place; in general, the earlier it takes place, the more damaging it is likely to be (van der Kolk et al, 1994). This is probably due to the young child's cognitive immaturity and consequent inability to make sense of traumatic experiences. Sexual abuse, as well as being damaging in its own right, may also reflect the generally dysfunctional nature of families who are unable to protect their children adequately.
There is considerable evidence that borderline patients have difficulty modulating emotion, and this appears to be linked with early trauma (van der Kolk et al, 1994). Trauma, in the form of sexual abuse, is also strongly correlated with self-mutilation in borderline patients (Herman et al, 1989). Self-mutilation such as cutting is often experienced as painless at the time, suggesting that it takes place in a dissociated state. Indeed, the combination of severe trauma and dissociative phenomena in BPD has led some researchers to link it with post-traumatic stress disorder.

Attachment and reflective self-function

Research based on attachment theory is beginning to elucidate the links between childhood trauma and the capacity to think about oneself and others. Borderline patients are typically preoccupied with their disturbed early relationships yet unable to give a coherent account of them (Patrick et al, 1994; Fonagy et al, 1996). Severe childhood trauma in these patients appears to result in a specific inability to think about their own thoughts and feelings, as well as those of others.
This finding is consistent with the observation that maltreated children have difficulty in expressing both negative and positive feelings. As well as contributing to problems in interpersonal relationships, the inability to think about feelings may combine with defective affect regulation to produce the impulsivity which is so characteristic of borderline patients.
Box 2.

Possible effects of childhood trauma in borderline personality disorder

Self-mutilation
Defective affect regulation
Lack of reflective capacity
Dissociation
Impulsivity
Disturbed interpersonal relationships

Identity and the self

The lack of a sense of self is a core feature of the psychopathology of BPD, and psychoanalysts have traditionally linked this phenomenon to pathological splitting of the ego and object. Splitting is often very marked in borderline patients, who may engender powerful yet conflicting feelings in different members of the psychiatric team. Such splitting has traditionally been thought of as a ‘primitive’ defence mechanism that indicates arrested psychological development. However, it may be an appropriate response to abuse from someone who is also a parent or carer. Recent research confirms the link between splitting and sexual abuse and suggests that it may, in fact, be a relatively sophisticated psychological mechanism for dealing with traumatic experience (Calverley et al, 1994).
The concept of self is central to the work of Heinz Kohut and the branch of psychoanalysis known as self-psychology (Kohut, 1984). Kohut's ideas have been incorporated into the treatment approach developed by Stevenson & Meares (1992). Ryle (1997), from the somewhat different perspective of cognitive–analytic therapy, has developed an aetiological model of BPD based on the concept of multiple self-states. These are partially dissociated states between which the patient switches abruptly. Each self-state is linked to specific moods, behaviours and symptoms and is associated with corresponding interpersonal roles. Both these therapies are described later in this paper.

New developments in treatment

Several new forms of treatment for BPD have been developed over the past few years and evidence is also emerging for the effectiveness of some of the more established approaches.

Dialectical behaviour therapy

Dialectical behaviour therapy (DBT; Linehan, 1993) is based on the principle that BPD is essentially the result of deficits in interpersonal and self-regulatory skills and that these skills can be taught in therapy. Defective affect regulation is seen as particularly important. Treatment consists of weekly individual and group therapy sessions based on a skills-training model, together with out-of-hours telephone contact with the therapist.
Fig. 1
An aetiological model of borderline personality disorder
Dialectical behaviour therapy has been shown, in a single study, to be superior to ‘treatment as usual’ in reducing self-harm and time spent in hospital, but not subjective experiences such as depression and hopelessness (Linehan et al, 1991). There were also significant improvements in social and global functioning and anger (Linehan et al, 1994). However, by one year after the end of treatment, rates of self-harm were no different in the DBT and treatment-as-usual groups, although both had improved (Linehan et al, 1993).
Box 3.

New therapies for borderline personality disorder

Cognitive analytic therapy
Brief psychoanalytic psychotherapy
Interpersonal psychotherapy
Dialectical behaviour therapy
Schema-focused cognitive therapy
Despite this essentially negative finding, DBT has attracted considerable interest; however, Linehan's study is open to a number of methodological criticisms. Only 39 patients were studied, all of them female, and of these only 20 were fully assessed. The level of self-harm required for entry into the study (two episodes in the last five years and one in the last eight weeks) may have led to the inclusion of patients who were less severely disturbed than those commonly seen in clinical practice. Furthermore, DBT involves a high level of input from professionals and it is not yet clear whether it is the skills training itself or simply the high level of support which leads to the reduction in self-harm.

Psychoanalytic psychotherapy

Psychoanalytic psychotherapy has long been used in the treatment of borderline patients but has never been subjected to formal evaluation. The available data suggest that only a minority of borderline patients benefit from psychoanalytic psychotherapy in its traditional form (Waldinger & Gunderson, 1984). However, a modified approach, which emphasises current rather than past experiences and in which the therapist takes a more active role, may be more suitable for the treatment of BPD.
Stevenson & Meares (1992) have described encouraging results using a specialised form of brief psychotherapy which is designed specifically to meet the needs of borderline patients. This model draws on both self-psychology and Hobson's ‘conversational model’ (Hobson, 1985). Patients are seen twice-weekly for a year and therapy can be delivered by trainee therapists following a treatment manual. In their study, this form of therapy produced significant improvements in violent behaviour, use of medication, self-harm and hospital admissions. Improvements were also observed in impulsivity, affective instability and suicidal behaviour and by the end of treatment, 30% of patients no longer met DSM–III–R (American Psychiatric Association, 1987) criteria for BPD.

Therapeutic communities

Recent work has provided evidence for the effectiveness of therapeutic community treatment. Dolan et al (1997) compared 70 patients treated at the Henderson Hospital with those referred but refused funding by their health authorities. Eighty per cent of their patients had a diagnosis of BPD and many also met the diagnostic criteria for other personality disorders. Forty-three per cent of the treated patients showed a clinically significant change in core borderline psychopathology at one year after discharge, compared with 18% of those who had been refused funding.
Another approach to evaluating the effectiveness of therapeutic community treatment is to calculate service consumption and costs to public services before and after treatment. Recent studies have found substantial reductions in service consumption and costs following treatment in three National Health Service therapeutic communities: the Cassel and Henderson Hospitals in London and Francis Dixon Lodge in Leicester (Chiesa et al, 1996; Dolan et al, 1996; Davies et al, 1999).

Interpersonal therapies

Interpersonal difficulties are one of the most common presenting features of BPD. Not only do they cause considerable suffering to the patient but they are also likely to manifest themselves in complex and ambivalent relationships with professionals.
Benjamin (1996) has developed a technique for analysing patterns of interpersonal behaviour known as the Structural Analysis of Social Behavior (SASB). This instrument allows dysfunctional interpersonal patterns to be identified and coded and has led to the development of a therapeutic approach that is aimed at modifying interpersonal behaviour. In therapy, maladaptive interpersonal patterns are identified and their origins explored. An eclectic mix of techniques is used including role play, free association, dream analysis and educational assignments. When the patient is ready to do so, the therapist helps him or her to ‘block’ maladaptive patterns and learn new ways of functioning.
The brief interpersonal therapy (IPT) developed by Klerman and his colleagues (Klerman et al, 1984) has also been adapted for use with borderline patients. Originally designed to treat depression, IPT is a structured and time-limited therapy which focuses on the relationship between symptoms and interpersonal difficulties. A small pilot study has been carried out using an 18-session programme for borderline patients (Angus & Gillies, 1994), but the results have yet to be published.

Cognitive–analytic therapy

Cognitive–analytic therapy (CAT) for borderline patients employs a collaborative approach between patient and therapist in order to identify self-states (Ryle et al, 1997). Inadequate parenting is thought to result in an inability to integrate these self-states, leading to rapid shifts between them. These shifts between self-states and their associated interpersonal roles are seen as a cause of the instability that borderline patients display.
In therapy, the patient is helped to make links between early experience and current behaviour. The collaborative nature of the therapeutic relationship also gives the patient experience of a new and more healthy way of relating and thus contributes to the process of change. Although promising, CAT has yet to be evaluated adequately in clinical practice.

Schema-focused cognitive therapy

Another novel but untested approach is schema-focused cognitive therapy (Young, 1994). This therapy concentrates on identifying and modifying the ‘early maladaptive schemas’ thought to underlie BPD. Schemas are:
“broad pervasive themes regarding oneself and one's relationship with others, developed during childhood and elaborated throughout one's lifetime, and dysfunctional to a significant degree” (Young, 1994).
Early maladaptive schemas have their origins in adverse childhood experiences and are particularly resistant to change. They cover themes familiar to psychoanalytic psychotherapists and are organised into five principal domains: disconnection and rejection; impaired autonomy and performance; impaired limits; other-directedness; and overvigilance and inhibition.
Therapy consists initially of identifying and activating core schemas (for example, with the use of imagery), which therapist and patient then discuss. Schemas are then modified using cognitive reconstruction, behavioural and experiential techniques and discussion of issues arising in the therapist–patient relationship.

Long-term outcome

Several studies have now established that the long-term prognosis in BPD is significantly better than is often assumed and that the majority of patients improve over time (for review see Stone, 1993) . For example, Links et al (1998) found that 53% of patients followed-up for seven years no longer met diagnostic criteria for BPD. In one of the largest studies, long-term follow-up of a cohort of patients treated at the New York Psychiatric Institute found that two-thirds were clinically well (Stone et al, 1987).

Future developments

Our understanding of the aetiology of BPD has grown considerably over the past decade and it is increasingly being seen as a disorder of psychological development. However, major questions remain. Are some individuals more vulnerable to the development of the disorder than others? Are there potentially protective factors? Perhaps most crucially of all, can early intervention with at-risk families help to prevent the development of BPD?
At the clinical level, there is an urgent need for more research into the outcome of different forms of treatment. Studies of treatments such as DBT and brief psychoanalytic psychotherapy need to be replicated, and the effectiveness of therapies such as CAT and IPT needs to be evaluated. The relative merits of different therapies have yet to be assessed and it is unclear how best to match patients to therapies. Many of the new therapies for BPD share a theoretically coherent, manual-based structure and it may be that the coherence and consistency this provides is particularly important for borderline patients. We do not yet know whether these structured, short-term therapies will prove sufficient on their own or will in future be used as a prelude to more exploratory therapy for suitable patients. Moreover, it is probable that most borderline patients will continue to be managed by general psychiatrists and the place of such specialised therapies within generic mental health services will need to be determined.
The apparent success of these brief therapies is somewhat at odds with the view held by many clinicians that borderline patients benefit from a relatively prolonged relationship with a therapist or therapeutic team. This view is consistent with the evidence for disordered attachment in BPD, which suggests that a stable therapeutic attachment may be helpful in allowing patients to develop psychologically in a more functional way. Long-term follow-up studies will be needed to clarify whether the effects of brief therapies persist beyond the end of the treatment period.
Despite many unanswered questions, recent developments give grounds for optimism. It is now difficult to sustain the view that all borderline patients are untreatable. Psychoanalysis, cognitive therapy and empirical research are converging, and a coherent aetiological model of the disorder is beginning to emerge. The outlook for this challenging group of patients may be starting to improve.

Multiple choice questions

  1. The prevalence of borderline personality disorder among in-patients is estimated to be:
    1. 10%
    2. 15%
    3. 20%
    4. 12%
    5. 5%.
  1. Multiple self-states are associated with:
    1. schema-focused cognitive therapy
    2. self-psychology
    3. cognitive–analytic therapy
    4. dialectical behaviour therapy
    5. interpersonal therapy.
  1. In borderline personality disorder:
    1. a disturbed sense of self is common
    2. patients are preoccupied with disturbed early relationships
    3. pathological splitting is uncommon
    4. the New York Psychiatric Institute follow-up study found that one-third were clinically well
    5. therapeutic community treatment produces a reduction in service consumption.
  1. With respect to childhood trauma:
    1. physical abuse is more common than sexual abuse
    2. defective affect regulation is related to early trauma
    3. trauma has been linked to difficulty thinking about oneself and others
    4. sexual abuse is strongly correlated with self-mutilation
    5. up to 87% of patients have suffered childhood trauma.
  1. In the treatment of borderline personality disorder:
    1. dialectical behaviour therapy is clearly superior to treatment as usual
    2. dialectical behaviour therapy reduces depression
    3. cognitive–analytic therapy is more effective than interpersonal therapy
    4. theoretical coherence may be important
    5. interpersonal therapy was originally developed to treat depression.
(http://apt.rcpsych.org/content/6/3/211.full, accessed on 08/03/2013)