How to Avoid Psychiatric Hospitalization When a Client with Borderline Personality Disorder Threatens Suicide |

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How to Avoid Psychiatric Hospitalization When a Client with Borderline Personality Disorder Threatens Suicide

How to Avoid Psychiatric Hospitalization When a Client with Borderline Personality Disorder Threatens Suicide

By David Allen, MD

Clients with borderline personality disorder (BPD) are notorious for suicide threats and gestures. They are also pros at making therapists feel panicky, helpless, and incompetent. No studies show that psychiatric hospitalization reduces the overall BPD suicide rate. In fact, clients often regress there. About 10 percent will eventually commit suicide, but the ratio of threats to actual suicides is quite low. Hospitalization should be a last resort.

Considerations you may not have been taught in training:

  1. The statement “I’m thinking about suicide” is rarely a threat. Such clients think about suicide a lot, without any specific intent or plan. They are supposed to be discussing that in therapy.
  2. If the client is vague about what they might do, that usually means they probably won’t act on a threat. Examples are statements such as “I might just not be around by our next appointment” or “I’ll probably do it at some point, and you can’t stop me!”
  3. If the client’s tone of voice sounds like a child teasing “Nyah, nyah, you can’t make me,” or if they say, “You don’t really care about me,” you can generally relax.

How to respond:

  1. The fallback intervention is a paradoxical offer to hospitalize. You can only use it occasionally, but you can refer back to it with “Remember what I told you?” The aim is to avoid the hospital. Say, “If you’re really going to do that, you need to be in the hospital, but only for your own protection. I’m worried that you will feel even worse if you are put in with a group of psychotic patients.”
  2. If they answer with “I guess I’ll be alright” in a non-reassuring tone of voice, listen to the words and not the tone. Reply, “Good, then let’s go on with what we were doing.” If they say they think they will commit suicide, go ahead and make arrangements. Usually, the intervention still leads to a short hospitalization. Be prepared for the possibility that they won’t show up. Later you may hear, “I felt better after I spoke with you.” Don’t get angry for having wasted your time. Instead, be thankful. Your intervention succeeded!
  3. The answer to “You don’t care about me” is “I wish there were some way I could prove that I do.”

Book Titles: Coping with Critical, Demanding, and Dysfunctional Parents

coping with critical, demanding, and dysfunctional parentsDavid M. Allen, MD, is professor emeritus of psychiatry and former director of psychiatric residency training at the University of Tennessee Health Science Center in Memphis, TN. He is author of How Dysfunctional Families Spur Mental Disorders.


I have BPD, I have a history of inpatient and emergency room care, as well as a history with outpatient care (CBT/DBT). I think the conundrum that many with BPD face is that there is so much pain associated with fear of abandonment, even if a threat is associated with trying to manipulate a situation such as prevent an abandonment it should be treated seriously. I've certainly made vague allusions to not being around, and then did actually make an attempt.

The other problem is that emergency rooms are traumatizing for people like us, and inpatient care is more an opportunity to regress and fall into impossible financial situations, which could perhaps increase interpersonal stress has as well. So while people with BPD are perhaps the biggest risk for suicide, the primary mechanism our society has ultimately an exacerbating impact and makes it less likely they will engage in those services when they should. BPD patients don't need more and more meds, we need consistent DBT and hospitalizations interrupt that essential care.

There are a handful of inpatient centers which are actually equipped to help those with BPD. But those are only for the wealthy, if you are a working class BPD, you have to avoid inpatient as much as you can. Which leaves people with BPD in an increasingly dangerous position. Society is leaving people like us people, we are not understood and we are demeaned and treated like children (honestly offended by some of the tone of this article). Just because you are hearing our problems, does not mean you can understand where a person is coming from when they talk about wishing to die. Try to empathize, but know that won't be enough. Don't base your thoughts on their safety based upon vague interpretations of statements, have a solid safety plan. Lament that our inpatient care for the mentally ill is totally screwed up, which requires that you use the threat of hospitalization as such an effective stick.