Depression, Borderline Personality Disorder - And Coping With Suicidal Thoughts

I've worked with numerous clients over the past decade who struggled to the point of questioning if life was worth living.  Over the years, my colleague San Mueller & I have developed a passion for working with clients who courageously keep going on until they can find ways to make life meaningful and worth living again.   In this blog I will be talking about a few statistics related to suicide, and discuss a few disorders and subsequent treatments that can help manage suicidal thoughts and behaviors.  

Suicide is the 10th leading cause of death in the United States.  It’s highest when individuals reach middle age, and those most at risk usually work in occupations with a lot of isolation and unstable employment prospects.  Women attempt suicide 2 times more than men, though men are 3-4 times more likely to commit suicide due partly to their preference for more lethal means such as a gun.


Regardless of gender or occupation, completed suicides are too common with all demographics.  As expected, suicidal thoughts can be highly alarming to family members and of serious concern to individuals when the thoughts begin to present in ways the person senses may not be normal.  It can be normal to have the occasional suicidal thought.  Research shows just about everyone has experienced them during their life.  Some thoughts could be classified as normal but are also potential red flags.  For instance, during a period of high stress someone might think, “I wish I would have never woken up,” or “I think I’d be okay if I got into a car accident today and that was the end.”  However, if these thoughts continue to happen for several days, you start losing interest in activities you once enjoyed, it’s becoming a habit where you don’t get up and do the things you were dreading, the thoughts are getting more serious and less normal.  If you start researching how you might commit suicide, planning where you might run off the road, have a plan with some intention, your suicidal thoughts have become a lot more serious and dangerous.  If you are concerned about your thoughts, hopefully you will reach out to a local therapist, call the National Suicide Hotline (800)-273-8255, or the local Behavioral Health Response (BHR) Crisis Hotline (314) 469-6644.


Two of the more common diagnosis I regularly work with that often accompany serious suicidal thoughts are Major Depressive Disorder and Borderline Personality Disorder (BPD). 


In my opinion, BPD is a poor label for a set of symptoms that many people struggle with.  Problems with Emotion Regulation is a much better way to describe this struggle.  It’s usually estimated to affect 5-6% of the population but due to under diagnosis in males, it very likely could be closer to 10% according to other research.  So a lot of people are struggling with this, and it usually starts to show itself in early adulthood.  The symptoms that are usually present create problems with living and feeling like you don’t have a life worth living.  These symptoms are extreme black and white thinking, idealizing people and then devaluing them when something goes wrong, so relationships are often very intense.  It's generally been accepted they are genetically more emotional people, and when the environment punishes or invalidates this emotion they learn to hide and suppress these emotions causing them to build up. Eventually this leads to even more emotion regulation problems than was originally present as the "build up" becomes "blow up."  This sets up a never ending negative feedback loop of intense relationships, broken relationships, fears of abandonment, unstable sense of self, chronic feelings of emptiness, inappropriate intense anger, suicidal thoughts, and impulsivity with alcohol, drugs, or self-harm to cope with the problems in living.   


Treatment for BPD has been researched heavily and consistently shown to be most effective with Dialectical Behavior Therapy (DBT).  DBT is a comprehensive program of weekly individual DBT counseling, weekly DBT skills group, coaching calls throughout the week, and a team of DBT therapists meeting each week to consult on the best ways to help the client.  The program has been described as a course in teaching someone extensive life skills, how to better live your life, versus a suicide prevention program.  However, after going through the program, reduced or eliminated suicidal thoughts is a common outcome.  The program teaches mindfulness skills, distress tolerance skills, emotion regulation skills, and interpersonal effectiveness skills. 

​Mindfulness skills teach them how to internalize a non-judgmental observer before making decisions, and have a healthier more accurate view of one's emotions and thoughts.  Distress tolerance skills are focused on impulse control, healthy ways one can distract to survive a crisis, accept situations, before doing something that can tear down all the progress in an instant.  Emotion regulation skills work to increase less mood dependent behaviors, improve wellness lifestyles, create a sense of mastery & competence along with how to build some positive emotions.  Interpersonal effectiveness skills work to achieve how to be taken more seriously in effective ways without damaging relationships or self-respect, learning to validate yourself and others.


Medications can be a part of treating BPD, other disorders existing along side BPD such as depression or anxiety can be common.  However, related to just BPD, medication has shown to be much less effective than DBT, as learning new life skills to manage our problems in living is not something a medication can do.


Like BPD, Depression is extremely common and often accompanies suicidal thoughts, sometimes considered the common cold of mental health.  It’s estimated to have an impact on about 7% of the population each year.  Unlike BPD, medication is very effective with depression, and the best treatment is a combination of talk therapy and anti-depressants.


Behavioral Activation is a treatment that has been shown to be very effective with reducing suicidal behaviors and depression.  Monitoring behavior and building in activities that break a downward spiral of depression is the basis for treatment.  Working together, the therapist and client try to create an upward spiral to break the depression.  One of the most powerful symptoms of depression is lack of motivation to do anything, everything feels “extremely heavy.”  Therefore, many times depressed individuals don’t do anything when they start becoming depressed.  They report feeling like bricks are attached to their feet and shoulders. This usually leads to more depression as they become more idle because the depression thrives when you shut down, it’s the fertile ground depression needs to continue growing.  As it grows, the depression now feels even heavier.  If they didn't "feel" like doing anything before, they definitely don't "feel" like doing anything now.  I’m sure you can now see clearly what is meant by a downward spiral.  It’s the therapists task to use motivational strategies and education to help create a little space where the individual can start monitoring activity and mood, building in more helpful activities to stabilize the depression and start working towards an upward spiral.   


Many people underestimate how powerful activity monitoring can be.  When I was in graduate school I had to monitor activities for a week and attach the corresponding mood with those activities.  I was astonished at the results and paradoxically I was aware all along of what the monitoring revealed to me.  I had been participating in numerous activities that didn’t provide a lot of joy, and I had been using little of my time to participate in activities that elicited joy.  I sense that individuals know this on some level, but it can be too subtle to break negative patterns and habits.  However, when seeing it on paper in black and white, sometimes it can have the power to change our behaviors for the better.  I made changes that week that have lasted for over 15 years.


Mindfulness skills discussed earlier can also help with depression.  Utilizing cognitive therapy, mindfulness practice can enhance our ability to notice our judgments and self critical thoughts.  Ideally we learn to catch ourself when our thoughts and emotions start to be accepted as facts versus information that should be used for further examination.  This can also be described as stepping back and building in a pause where we can insert a more accurate and helpful framework.   Emotions and thoughts fire so quickly that it can be hard to step back.  Practicing mindfulness regularly can slow down the process just enough to begin allowing a different process to unfold, like challenging unhealthy or distorted thoughts.  


I hope you gained something from this short discussion on Depression, Emotion Regulation Issues, and treatments that can help reduce suicidal thoughts.  We always welcome comments and invite anyone to reach out for further information or questions.


Best Regards,
​
Chad Randall, M.Ed., LPC, CCDP-D
​Elephant Rock Counseling, LLC
Kirkwood, MO