Objective 1: To enhance our knowledge of the contributing factors which led

Personality Disorder (BPD).

A small minority of individuals with BPD are the subject of a guardianship order. What has set the individuals in this study apart from those individuals that have a BPD diagnosis but do not have a corresponding guardianship order? Anecdotal evidence from both OPA guardians and findings from this study suggested that three factors contributed to a guardianship order. The first is the level of self-harm in which the person engaged; the second is the corresponding effects these behaviours had on others such as carers, and hospital staff for example; and the third factor is the apparent inability of the person to accept care and/or medical interventions afforded them. These factors possibly supported the applicant’s belief that an independent guardian was required.

Suspecting that the level of self-harm and its corresponding effects on others might prove a significant contributing factor to an application being brought to VCAT, I rated each participant on a 10-point rating (where 1 signified “no self-harm” and 10 “extreme self-harm”). Because of the need to safe guard confidentiality I relied on my supervisor also to examine all information with regard to each participant. Her ratings and mine never differed by more than 1 point.

Table 2.

Summary of Effect of Self-Harm and Guardianship Orders

As indicated in Table 2 all participants expressed a desire to kill themselves and engaged in extreme self-injurious behaviours. The extent to which each participant engaged in self-harm and its effects on others is briefly described.

3.11 Case 1 (Joe):

Joe rated a high level, seven, on the level of self-harm and slightly higher, eight, on the corresponding effect on others.

Joe engaged in illicit drug use, and frequently severely slashed himself. Upon self-presentation or after transportation by others (often the police intervened as Joe’s public acts of self-harm engendered feelings of helplessness in others) to the hospital department, Joe would discharge

Score out of Ten

Case No. Pseudonym Level of Self Harm

Effect on Others No. Guardianship Orders 1 Joe 7 8 1 2 Jane 10 10 3 3 Bill 9 10 2 4 Dave 9 9 4 5 Chris 9 9 2 6 Nigel 10 10 4 7 Andre 10 10 3

himself without receiving the recommended medical treatment. Conversely, Joe accepted medical treatment but continued to slash himself in the emergency department or hospital car park with whatever implement he could find. With regard to his effect on carers or others, on one quite infamous occasion at a Magistrates’ Court hearing (and without any apparent warning), Joe became violent, upturned and destroyed court furniture. Jagged pieces of furniture were then used as tools to engage in acts of self-harm within the courtroom. The courtroom was subsequently cleared and police were again used to transport Joe to hospital. As was so often the case, all present were reportedly quite traumatized at what they had witnessed.

3.12 Case 2 (Jane):

Jane demonstrated extreme levels of both self-injurious behaviours, and its effects on others with a score of ten on each rating.

Jane displayed extreme levels of self-harm including: self cannibalization of forearms leading to exposure of tissues and muscle, insertion of foreign objects into self that is, wire and biros into urethra, fish hooks into vagina, super gluing of eyes, and slashing of face and arms. The majority of these acts required surgical removals and or medical interventions. Not only were many of these acts of self-harm in front of others, but also on occasions Jane also threatened staff at hospitals with her infected blood etc. Thus Jane presented an ongoing risk to the Hospital Accident and Emergency (A & E) Departments’ staff.

3.13 Case 3 (Bill):

Bill rated a very high score of nine on the level of self harm and received a score of ten, on the effect on others.

Bill engaged in significant acts of self harm. He regularly violently threw himself to the ground and head butted the concrete. As a consequence, he endured fractured collar-bones, sub-dural haemorrhages, and retinal

detachments. In addition, to self-harming in front of others, Bill was also extremely violent to his fellow residents where he resided.

3.14 Case 4 (Dave):

Dave received a very high score of nine on both the level of self-harm and the effect on others rating.

Dave was also a diabetic. Following surgery for an appendectomy, he inserted foreign objects into his wound, which resulted in wound contamination. He was subsequently non compliant with the prescribed antibiotics and continued to interfere with his wound, such as the insertion of bark, razor blades etc. Dave also swallowed glass, damaged his eyes with applications of household chemicals, and was non compliant with recommended treatments. Dave would also regularly self-harm in front of others, and threatened those with whom he resided by lighting fires. Furthermore, he made physical and indeed homicidal threats to staff at a rural A & E Dept.

3.15 Case 5 (Chris):

Chris also rated a very high score of nine on both the level of self-harm and effect on others rating.

Chris was also an insulin dependent diabetic, and his treatment required careful management and daily monitoring. He engaged in the denial of food and water, and regularly overdosed on his insulin. Chris provided false Blood Sugar Level (BSL) measurements to his carers, and often refused to follow an adequate diet. He engaged in extreme self-neglect, which resulted in amputations of some of his extremities. Although not physically violent to others, Chris inflicted significant psychological trauma on his carers, as on occasions they found him unconscious in his unit due to his self-neglect and abuse.