LMCP

Management of the effects of psychological trauma experienced as a child

in clinical practice

According to van Dijke et al. (2017), traumatic events in childhood, such as neglect,

physical, sexual, and emotional abuse, have been associated with borderline personality

disorder (BPD). These traumatic events have been identified in many adults diagnosed with

BPD and manifest in affect and mood dysregulation, dissociation, poor interpersonal

effectiveness, and distress tolerance (van Dijke et al., 2017). The impacts of this diagnosis

are wide-ranging however, people with BPD tend to experience difficulties in daily

functioning due to heightened emotional sensitivity and struggle in managing impulsive

behaviours (Acres et al., 2021). BPD is also associated with high rates of self-harming

behaviours, and death by suicide rates are between 3% and 10% among this cohort of people

(Acres et al., 2021).

In order to address the psychological trauma and provide treatment, clinicians need to

have the knowledge and depth of skills founded on evidence-based practice when working

with people with BPD (Choi, 2018). Evidence-based practice combines patient experience

and values, current research, professional expertise, and clinical judgment to provide the best

available treatment options (Aveyard & Sharpe, 2009).

One of the most common treatments for BPD is Dialectical Behaviour Therapy (DBT),

which is an evidence-based form of skills therapy for people experiencing BPD or complex

behavioural difficulties due to past trauma (Dimeff & Linehan, 2001). DBT addresses

distress tolerance, emotion regulation and interpersonal relationships and can be used as an

effective form of psychotherapy that could strengthen individual resilience, psychological

wellbeing, and behaviours (Choi, 2018). Research evidence has also shown that DBT lessens

self-harming behaviours, inpatient admissions, suicidal acts, and an overall improvement in

mood, anger, dissociation, and global functioning (Dimeff & Linehan, 2011).

People with BPD tend to present frequently at emergency departments due to requiring

treatment for self-harming injuries, heightened state of distress and dysregulation and suicidal

ideation (Acres et al., 2021). Despite the evidence for treatment, patients with BPD diagnosis

and their carers are still reporting gaps in the care they receive, with restrictive practices such

as seclusion, physical and chemical restraint continue to be used in emergency departments

and inpatient units (Acres et al., 2021). These types of practices often intensify the distress

and previous experiences of trauma, thus leading to harmful impacts and poor treatment

trajectory (Acres et al., 2021). Additionally, patients with BPD typically access simplistic

forms of treatment or are treated under a medical model with medications to manage their

anxiety, mood fluctuations, emotional dysregulation, and anger (Choi, 2018). These

approaches might provide temporary relief and a sense of safety, however they do not address

the past and current trauma and circumstances that maintain the presenting problems (Choi,

2018).

These trends indicate a gap between evidence-based treatment and what patients and their

carers experience when accessing the healthcare system when seeking treatment for BPD.

Acres et al. (2021) found that health professionals, particularly nurses in emergency

departments, did not have the relevant training to identify and address the crisis patients with

BPD presented. Furthermore, due to this lack of training and awareness, there is a culture

perpetuated in emergency departments that people with BPD are not presenting with a

disease, therefore they do not require the same level of care and treatment as other ill people

(Acres et al., 2021).

Another gap identified in research by Giffin (2008) is the lack of communication and

understanding of the health service system and where to access evidence-based treatment.

Patients and their carers are often faced with calling multiple services to access assistance,

not understanding the role and capacity of each service (Giffin, 2008). This research also

highlighted inconsistency and contradictory advice health care professionals gave due to

diagnostic uncertainty or confusion (Giffin, 2008). As a result, patients and their carers faced

inconsistency, contradictory advice, incomplete and ad hoc treatment plans, and an overall lack of

support (Giffin, 2008).

Additionally, Linehan (2015) identified that DBT is a time-consuming process for the mental

health services due to DBT requiring adequate training, ongoing availability, and commitment for

over 12 months for weekly group and individual therapy and engaging in weekly consultation with

fellow DBT therapists. This level of commitment can prove to be a resource drain on public mental

health services, often resulting in DBT not being provided as a treatment option (Linehan, 2015).

In conclusion, this paper has demonstrated that BPD is a severe mental illness that causes a high

rate of suicide, self-harming behaviours, and poor global functioning. It is a condition that produces

heightened distress for patients and their carers and has a high burden of disease cost to the health

services. Although an evidence-based treatment is available to these patients, there are still

significant gaps where practice lags behind the evidence.

References

Acres, K., Loughhead, M., & Procter, N. (2021). From the community to the emergency

department: A study of hospital emergency department nursing practices from the

perspective of carers of a loved one with borderline personality disorder. Health &

Social Care in the Community (00), 1-9. https://doi.org/10.1111/hsc.13558

Aveyard, H., & Sharpe, P. (2009). Beginner’s guide to evidence-based practice in health

and social care professions: A beginner’s guide. McGraw-Hill Education.

Choi, H. (2018). Family systemic approaches for borderline personality disorder in acute

adult mental health care settings. Australian and New Zealand Journal of Family

Therapy, 39(2), 155–173. https://doi.org/10.1002/anzf.1308

Dimeff, L. & Linehan, M.M. (2001). Dialectical behaviour therapy in a nutshell. The

California Psychologist, 34, 10-13.

Giffin, J. (2008). Family experience of borderline personality disorder. Australian and New

Zealand Journal of Family Therapy, 29(3), 133–138.

https://doi.org/10.1375/anft.29.3.133

Linehan, M. (2015). DBT skills training manual (Second edition.). The Guilford Press.

Van Dijke, A., Hopman, J. A., and Ford, J. D. (2017). Affect dysregulation, adult attachment

problems, and dissociation mediate the relationship between childhood trauma and

borderline personality disorder symptoms in adulthood. European Journal of

Trauma & Dissociation 2(2), 91–99. https://doi.org/10.1016/j.ejtd.2017.11.002