How do you deal with self-harm and suicidal tendencies?

[Isus]

To be totally honest, our kid, DS21, is not with BPD, his main issue is more PTSD (or maybe more C-PTSD type, while one incident as a teen started PTSD, he does have long and continuous trauma history before that) and dissociation and anxiety symptoms associated with that, but during the psychiatric hospitalisation after his last crisis a psychiatrist had discussed with him about BPD traits to explain his self-harm behaviours, feeling of emptiness and suicidal ideation. He also has some degree of splitting and things like that but would not cut the diagnostic line. He is also very high functioning in some areas of life, lives independently few hours away, is in age appropriate romantic longer term relationship, doesn't ask much from us and is very ambitious with his career path. He has history of lots of social skills issues but has addressed those with help of a professional and is doing much better.

But he self harms. Doesn't cut, because that would be noticed and would cause him trouble, but uses other ways to cause himself physical pain. He is very secretive about it and doesn't usually admit it and is careful to not leave much marks in his body. Ways he does it, are not life threatening nor likely to cause any permanent harm to his body. But it appears to be regular and he really goes for pain. He also doesn't make suicide threats and has only admitted suicidal ideation few times, and even then brings it up more like: "The fall year ago was really tough, I was even thinking about suicide a lot and couple times was actually preparing it." In other words he doesn't tell anyone, when he is having lots of suicidal ideation, he confesses later, when he is feeling bit better. There has also been at least one suicide attempt. That wasn't planned, but very impulsive. He had had a slip with addiction, he was in serious trouble with that after the traumatic incident that happened, but has now been clean over 4 years with only few short slips, and other emotionally difficult experience and did this very impulsive decision to let it all go. He changed his mind mid fly, literally, and manage to stay alive and mostly unharmed. This was over a year ago. He tried to lie about it a long time and told everyone it was just reckless accident for months before he admitted that it had actually been deliberate. 

He is seeing psychiatrist regularly, is on medication and we were finally able to harass him back to therapy. He did a year of intensive exposure type therapy for his PTSD, but after a move had to stop with that therapist. He planned a half a year break and finding a new therapist but it took two years and he was really dragging his feet starting again. Therapy seemed to help him a lot last time, but he just started again and can't know how he will click with the new therapist yet.

We actually have quite a good relationship with him. Regular calls and some visits, and he stays home at summer some periods of time and while he sometimes really takes his time, he tends to eventually open up to me and sometimes also to his dad. 

His self-harm is not life threatening, but suicidal ideation could turn so and me and my hubby are at loss how we should relate to those things. I have talked with him about not trying to hide self harm from his new therapist and how he shouldn't be so ashamed of it but instead try to look for help to stop it. He has also promised us, on his own accord, that he will not kill himself,  but I guess that has little bearing to how suicidal mind works when crisis. Our son fears admitting or showing any of this mental health issues to people around him could seriously hinter his career ambitions, and is likely right, and that is a reason he tends to try hide everything from people around him. So me and my hubby tend to be among people most likely to know when he is having more difficult time. And we are having difficult time making up our minds how we should act, when things are really rough for our son and we feel there is legitimate worry for something really bad happening to him.

There are people we could contact near him for help, if really needed but our son would consider it a real break of trust and wouldn't easily forgive that. Still, of course, if we were seriously afraid he could be in immediate danger to commit suicide, we would do it, but with everything else it is a very fine line and we are struggling trying to come up with some guidelines on when to get involved and when to sit back and just try to advise him to seek appropriate help.

Our objective is to better understand the struggles our child faces and to learn the skills to improve our relationship and provide a supportive environment and also improve on our own emotional responses, attitudes and effectiveness as a family leaders

[lbjnltx]

Hi Isus,

I'm glad to see you back though sorry to hear that your son is self harming and engaging in suicidal thoughts sometimes.  This is hard stuff to deal with and understand.  I would venture to say that most of the members of the site are posting about a loved one that doesn't have/meet the criteria for diagnoses of BPD though they definitely have traits of the disorder.  Your son may fall into the category of "Traits of BPD".

The self injury is a low level coping skill that brings relief in some way from the intense feelings he has.  The goal is to replace that lower level coping skill with a higher level coping skill.  Dialectical Behavior Therapy addresses the intense emotions of the person and teaches the skills needed to gain a balance of logic/reason mind and emotion.  When these skills are used the impulsive actions, the emotional thinking and suicidal ideation loosen the grip on our kids.  Does the new therapist your son is going to see practice DBT?

It's good that your son confides in you and your husband about his feelings/thoughts.  It is important that he has someone he trusts to turn to.  One of the ways we can help our kids is to validate their feelings and remain empathetic in our communications with them.  Since you have an agreement with him not to take his own life do you think he might also agree that if he feels suicidal that he will call an anonymous help line?  Professionals can assess the risk level and counsel him through any crisis.

Will your son allow you to contact his psychiatrist or therapist with any concerns you have? Will he allow them to talk to you about his treatment and how you can help?  He need only sign a release.

lbj

[Someday . . .]

Have you thought of finding a place (residential) that deals with trauma and PTSD?   I don't know if you have the resources, but my daughter and I were interested in a place in Florida called The Refuge - a Healing Place for Trauma and PTSD.    I have read really good reviews and talked to someone who has gone through the program, I have heard nothing but good things.   You may want to check it out.   Best of luck/everything to you in dealing with this very difficult situation.

[Isus]

Thank you for replies. In my country residential treatment for mental health issues is only available for most serious cases and also substance abuse and addiction treatment is mostly community base intensive outpatient treatment.

DBT is available but mostly in hospital programs for their 'day hospital' patients. My son doesn't meet the criteria for that and wouldn't be willing. DBT also usually involves also group therapy and that is a big no-no for him. His new therapist, like his former too, is specialised on prolonged exposure therapy and at least doesn't mention anything about DBT in his credentials. Prolonged exposure therapy is also recommended for PTSD on our national standard of care so I'm not sure if my son would need to provide reasons to choose some other type of therapist to keep his funding for therapy. And anyway, finding a suitable therapist was quite a job as it was. He lives in middle size city but still there is only so many options. And he has demanding schedule as it is, so driving any more than maybe an hour at most three times a week for therapy would be undoable. So it was a limited pool of trauma specialised therapists willing to take new intensive patient. And son clearly wanted a male therapist, he never said that, but would keep finding faults of any female therapists he had a meet and greet session, so the reality is, that he has to try to make do with the therapist he did find.

Son has given release for his psychiatrist to speak with us and we were in fact part of forming a treatment plan. The other professional in his life, his sport psychologist also has a release to talk with us. He is the one with whom he has worked on social skills and life management among other things. However son was reluctant to give his former therapist a release and we didn't push. It seems to be the same with new one and in some ways I do find it healthy, he is an adult after all. I could push and he would likely cave, but he would likely feel resentful about it. And he has given releases for his therapist, psychiatrist and sport psychologist to talk, so I guess our worries would travel to therapist through them if they were grave enough.

He has actually called to anonymous helpline before, but appa5rently he feels unworthy to bother them, because his issues are 'not that bad.' When he told about that to me couple years back, we made a deal that me and hubby would keep our phones on also during the night  and we told him we still had room for few more sleepless nights because of him so he could call any time and even just chitchat if he was stuck in the bad place and just needed help getting his thoughts out from it. Of course I also told him, that the help lines exist just for people like him, when he is in crisis, but I'm not sure if he is able to think so rationally when he has a bad moment.

He is extremely competitive and perfectionist and his sense of worthlessness can be bottomless bit.

[lbjnltx]

Hi Isus,

If  your son is self directing and motivated he can learn the DBT skills online:

www.dbtselfhelp.com

There are also workbooks available for purchase online.

Should your son pick this up it would be helpful to him if the family spoke the same DBT skills language and could support him in using the skills when he dysregulates or goes into a crisis.

Just an optional resource.

lbj

[Isus]

Thanks for the link. Seems like there are lots of the same concepts and ideas both his sport psych and former therapist worked with him.

However I'm bit reluctant trying to recommend this page to my son. Not because it would be a bad page, but because all this is a touchy subject and my son tends to have difficulties enforcing boundaries especially when it comes to people he cares about. I tend to be careful not to push or browbeat anything around these very personal topics, at least if I do not find it absolutely crucial.

But I will familiarise myself more about these concepts, because it really does sound like my son actually is already familiar with many of them.