Despite recent clinical and media attention to self-injurious behavior, not enough is understood regarding the actual experience of individuals who intentionally injure themselves without causing lethal harm. Even the terms and their definitions are unclear and conflicting. Several terms that have been used to discuss self-directed harm need to be clarified. Deliberate self-harm includes two forms of self-destructive behavior: one with an intent to die and one in which the self-inflicted damage does not connote this intent. Both forms involve self-inflicted physical harm
but do not include behaviors in which individuals provoke others into harming them, such as getting into fights. The two types of self-harm discussed here are defined as follows:
1. Suicide attempt: A suicide attempt is defined as an intentionally selfdestructive act performed with at least partial intent to die. Although this is an apparently straightforward definition, the assessment of an individual’s subjective intent is challenging for a number of reasons.
Intent may be difficult to determine through direct inquiry, because retrospective reports can be influenced by reinterpretation and by outcome and may no longer be accurate descriptions of the individual’s state of mind at the time of the self-injury. Clinically, suicidal intent is often deduced by external behaviors or factors (such as how medically lethal the self-injury is) or by the circumstances (such as the likelihood of being discovered during or immediately after the act surrounding the self-injury). These deductions can lead to erroneous assumptions, particularly for individuals with BPD who self-injure for many reasons and in whom the intent to die is often ambiguous. Perception of intent can also be distorted by the existence of previous nonlethal attempts (Stanley et al. 2001).
2. Self-injurious behavior: Nonsuicidal self-injury, sometimes called selfmutilation, is defined as intentional self-destructive behavior performed with no intent to die. Such self-injury with no suicidal intent is quite particular to the BPD diagnosis and can be understood within the context of BPD pathology as an effort to regulate emotions. Although suicidal intent is often ascribed to these behaviors by clinicians and family members, individuals with BPD are often quite clear that their intent is quite to the contrary and that these behaviors are often used in an attempt to feel better.
Two other terms are important to mention: self-mutilation and parasuicide. Although the term self-mutilation is commonly used to describe nonsuicidal self-harm, we believe that it is not inclusive enough. Some forms of self-injury, such as cutting and burning, involve mutilation; others, such as head banging and hitting oneself, do not. The term parasuicide is often used incorrectly. Although the term is mistakenly thought to include only behaviors without suicide intent, its actual definition is any self-injurious behavior, with or without suicidal intent, that does not result
in death. Thus all suicide attempts fall into the category of parasuicide, as do self-mutilation and nonsuicidal self-injury.
Suicidal and self injuries in BPD : a Background and Definitions
Outpatient Psychotherapies for personal disorder patient
Establishing an ongoing and productive working relationship with a therapist is a fundamental goal in any treatment, but it is of particular importance for individuals with BPD because it is often very difficult to facilitate with these patients. Consequently, therapists practicing a wide variety of therapy disciplines have recognized the importance of employing a supportive stance with their borderline patients. Winston and colleagues (2001) advocated the notion that “supportive therapy can be considered a ‘shell’ that fits over most theoretical orientations” (p. 346).
That is, whether the core orientation of the treatment is from a cognitivebehavioral or a psychodynamic tradition , a supportive demeanor is necessary to engage and keep the patient in treatment. Although it is important in establishing the alliance, this approach also allows the therapist to model an alternative way of interacting through such interventions as empathic responses and validation of feelings. The therapy relationship is used to teach the patient about his or her difficulties with other people, to enhance the patient’s self-esteem, and to assist in managing anxiety. A variety of psychotherapeutic approaches have incorporated supportive elements in treating patients with BPD, and many therapists now employ supportive psychotherapy as a distinct approach in and of itself.