The overall aim during the management of a crisis is to help the person to return to a more stable level of mental functioning as quickly as possible without inducing any harmful effects that might prolong the problems. The person’s autonomy should be maintained as far as possible, their safety and that of others assured, and their emotions, impulses and behaviours reduced to a manageable level. Supportive and empathic comments are necessary in the first instance and these may be particularly beneficial if the initial contact in the crisis is by telephone. Medication use should be limited, following the general guidance below, and should be only for short-term use. Specific goals of treatment should be set.
Vignette of a service user accessing services during a crisis
Being faced with someone with borderline personality disorder in crisis can unfortunately be perceived as quite a daunting prospect for some people. In my experience, though, it needn’t be. Responses don’t need to be that profound or from people with a lot of experience of working with this disorder, they just need to be human. Despite this, I have often found that responses to me during such crises were variable and at times unhelpful. However, I have been fortunate enough to have had some very good responses over the period of my disorder that illustrate this point.
I was experiencing a period of extremely low mood. My psychiatrist who had seen me through most of my journey had recently retired, I had been raped about 6 months previously, and after a destructive relationship had also been through a pregnancy and termination. After previously making so much progress, I was deteriorating rapidly in mood. I had cut-off from my psychologist and was withdrawing from work with my CPN. Although most of the time I was too low to care, at other times I was desperate for connectedness and needed to know that someone was aware of how desperate I was feeling.
I made contact with the out-of-hours social work team by telephone. This is a service that deals primarily with emergency child, welfare and older adult issues, but takes over from the adult mental health out-of-hours service after 10pm. Although most of the social workers are Approved Social Workers and have knowledge of the Mental Health Act and the issues associated with it, the majority of them have not had any specific therapeutic training or any specialist personality disorder related training. The point I am making is that none of them was a skilled therapist with experience of people with borderline personality disorder.
I phoned them and got through to one of the duty social workers who helped me to calm myself enough to talk. This was achieved by him remaining calm, reassuring me and not making me feel that I had limited time or needed to rush. A few gentle questions helped, not, what I call, big questions such as ‘How can I help?’ or ‘What’s happened?’, but smaller questions such as ‘I can hear you’re upset, how long have you been feeling like this’, ‘do you know why you’re feeling like this?’ Big questions such as ‘How can I help?’ or ‘What’s wrong?’ always feel to me too overwhelming and too difficult to find a starting point.
It only took a few little questions to get me started and to begin to articulate what I was feeling. I hadn’t spoken to anyone in days – so I really appreciated not feeling rushed, pressurised into speaking or sensing that the other person was getting frustrated with my inarticulateness. Once I began to speak, it became easier to express my distress with the help of some prompts, some empathy and some help with articulation when I was struggling to express myself. I didn’t need much. I just needed a sense of connection to another human being, to feel reassured; I needed to feel that the person cared enough to have some empathy. I didn’t need anything done, nor crisis admission or referral (even though I would need a more assertive intervention in the weeks to come, that wasn’t what I was looking for or needed at that moment). I didn’t even need anyone specialised. I just needed a caring human response, to hear a voice.
We were on the telephone for only about 30 minutes in total, but it was enough to help and to ‘hold’ me through the night. The social worker gave me the option to ring back again in the night if I needed to, and although I didn’t wish to, it helped me to contain my feelings knowing that the option was there. The other useful outcome of this phone contact was the knowledge that there would be some kind of follow-up the next morning. The social worker following my phone call sent a fax to my CPN outlining the details of my contact with a request for my CPN to ring me to check that I was OK and if any further follow-up was needed. Just knowing that a follow-up and human contact were in place for the next day makes such a big difference in helping to contain the intense emotional distress that can occur with this disorder and stopping situations escalating into admission, crises or self-harm. On this occasion and during a number of previous situations I didn’t need much from my CPN once he rang; sometimes I would need an extra visit, but on other occasions the knowledge that the phone call was to take place was enough to settle me for the time being. Knowing that I’d have an opportunity to talk about the feelings I was struggling with was enough to enable me to manage until the next scheduled appointment time.
