Function and Psychotherapy of Chronic Suicidality in Borderline Personality Disorder: Using the Reinforcement Model of Suicidality

Abstract

Although great advancements in evidence-based therapies, chronic suicidal patients with borderline personality disorder (BPD) still challenge our mental health system. While BPD patients continue suffering from distress and aversive emotions, therapists and relatives feel often stunned and helpless when confronted with suicidality resulting in interruption of therapies, repeated presentations to emergency rooms and referrals to hospitals. Reviewing the current knowledge of the functions and background of non-suicidal self-injury, we learned that reinforcement mechanisms play an important role to understand why individuals act in deliberate self-mutilation. While individual motives for non-suicidal self-injury and suicidal behavior including suicidal ideations can differ, the principle mechanisms appear to be transferrable. Elucidating the individual motives and function of suicidal behavior is an important therapeutic step, giving us access to very central maladaptive schemes and false believes that we need to address in order to reduce chronic suicidality in BPD patients. This Perspective article aims to give a better idea of what is behind and what are the differences between non-suicidal self-injury, suicidal ideations and suicide attempts. It further integrates recent developments of behavioral science in a reinforcement model of suicidality that can provide therapists a practical armamentarium in their work with chronic suicidal clients.

Keywords: DBT; behavioral analysis; borderline personality disorder; non-suicidal self-injury; psychotherapy; reinforcement; suicidality; suicide attempt.

Figure 1

Chain analysis and stimulus-organismic-response-contingencies (SORKC) model of suicidal symptoms: A behavioral (chain) analysis of suicidal symptoms (e.g., suicidal ideation, internet research, preparation of suicide) that occur after the boyfriend of Jess questioned their relationship (cue, S). Jess instantly is surprised and fears losing Pete (primary emotions directly related to the situation; grief would be likely also). The first emotions disappear rapidly while Jess's maladaptive cognitive schemes (O) get activated (her interpretation of the situation against the background of her childhood experiences). These judgements in turn activate secondary emotions (like helplessness, hopelessness, panic) causing significant distress. Of note, these transitions from primary emotions to secondary emotions can be very fast letting patients even not notice their primary emotion at all (14). Thinking of suicide, the visit of suicide chats in the internet and suicidal communication with peers (R) calms Jess down and gives her a kind of feeling of control and hope (“I could escape,” “There is a way out,” “I must not suffer”). This contingency between psychological pain and relief (K/C) acts as a strong negative reinforcer (¢-) that increases the likelihood of suicidal ideations in the next situation of distress. On the other hand, long-term (i.e., after the immediate relief of pain) emotions like feeling of insufficiency, shame or loneliness occur (“I can't live alone,” “I am incapable in relationships,” “Anybody likes me,” “I am alone in the world”) that support in turn the assumptions/maladaptive schemes. The vicious cycle of reinforcement of suicidality and repeated confirmation of central cognitive/emotional schemes results in long-lasting, recurrent, chronic suicidality.