The importance of risk assessment when working with BPD
This is a very important topic and when a therapist chooses to work with this client group then risk assessment becomes vital. With a client that has Borderline Personality Disorder, self harming is very a very common method of coping with the turmoil of emotions that they feel on a daily basis. It may help them cope with certain issues such as dissociation or emotional regulation issues. Usually within a hypnotherapy context, self harming can be managed, but when it steps over that line and develops into suicidal idealation, it becomes difficult. Even then it can be difficult to assess and there maybe no intention there at the time.
Usual methods that I have found effective when working with clients that have BPD are:
Contracting at the beginning of therapy that if the client develops suicidal idealation/intent, other agencies can be involved. Usually this is already the case - the community mental health team or a psychiatrist may be involved. The nature of the contract would contain certain conditions around self harming, if the risk increases and that the client will monitor their mood regularly.
Contact between the sessions: this is a very important concept in certain therapies such as DBT. If the client finds themselves in the middle of a crisis situation, they know they can ring the therapist during a designated period for support. It is important to add at this point that the telephone conversations are purely coaching sessions around the skills that the client has learned (such as self hypnosis) and not therapy, that is left to the therapy session.
The use of formalised assessment tools: during the course of therapy the therapist would teach the client the necessary tools and skills to develop insight into their concept of risk. This may include skills such as self monitoring or the use of self-hypnosis to ascertain their psychological state. However, the use of formalised risk assessment and psychological assessment tools can be very helpful with this. A common technique is the "core" outcome measures. This is great from a documentation standpoint and it's something that you can do with the client on a regular basis to assess mood and any other concerns that come up.
The client must agree to the actual fact if risk increases further then they must seek help from the community mental health team or crisis team. If this is not agreed at the beginning of the therapy, then it is highly advisable to not see that client alone. You will get a lot of clients that have been felt they have been let down by the NHS, but it has to be explained that as the therapist you can not provide that level of support the client needs to maintain their safety.
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