Essay Grade

The Case of Cathy
Cathy is a 32-year-old, divorced, heterosexual African American female. She came to
her first initial intake session with complaints of depression with passive suicidal
thoughts, anxiousness, and trouble sleeping. She presented as casually groomed,
coherent, and goal directed. Cathy’s primary concern was that she has been having
episodes 3–5 times a week during which she reported she cannot breathe, her heart
feels like it will explode, and she feels like the “walls close in.” She stated that this has
been going on for about a year, but lately it has been getting worse. She self-referred
after being prompted by her sister to contact a social worker. The following is a
summary of the initial appointment and assessment for Cathy.
Cathy is the oldest of four children (two brothers and one sister), all of whom are
married and live in the same community. Cathy works in a doctor’s office and lives in a
one-bedroom apartment where she often “isolates.” She is the primary caretaker of her
mother, who was involved in a car accident 20 years ago and was left a quadriplegic.
Cathy goes to her home daily to help with her personal hygiene.
Cathy has an arrest history and was incarcerated for 3 years for drug-related charges.
She was charged with possession and intent to distribute. Cathy stated that at that time
she was addicted to heroin and using daily. When she completed her prison sentence,
she was paroled and mandated to attend a 1-year outpatient drug treatment program,
which she successfully completed. Cathy reported that she started using cocaine 2
years ago, stating that it helps her do her fast-paced job better and it keeps her energy
up so she can help her mother early in the morning and late at night. She said no one in
her family or at her job knows that she has been doing drugs. She drinks alcohol daily
(two to three drinks). Cathy also takes numerous medications prescribed to her by her
primary care doctor, including an antidepressant and pain medication.
As we discussed her presenting concerns, multiple issues came up. Cathy shared her
feelings about being her mother’s primary caretaker, stating, “I love my mom, but
everyone expects me to care for her. It feels so unfair, but it’s because I am not married
and don’t have any children.” She said her father does not help with the care of her
mother and that all he does is “hang out.” She reported feeling increasingly frustrated
with this added responsibility and resentful that her father and siblings have relegated
this job to her. She was dysphoric as she shared this content and described some
shame at being “stuck.” She described her father as a “manipulative loser.”
She also stated that she recently allowed one of her brother’s friends to move in with
her as a favor because he was homeless and had nowhere to go. She said she
believed he was a sweet person who just has had a hard time in life, and she wanted to
help him. She had been supporting him financially over the last month, and she was
concerned because it appears that he has not made any effort to get a job. She feared
she made a mistake allowing him into her home and worried she will not be able to get
him to leave.
Cathy said that she and this new roommate had sex one time when he first moved in.
She said they both got very intoxicated, and she is not sure exactly what happened, but
she blacked out and found him in her bed, undressed. She then told him she had
herpes, and he responded that it had been a “mistake” and that he did not want to have
sex with her again because he was afraid of getting infected. Cathy became angry with
him at this. Cathy explained that her ex-husband’s cheating had resulted in this lifelong
disease, and she expressed anger and resentment toward him. She said even though
the herpes is controlled with medication, she feels embarrassed and fears she will never
have another healthy relationship. She said she feels used, slighted, and humiliated by
the man now living in her home.
Cathy then shared that when she was 12 years old her father began molesting her. She
stated that she tried to forget what happened to her, but this recent incident with her
new roommate brought it up again. Cathy complained of recent nightmares related to
the abuse and exaggerated startle reactions to other people’s movements.
Adapted from: Plummer, S.-B., Makris, S., & Brocksen, S. (2013). Social work case
studies: Concentration year. Baltimore, MD: Laureate Publishing.
Personality Disorders
Personality Disorders
Program Transcript
[INTRO MUSIC PLAYING]
DIANE RANES: Personality disorders take time to diagnose. James Morrison
points out that these illnesses quote, “primarily involve problems relating to
oneself and to other people. They are lasting patterns that can show up in the
realms of thought, feelings, behavior, and motivation: they affect interpersonal
relationships and the control of impulses,” end quote. The DSM V would agree
with him and sees personality disorders similarly as quote, “enduring patterns of
inner experience and behavior that deviate markedly from the expectations of the
individual’s culture and are manifest in many areas of cognition, emotional
responses, interpersonal functioning, and impulse control,” end quote.
So to give a PD diagnosis, the pattern should be pervasive and inflexible almost
to the point that the individual is so comfortable with the dysfunction that they
may not be fully aware of it. One also needs to be aware, in personality
diagnosis, of gender biases. For example, antisocial personality disorder is
diagnosed more in males, while borderline personality disorders are diagnosed
more in females.
In making this diagnosis, one considers the lifelong background back to
adolescence and young adulthood of attitudes, behaviors, and consequences
looking for stable and repeated patterns, again across different life situations and
different contexts such as work, social, sexual, and family life. Morrison advises
the professional to look closely at these areas. First, the lifelong history of the
person back to adolescence and young adulthood, second the person’s affects
and attitudes, third, the behaviors observed over time, four, functioning with you
within the therapeutic relationship, and five, consideration of how the person
functions with other people in the person’s life.
In updating the DSM V, the decision was made to view the personality disorders
within two different approaches. The first approach, the one you’ll be using most
often right now, is the traditional diagnostic model for these illnesses by using a
category that the client fits or does not fit into. In this model, the personality
disorders are generally thought of in three clusters or groups organized around
particular characteristics.
So for example, cluster A consists of eccentric and odd types of personality, such
as the paranoid personality, schizoid, or schizotypal personality disorder. Cluster
B encompasses dramatic, impulsive, and erratic types. Those might be antisocial, borderline, histrionic, and narcissistic personalities. Cluster C has as a
binding element anxious, fearful responses. And those personality disorders
would be avoidant, dependent, or OCD.
© 2018 Laureate Education, Inc.
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Personality Disorders
As you have learned, the categorical way of looking at people has significant
problems. For personality disorders, these diagnostic problems are magnified as
there’s even greater variety in how the illness is present in individuals. For
example, in borderline personality disorders alone, there are at least six highly
distinctive subgroups that the research has identified who meet the criteria for the
illness, yet differ enormously from each other in antisocial behavior, in self-injury,
and in past suicidal attempts, just to name a few factors.
So one major problem in personality diagnosis is obviously the mixed nature of
those who fit a personality disorder diagnosis. Professionals in the field have long
known that this categorical system leaves out a lot of people who are seriously in
trouble with the impact of functional problems in their lives that are woven into
their personality, but don’t really meet all of the criteria necessary for a diagnosis.
That’s usually five of nine criteria in the old model. Since access to care is often
based on the requirements of medical necessity or having a diagnosis, many
individuals who need help and don’t have full presentations don’t receive it.
Because of these shortcomings, the DSM V created and is testing what it calls an
alternative model of personality disorders. This is a whole section towards the
back of the manual. This new model allows for more flexible decisions based on
functioning traits and dimensions of impairment.
Criteria to have one of the personality disorders in that model looks at the level of
personality function in areas like identity, self-direction, empathy, or intimacy.
Plus it looks at pathological personality traits. And there is a table of 25 of these,
but they’re grouped in five major areas– detachment, antagonism, dis-inhibition,
psychoticism, and negative emotions. So one has personality function limits, one
has pathological traits. And again, the impairments are stable and pervasive
patterns.
The advantage of the alternative model is that patients who don’t meet a full
presentation in the traditional model, but are having significant disruptions in their
functioning, can be diagnosed for the first time. But the negative side is that this
system has not yet been validated in the community. So while clinicians are
interested in it, most treatment settings have not opted to use it yet. But it has
more flexibility, it can be used, and the DSM tries to guard against overuse by
making it very clear that if the symptoms are better explained by a nonpersonality disorder diagnosis, that diagnosis takes precedent. Lastly, the new
system allows the diagnostician to use a category called Personality DisorderedTrait Specific, which can be used if there is a single dominating impairment from
among those that I’ve mentioned for the individual.
So currently, as I said, most settings continue to use the traditional model and
are waiting for validation of the alternative model. But whatever model you are
using, if you have worked with someone for some time or problems keep
reoccurring in a rigid, pervasive, and particular pattern throughout a complete
© 2018 Laureate Education, Inc.
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Personality Disorders
history, and the history for personality disorder should go back to adolescents
who are young adulthood, then the diagnostician has to consider a personality
disorder.
Personality Disorders
Additional Content Attribution
FOOTAGE:
GettyLicense_151218134 (Counsel session)
Credit: [simonkr]/[Creatas Video]/Getty Images
GettyLicense_469868421 (Suffer in silence)
Credit: [alvarez]/[Vetta]/Getty Images
GettyLicense_460910224_h1 (Work stress)
Credit: [hoozone]/[Vetta]/Getty Images
MUSIC:
SC_Light&Bright06_T32 and/or SC_Business01_T41
Credit: Studio Cutz
© 2018 Laureate Education, Inc.
3
AUSTRALIAN SOCIAL WORK, 2016
VOL. 69, NO. 2, 206–214
http://dx.doi.org/10.1080/0312407X.2015.1054296
PRACTICE, POLICY, & PERSPECTIVES
Borderline Personality Disorder and Access to Services:
A Crucial Social Justice Issue
Angela Ferguson
Faculty of Education and Social Work, University of Sydney, Sydney, New South Wales, Australia
ABSTRACT
ARTICLE HISTORY
A diagnosis of Borderline Personality Disorder (BPD) can significantly
affect access to services. Two Australian approaches to addressing
this crucial social justice issue are compared: Project AIR (Affect
Integration and Recovery), exemplifying changes within the
existing psychiatric paradigm; and Adults Surviving Child Abuse’s
Practice Guidelines for Treatment of Complex Trauma and Trauma
Informed Care and Service Delivery. Changes within the existing
paradigm do not address stigma and fragmented services that
create barriers to service. By comparison, the Guidelines represent
a trauma informed perspective that recognises underlying
complex trauma for most with the BPD diagnosis. Implications for
services are discussed.
Received 16 February 2015
Revised 27 April 2015
Accepted 1 May 2015
KEYWORDS
Mental Health; Practice
Standards; Trauma; Health
Social Work; Social Exclusion;
Domestic Violence
Borderline Personality Disorder (BPD) is a psychiatric diagnosis characterised by a “pervasive pattern of instability of interpersonal relationships, self-image, and affects, and
marked impulsivity” (American Psychiatric Association [APA], 2013, p. 663). The term
BPD was first described in 1938, with “Borderline” referring to being “on the ‘borderline’
between neurosis and psychosis” (Grenyer, 2013, p. 464). In 1980 BPD was added to the
American Psychiatric Association’s diagnostic manual (the Diagnostic and Statistical
Manual of Mental Disorders, currently in its fifth edition [APA, 2013]), formally entering
the psychiatric canon (Grenyer, 2013). It is estimated to affect 1.6% of the population, and
is found among about 20% of psychiatric inpatients (APA, 2013). Seventy-five percent of
people diagnosed with BPD are women (APA, 2013). In addition to the gendered nature of
BPD, it is well recognised that women with BPD usually have multiple “comorbidities,”
such as substance abuse, eating disorders, depression, physical health issues, and
anxiety (APA, 2013; Ross, 2007). This leads to complex needs that are typically inadequately dealt with by mainstream mental health services (Fanaian, Lewis, & Grenyer,
2013).
In addition, the stigma surrounding BPD creates significant barriers to effective service
provision (Fanaian et al., 2013; Mental Health Council of Australia [MHCA], 2005). BPD
is widely recognised as one of the most stigmatised psychiatric diagnoses (MHCA, 2005).
By its very nature, BPD affects the relationship between those who need services and the
services themselves. The “antisocial,” “difficult,” “manipulative” aspects of BPD can be
CONTACT Angela Ferguson
afer4066@uni.sydney.edu.au
© 2015 Australian Association of Social Workers
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seen as defects within that person (Mental Health Coordinating Council, 2013). This
means people diagnosed with BPD are likely to be misunderstood, blamed for the situations they are in (which can often be self-destructive), and ultimately isolated with
their problems. This makes the exclusion of people with BPD from services an urgent
social policy issue to address.
It is also well recognised that women with BPD are more likely to experience revictimisation in the form of intimate partner violence; while the numbers vary, it is typically many
magnitudes higher than those without BPD (Adults Surviving Child Abuse [ASCA], 2012;
Chu, 1992; Herman, 1992). Intimate partner violence (IPV) (used here in place of the term
“domestic violence”), is defined by a pattern of coercion and control by the perpertrator
(Chu, 1992; Wall & Quadara, 2014; World Health Organisation, 2002). While the responsibility for the IPV, of course, remains wholly with the perpetrator, it is recognised from an
ecological perspective that characteristics of women with BPD may make revictimisation
more likely (Chu, 1992). While not all people experiencing IPV or diagnosed with BPD are
women, throughout this article the term “women” will be used in recognition of the gendered nature of both phenomena.
The combination of exclusion from services due to complex needs and stigma, and the
increased likelihood of women needing services due to being in violent relationships as
adults, means that addressing service provision is a crucial social justice issue. In the
Australian context there are different approaches that in their own way address the lack
of service for those diagnosed with BPD. Two of these will now be compared. One is a
project operating from within the psychiatric paradigm, Project AIR (AIR stands for
Affect Integration and Recovery) from the Illawarra region of New South Wales, Australia.
The other is the document Practice Guidelines for Treatment of Complex Trauma and
Trauma Informed Care and Service Delivery, by Adults Surviving Child Abuse (ASCA),
a national organisation which advocates around the needs of adult survivors of child
abuse and neglect (ASCA, 2014).
Two Approaches Addressing Access to Services
Project AIR
Project AIR “aims to enhance treatment options for people with Personality Disorder …
[and] promotes a personality disorders-friendly health service” (Project Air Strategy for
Personality Disorders, 2013). Project AIR offers information and resources for health professionals and the public about personality disorders, training events, and complex case
review services. Project AIR publishes guidelines for evidence-based treatment such as
long-term psychotherapy (Grenyer, 2013; Project Air Strategy for Personality Disorders,
2012).
Project AIR attempts to raise awareness of BPD and its treatment in the community
and within human services, to reduce the stigma attached to BPD and to improve treatment outcomes. The Project was recently presented a Mental Health Matters award as
“an example of successful collaboration between institutes, local health districts and
community (families, carers, and consumers) to contribute to improved wellbeing of
people with personality disorders and their families” (Project Air Strategy for Personality
Disorders, 2014).
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However, Project AIR operates within the dominant psychiatric framework, which may
place limits around its ability to improve access to services for those diagnosed with BPD.
From a social work perspective, the disciplinary power of psychiatry is maintained
through the power of “expert” language to create “reality,” including through diagnostic
categorisation (e.g., American Psychiatric Association [APA], 2013; Fawcett, Weber, &
Wilson, 2012). There is a longstanding reluctance within the psychiatric framework to
reclassify BPD as “complex trauma,” despite evidence that the majority of those diagnosed
with BPD have a history of complex trauma, for example, “repeated extreme interpersonal
trauma resulting from adverse childhood events” (ASCA, 2012, p. xxviii). In the Project
AIR context, it is recognised that a history of complex trauma is found in 81% of patients
of Project AIR clinicians (Lewis & Grenyer, 2009). However these clinicians advocate
against a complex trauma etiology of BPD, arguing that trauma is one of many factors
that may lie behind BPD, and that BPD arises from a “combination of genetic inheritance
and life experience” (Project Air Strategy for Personality Disorders, 2012, pp. 5–6).
The “Guidelines”
The Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care
and Service Delivery (ASCA, 2012), recently published by Adults Surviving Child
Abuse, comes from a different theoretical frame to Project AIR. The Guidelines are
grounded in an understanding that most people with mental health diagnoses have a
complex trauma history, making it a public health issue. The Guidelines are an attempt
to change the structure and focus of services so that all services become trauma informed,
to address “the wider needs of those accessing support across a diversity of service settings”
(ASCA, 2012, pp. xxxiii, 88; MHCC, 2013; Wall & Quadara, 2014). The document also
contains extensive discussion of the current research in complex trauma, to inform
policy and practice.
The view of the Guidelines that BPD is complex trauma is highly contested. Judith
Herman was influential in suggesting that “BPD might be understood as a type of
complex post-traumatic stress disorder … deriving its characteristic features from one
form of adaptation to the traumatic environment” (Herman, 1997, p. 126). Importantly,
recognising the social context of mental illness, the use of the term “complex trauma” is
also suggested to be less stigmatising as it removes personal “defectiveness” (Herman,
1997; Lewis & Grenyer, 2009). There is limited support for traditional views of the development of BPD, and a growing number of studies that “indicate that severe childhood
trauma, neglect and loss are associated with later BPD” (Briere, 2004, p. 77; Ross, 2007;
Wall & Quadara, 2014); a history of complex trauma is found in more than 75% of the
cases of diagnosed BPD, a similar figure to the 81% cited in Project AIR (Chu, 1992;
Lewis & Grenyer, 2009). Those with most severe symptoms of complex trauma tend to
report high rates of child sexual abuse, particularly incest (Chu, 1992).
Even when there is an abundance of evidence that delineates the types and extent of abuses of
children and others in our society, even when the clinical syndromes experienced by such
abuse victims have been meticulously and repeatedly documented, and even when the
sorts of symptoms and phenomena encountered make perfect sense in light of the sorts of
trauma experienced and their duration, our mental health and child safety systems can
rebrand or invalidate to an extent that maintains collective silence. (ASCA, 2012, p. xi)
AUSTRALIAN SOCIAL WORK
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The Guidelines therefore are located in a rather different framework to Project AIR.
Rather than working narrowly within existing systems, the Guidelines suggest a radical
overhaul is needed. The difference is perhaps summarised by the concept of “what happened to you?” versus “what is wrong with you?” (ASCA, 2012; MHCC, 2013).
Critical Analysis
To critically analyse whether either the Guidelines, or changes within the existing paradigm, such as Project AIR, are likely to enhance service provision to people diagnosed
with BPD, it is necessary to look at the wider context of organisations, workers, political
context, and how they interrelate (Fawcett, Goodwin, Meagher, & Phillips, 2010). For
women diagnosed with BPD, who are often also experiencing IPV, it is recognised that
“stigma” and “fragmented services” are significant barriers to receiving service, and therefore an exploration of these issues is integral to evaluation of Project AIR and the Guidelines, but more importantly, to improving service for these women (Fanaian et al., 2013;
MHCA, 2005).
Stigma
Stigma is recognised as a constant, cumulative stress that can work against recovery
(Pilgrim, 2005; Rogers & Pilgrim, 2003). For people with a diagnosis of BPD, stigmatised
attitudes from service staff have significant impact on their ability to access services. The
relationship of clients with therapists is known to be the main influence on the efficacy of
any treatment provided (ASCA, 2012). Being believed and respected by staff is central to
engagement with services. It is well known that people with BPD can raise strong negative
reactions in staff, and the term BPD has a history of being used as “little more than a
sophisticated insult” (Herman, 1997, p. 123; Project Air Strategy for Personality Disorders,
2012). There are well-known, complex transference and countertransference issues in
complex trauma and BPD (Grenyer, 2012; Herman, 1997; Middleton & Higson, 2004).
Within the context of Australian mental health services, there are many documented
examples of the exclusion, shaming, and rejection of people with a diagnosis of BPD
(e.g., MHCA, 2005). It is significant that the first recommendation in the recently published Guidelines for Caring for People with BPD is for staff to “acknowledge that BPD
treatment is a legitimate use of healthcare services” (National Health and Medical
Research Council, 2013, p. 1).
However, the basis for reducing stigma within the existing psychiatric paradigm, as
exemplified in the Project AIR model, appears to rest solely in education about the treatability of BPD, and about the biological origins of the disorder (Grenyer, 2013; Lewis &
Grenyer, 2009). These seem to be fairly weak tools for reducing stigma when one considers
the extreme levels of stigma BPD holds in our society (MHCA, 2005). It has been
suggested that the BPD label has “an indwelling pathological permanence from which
one could not recover. These and other stigmatising labels, which offer no clear link
between abuse, trauma and a woman’s response, let alone the ecological context … may
result in highly inappropriate treatment” (Taft, 2003, p. 13).
Education about the biological and environmental determinants of BPD, as offered by
Project AIR for example, does not necessarily remove the stigma, as the “disorder” remains
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with the person. By contrast, reclassifying BPD as complex trauma “provides the basis for
a cooperative therapeutic alliance that normalizes and validates the survivor’s emotional
reactions to past events, while recognising that these reactions may be maladaptive in
the present” (Herman, 1997, p. 127). For example, it recognises that the “exquisite attunement to unconscious and nonverbal communication” of people with BPD (that may be
otherwise interpreted as difficult “hypersensitivity”) actually had “survival benefits” in
the context of ongoing childhood abuse (Herman, 1997, p. 139). Acknowledging that
the distressing symptoms come from complex trauma leaves the room open for recovery,
for the rebuilding of a sense of self, and of relationships with others (Herman, 1997). By
comparison, approaches that minimise the connection with trauma lose the opportunity
to powerfully address stigma as one of the implications of trauma (Herman, 1997). Despite
best intentions, it colludes with silencing forces that psychiatry exerts (Bracken & Thomas,
2001), both to individuals and to society as a whole. This can be seen as part of our
society’s efforts to dismiss the pervasive violence against women and children (ASCA,
2012).
Fragmented services
The “comorbidities” of BPD create barriers to service, because people with BPD frequently
have multiple “diagnoses,” and are moved between fragmented services, depending on
which “comorbidity” is causing greatest concern at the time (Najavits, 2002). From an ecological perspective (Heise, 1998), it could be suggested that these “comorbidities” are actually responses to unresolved trauma. Therefore it is inappropriate to treat these as
pathologies while not addressing the underlying trauma (Wall & Quadara, 2014).
However, policy and practice within Australian mental health systems, as well as wider
human services, remains structured around single diagnoses (ASCA, 2012; MHCC,
2013). This can be damaging rather than healing for those with BPD:
Experience is now known to impact brain structure and functioning, and in the relational
context of healing this includes experience of services. Neural integration is not assisted—
indeed is actively impeded—by unintegrated human services which are not only compartmentalised, but which lack basic trauma awareness. (ASCA, 2012, p. xxx, emphasis in original)
Our existing mental health paradigm does not provide a framework for these comorbidities
to be adequately addressed. For example, Project AIR is an isolated pilot project within an
existing health system (which in itself is somewhat symbolic of how those with BPD are
treated). This still leaves the responsibility for these issues with the patient, rather than
seeing them as adaptive coping mechanisms for dealing with the results of trauma.
From the above discussion, it is clear that the Guidelines, if adopted, are better placed to
improve service provision, not only for those with BPD but for all service users. Project AIR
is a positive step in raising awareness and attempting to educate about the treatment options
for BPD, which is important in increasing the likelihood that people will be offered appropriate services. However, it cannot effectively deal with either the stigma or how to best treat
the complex “comorbidities” which most people with BPD have. The Guidelines’ recognition of the social ecology surrounding service users enables both these issues to be
addressed (e.g., ASCA, 2012) and also allows it to promote collaboration and integration
of IPV issues, which is important, in view of revictimisation in adult relationships.
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Significantly, an ecological approach does not just treat IPV as yet another problem in the
chaotic relationship patterns of BPD. A number of examples of this will now be considered.
Implications: Trauma-informed Services and Intimate Partner Violence
The ecological basis of the Guidelines allows IPV to be integrated into the picture of what
is happening to the individual woman with BPD, while recognising the broader factors
including the suppression of the trauma narrative (Herman, 1997), and societal silencing
of women and children, including the coercion and control exerted by psychiatry (Bracken
& Thomas, 2001). To address the stigma of BPD, the complex trauma basis of BPD must
be recognised. To address the complex needs of those women with BPD and IPV, whose
needs are clearly not being met by existing fragmented services, collaborative, traumainformed services must be established. These are important reasons to implement the
Guidelines, to address the service needs of these women, including regarding IPV, and
to promote ongoing healing.
A significant benefit of services becoming trauma-informed is that staff members who
are trauma-informed will have a “high index of suspicion about partner abuse and other
forms of violence among women presenting with symptoms of trauma” (Taft, 2003, p. 20).
Being aware of the dynamics of revictimisation is imperative. They would also recognise
that services can, and often do, retraumatise women (ASCA, 2012), or “be unwittingly
drawn in to the abuser’s web of control, further harming the woman’s emotional self”
(Humphreys & Thiara, 2003; Taft, 2003, p. 1). Important to note here is that a diagnosis
of BPD can also follow IPV, as part of a victim-blaming response to IPV (Humphreys &
Thiara, 2003).
It is also important for an understanding of trauma to inform all services because it may
not always be clear that a complex trauma history is present for individuals, due to dissociation and amnesia, or due to reluctance to disclose (Taft, 2003). If services are not
trauma-informed, it can mean that “repeated victimization … patterns of current severe
relational disturbances … [and] a devalued and debased sense of self” are not recognised
as arising from trauma and the individual labelled as deviant or uncooperative (Chu, 1992,
p. 266; Herman, 1992).
In addition, trauma-informed services will be aware of effective treatment for trauma
patients. Therapy that works for those with post-traumatic stress disorder (PTSD) can
actually be harmful when used with complex trauma patients (Chu, 2010)—unfortunately,
misunderstanding this fact can cloud debate about the similarities between BPD and
complex trauma, when complex trauma is equated with PTSD (Lewis & Grenyer,
2009). Awareness of these differences is important so that staff do not prematurely
attempt to uncover abuse. The phase-oriented treatments indicated for treating
complex trauma emphasise establishing safety first, which can be a long process (Chu,
1992; Herman, 1997; Lewis & Grenyer, 2009). This has implications for many aspects
of service provision: for example, it can be retraumatising to uncover abuse in initial
assessment processes; and provisions must be made for longer-term therapy, to allow
time to establish safety first (Briere, 2004; Najavits, 2002; NHMRC, 2013; Project Air
Strategy for Personality Disorders, 2012).
Part of establishing safety is to ensure safety planning for situations of IPV, and collaboration between mental health and IPV services must be established for this reason. It has
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been pointed out that inpatient mental health treatment plans rarely integrate reference to
any abuse documented in the treatment notes (Howard et al., 2010). There is also an
imperative for mental health workers to be aware of safety planning, in order to assist
women to translate new skills (e.g., communication skills) into their relationships in a
safe way (e.g., Davies, 1998). For example, psychoeducational groups to improve communication and assertiveness skills of women with BPD should also work through the
safety implications of this in violent relationships.
Outside of the health and IPV services arena, there are other organisations, such as judicial and statutory bodies, which have significant impact on women with complex trauma
histories. These also need to be trauma-informed, and informed about IPV (Hunter,
2006). Those with a diagnosis of BPD may be blamed for IPV, or silenced if the emphasis
by police or in court