Dramatherapy for Borderline Personality Disorder

Empowering and Nurturing people through Creativity

Nicky Morris

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351811132
• Edition: 1
• Topic: Psychology
• Subtopic: Autism Spectrum Disorders
• Index: Psychology

Dramatherapy for Borderline Personality Disorder: Empowering and Nurturing People Through Creativity demonstrates how dramatherapy can empower those individuals struggling to live with borderline personality disorder, and help them embrace and control the emotional inner chaos they experience.

Based on current research into the aetiology, symptoms and co-morbid disorders associated with BPD (and emotionally unstable personality disorder), this book demonstrates the effectiveness of dramatherapy for individuals and groups on specialist personality disorder wards and in mixed diagnosis rehabilitation units. It also reveals a creative approach for making dramatherapy work in harmony with approaches such as dialectical behaviour therapy and cognitive behaviour therapy.

Aimed at those working with service users, and utilising a range of case studies and clinical vignettes, Dramatherapy for Borderline Personality Disorder provides an insight into the potential of dramatherapy, which will be welcomed by mental health professionals.

Part 1
Definitions, history, theory and treatment options

1
Introduction

Colliding emotions
Held within a creative vessel
Identity fused with pain
Disentangle
See oneself through new eyes

—N. Morris, 2016

This book demonstrates the positive impact of dramatherapy on individuals with borderline personality disorder (BPD), enabling them to gain new perspectives and to distinguish between their emotional pain and core selves. Historically spurned by the health care system, this client group presents a significant challenge to mental health services and effective interventions are vital. Dramatherapy has the capacity to embrace and contain the inner turmoil they often experience, described by Kellogg and Young as “a kind of inner theater in which the forces of cruelty, rage, submission, and self-numbing each take their turn on the stage” (2006, p. 447). For thirteen years, I have facilitated safe and stimulating dramatherapy sessions, in which clients are able to explore their inner selves, express themselves freely and interact playfully – a process that enables positive transformation.

I do not work in isolation and it is the combined effort of many individuals across various disciplines (as well as supportive friends or family) which genuinely helps people towards recovery. This includes RMNs (registered mental health nurses), HCAs (health care assistants), OTs (occupational therapists), OTAs (occupational therapy assistants), ward doctors, consultant psychiatrists, psychologists, clinical managers and social workers. Working within a multidisciplinary team has its challenges, however, and it is vital that colleagues support one another, take care of their own mental and physical health needs and fully utilise supervision. As Holloway and Seebohm acknowledge:

Our workplace can often feel difficult, competitive and isolating. But we do not want to lose sight of the possibility of restoring, maintaining or finding more creative, collaborative and relational ways of working, which are implicit in the roots of our profession, and find their potential expression in the theatrical notion of ‘ensemble’.

(2011, p. 5)

This is the first dramatherapy book to focus predominantly on BPD and is intended for clinicians, service managers, commissioners and students. It will demonstrate the effectiveness of dramatherapy for individuals and groups on specialist personality disorder wards and in mixed-diagnosis rehabilitation units. It will reveal how dramatherapy also works in harmony with approaches such as DBT (dialectical behaviour therapy), CBT (cognitive behaviour therapy) and OT (occupational therapy), as well as treatment models such as MBT (mentalisation-based therapy), TFP (transference-focused psychotherapy) and ST (schema therapy).

Although women with BPD are at the centre of this book, the plight of men is also considered. Whilst their methods of self-harm and levels of emotional distress are thought to be similar, men with BPD have distinctly different personality traits, co-morbidities and use of treatment (Sansone and Sansone, 2011, p. 16). In support of the evidence base, many examples of personal practice will be described and analysed. Research questionnaires completed by ten colleagues from various disciplines and thirteen dramatherapists working across the UK will also be examined and shared. Poetry and song lyrics feature throughout the book, mostly written by service users and a couple of my own reflective pieces. As Motion suggests, poetry is “a fundamental requirement of the human spirit” (2009).

Battling stigma

At the age of 68, Dr Marsha Linehan – who developed DBT for people diagnosed with BPD – shared for the first time that she had experienced severe mental health problems since her teens and had been hospitalised at the age of 17 for extreme social withdrawal. Following her interview with Linehan, Carey (a journalist with the New York Times) reflected that “the enduring stigma of mental illness teaches people with such a diagnosis to think of themselves as victims, snuffing out the one thing that can motivate them to find treatment: hope” (2011, part 1, p. 1). Linehan’s decision to share her story publicly was part of her fight against stigma regarding mental health problems.

Mental health charities across the UK, the US and other parts of the world continue their efforts to reduce stigma by promoting positive mental health awareness. Despite a general improvement, however, people with BPD continue to face prejudice and are often confronted with a lack of empathy and understanding (Gunn and Potter, 2015, p. 113). Historically, they were labelled as treatment-resistant and manipulative. In his review on the development of the diagnosis, Gunderson (professor of psychiatry and pioneer of BPD research and treatment) identified the following as a recurring theme: “the persistence of borderline personality disorder as a suspect category largely neglected by psychiatric institutions, comprising a group of patients few clinicians want to treat” (2009, p. 530). Preconceptions about people with BPD will be challenged in this book and the causes of the disorder explored in depth.

The National Institute for Health and Care Excellence (NICE) states that “People with borderline personality disorder should not be excluded from any health or social care service because of their diagnosis or because they have self-harmed” (2009, p. 11). I have worked with several clients who have been treated with disdain by hospital staff, however, when attending accident and emergency services in the UK, after severely self-harming. Some were accused of misusing valuable resources and others refused treatment. Mental health nurses and health care assistants escorting these clients were also accused of not doing their jobs properly. Self-harm can be severe, even life-threatening. Individuals who feel driven to commit such dangerous acts against themselves need compassion and care, not rejection and judgement. NICE also reminds professionals offering services to clients with BPD that many will have experienced “rejection, abuse and trauma, and encountered stigma often associated with self-harm and borderline personality disorder” (2009, p. 12). They have suffered enough and this is a crucial part of the motivation for writing this book.

In 2017, brothers Harry, Prince of Wales, and William, Duke of Cambridge – together with the Duchess of Cambridge – launched a campaign to raise the profile of mental health in the UK, joining the fight against stigma. For the first time, they spoke publicly about the impact of the loss of their mother, Princess Diana, who had suffered from mental health problems and tragically died in 1997. On their website, they reflect that “Too often, people feel afraid to admit that they are struggling with their mental health. This fear of prejudice and judgement stops people from getting help and can destroy families and end lives” (Heads Together, 2017).

Personal motivation

In my early twenties, I lost my mother to cancer, four weeks before my wedding day. This loss had a significant impact on my mental health and I felt unable to continue with my acting career. With support, I found the courage to pursue a new vocation and trained to become a dramatherapist. I also became a mother, which brought new challenges as well as joy. dramatherapy then helped to reignite my spirit and gave meaning back to my life. Since qualifying from Roehampton University in 2005, I have worked in adult mental health units across South East England, in both the public and private sectors.

At the age of 8, I began to write poetry and songs to express how I was feeling, particularly when I was experiencing difficult emotions and thoughts. As an adult, I have transferred this skill into my professional work as a dramatherapist, putting the words of the people I work with to music. I concur with Andrew Motion’s belief that “poetry is as natural and necessary as breathing” (2009). Encouraged by service user Sandra, I wrote a poetic song about my own experience and the words of the chorus are pertinent to this book:

I am no saviour, I have no cures
Just a woman, once a child,
With no answers, I am blind

The final three words (I am blind) symbolise the helplessness that may be felt when working with people who have experienced such depths of emotional pain. Whilst impassioned to help them, our efforts may at times feel somewhat futile. This is where regular clinical supervision and a supportive multidisciplinary team are essential in helping clinicians to remain grounded and hopeful.

Summary of chapters

Following this introduction, Chapters 2 and 3 focus on defining BPD and exploring recommended treatments, including dramatherapy.

Chapter 2 offers a comprehensive description of BPD – also known as emotionally unstable personality disorder (EUPD) – including a historical perspective, diagnostic criteria and co-morbid conditions. It begins with the history of the diagnosis, summarising how it developed and was first acknowledged in psychiatry. The impacts of mental health problems on the UK’s population are then shared, highlighting the percentage of mental health service users with BPD. The diagnostic process and the most recent definitions offered by the American Psychiatric Association (APA, 2013a, 2013b) and the World Health Organization (WHO, 2016) are also described and symptoms and co-morbid disorders identified.

Chapter 3 describes a wide array of psychological and psychosocial treatments relevant to people with BPD. These are crucial, as there is no medical cure for the disorder, only psychiatric medicines that may relieve some of the symptoms associated with co-morbid disorders. The 2009 NICE guideline on the treatment and management of people with BPD offers a comprehensive account of several interventions. Some are more highly recommended than others, based on the strength of their evidence base. There is also helpful information on the NHS Choices website (2017) and in a detailed handbook commissioned by the UK’s Department of Health (Bolton et al., 2014).

Chapter 4 presents the rationale for selecting dramatherapy as a key intervention for the BPD client group. Specific reference is made to the 2015 Quality Standard from NICE (QS88) and a definition and brief history of dramatherapy are given. The methods used by thirteen dramatherapists with experience of working in the field are revealed alongside the approach I have developed and refined for women with BPD: a person-centred, transpersonal approach, influenced by Jung (1968) and Rowan (1990), comprising dramatic rituals, projective techniques and play. With the potential to support both male and female clients with BPD, dramatherapy is explored in relation to attachment and trauma, and the importance of evaluation and evidence is discussed.

Part 2 includes Chapters 5 through 8. The first two focus on the clinical practice of dramatherapy in two different settings with the client group, including many clinical vignettes. The penultimate chapter explores existential issues concerning grief and the client group’s ambivalence towards life and death: self-harm versus self-preservation. In the final chapter, belief, hope and courage are presented as the antithesis to this and the role of dramatherapy is illuminated.

Chapter 5 is a response to working with women on a Tier 4 secure ward for women diagnosed with BPD and co-morbid conditions. Recurring themes are highlighted and six styles of intervention described, supported by session vignettes and samples of creative work. A detailed case study of a client’s one-to-one drama-therapy journey follows, explored in relation to schema therapy (Kellogg and Young, 2006), Rowan’s subpersonality work (1990) and several Jungian concepts: integrating internal aspects, the shadow and individuation (Jung, 1968). Finally, feedback from colleagues and clients is shared.

Chapter 6 describes the work on a secure step-down unit for women with severe and enduring mental health difficulties, predominantly BPD and paranoid schizophrenia. We also have service users with bipolar disorder and schizo-affective disorder, as well as those with co-morbid disorders, such as PTSD (post-traumatic stress disorder), anorexia nervosa and drug or alcohol dependency. Freedom, choice and acceptance are themes that often arise, and the dramatherapy group provides service users with a space in which to safely voice their frustrations and celebrate their individuality. A selection of session vignettes, key themes and interventions is shared in this chapter, together with creative pieces, to illustrate the vitality of the work generated. The issue of stigma and mental health is explored in relation to the use of drama and songs born in the therapy space and then performed for service users, hospital staff and close friends and family. Finally, three colleagues from different professions share their thoughts about dramatherapy, demonstrating how the intervention may be perceived and can work in relation to a multidisciplinary approach.

Chapter 7 introduces grief as an enduring theme that arises on both conscious and unconscious levels within dramatherapy sessions. The client group’s ambivalence about life and death is also prominent, as many express their emotional pain through severe acts of self-harm, which place their lives in jeopardy. Case and session vignettes are used to highlight how the therapeutic process supports clients struggling to cope with issues around death. Many struggle with suicidal thoughts; some have survived suicide attempts and others have friends or family members who have committed suicide or died from natural causes. As Yalom explains, whilst self-awareness makes us human, it also reveals our mortality, and “Our existence is forever shadowed by the knowledge that we will grow, blossom, and, inevitably, diminish and die” (2008, p. 1). The emotional pain experienced by clients, whether in response to their past or present, may also have a considerable impact on those working with them. This issue is explored in relation to personal practice and research, including feedback from colleagues and dramatherapists. The complexity of the therapeutic relationship is then considered with regards to attachment and rejection, hope and futility, transference and countertransference.

Chapter 8 demonstrates that with belief, hope a...