Responding to a crisis

People with BPD will require many healthcare resources, particularly during real or perceived periods of crisis. Given the high prevalence of BPD in the primary care setting, nurse practitioners and other health service providers are likely to encounter a patient with BPD in crisis. A crisis situation may be triggered by seemingly minor incidents or precipitated by threats of separation, fear of rejection, or expectations that BPD patients assume responsibility for themselves. During the crisis, patients with BPD may present to the primary care facility in a disinhibited state (i.e., impulsive, angry, raging, verbally and/or physically aggressive) and may display transient psychotic symptoms. Self harm behaviors and suicidal ideations are the main reasons people with BPD present for healthcare services.

Approximately 69% to 80% of individuals with BPD will self harm or attempt suicide while in a crisis situation and 10% of individuals with BPD will ultimately commit suicide. Assisting the patient in resolving the immediate problem is the key component in crisis management. However, to intervene effectively, you must know how to recognise when a person is in crisis.

The following comments are almost certainly “a cry for help”, which means they need someone to listen, acknowledge their pain, validate their emotions and witness their process:

“I’m having a hard time.”
“XYZ experience brought up a lot of things for me.”
“I’m depressed.”
“I can’t talk or think right now because I’m too upset.”
“I had a triggering experience.”
“I want to go out and drink (or do something risky to themselves or others).”
“I wish I was dead.”
“I’m having a breakdown.”
“I can’t take it anymore.”

This is your cue to stop and listen by following up with an affirming statement like:

“What happened?”
“Are you okay?”
“Can you name (or be more specific about) what you’re feeling?”
“I’m listening. Tell me more.”

Things you can say or do to help a person in crisis:

Acknowledge their feelings
Witness their process
Affirm their right to speak
Validate their emotional experience
Listen without judgement and be sensitive
Allow them to process what is going on
Let them cry

If you are a health practitioner, consider the following recommendations when confronted by a BPD patient in crisis:

Behavioural interventions
Establish therapeutic boundaries that provide structure, containment, and direction for the patient. Unclear boundaries may decrease the patient’s sense of safety and trust, which may increase stress and anxiety levels.
Ask direct questions about suicide. Inquire about previous suicide attempts and assess the current level of risk to self or others.
Inquire about effective management strategies used in the past.
Assist in alleviating anxiety by encouraging the use of coping skills and focusing on the current problems.
Explore reasonable changes that will enable the patient to deal with the current problems.
Develop a formal behavioral treatment plan and schedule a follow-up appointment at an agreed-upon time.
Medication management

Following the crisis, assess the impact of personal, social, and environmental factors as antecedents. Evaluate the overall treatment strategy, including medication management and safety concerns. Finally, develop a treatment plan in concert with the patient and his or her significant others. Long-term treatment options should include psychotherapy, which is best managed in the psychiatric setting.

This information has be adapted from Clinical Advisor – Crisis management of a personality disorder.