- fear of hospitalization
- uncertainty about whether or not they will attempt suicide
- desire to conceal a planned suicide attempt.
Hospitalize for suicidality?
If possible, consult with other professionals when making difficult decisions about hospitalizing a patient. These decisions often are subjective and open to influence by therapists’ emotional reactions. Psychotherapies for BPD emphasize the importance of consulting with other clinicians when working with this population. DBT requires a therapist consultation meeting, and cognitive therapies also have recommended consultation.18-20
If you work alone in private practice, consider consulting by phone with colleagues experienced with working with BPD patients. Document this consultation to help protect yourself from liability should an adverse outcome occur.
Little evidence supports hospitalization as an effective treatment for suicidality in BPD.24 It has been argued that hospitalization might increase future suicidal behavior when the patient perceives it as a positive experience or a means of escaping problems.18 The patient’s safety must remain a top priority, however, and we recommend admission if the patient is in imminent danger or has engaged in self-injurious behavior requiring medical attention.
The length of a hospital stay should be determined on a case-by-case basis. In general, it has been recommended that hospitalization for BPD patients be crisis-oriented and brief to avoid reinforcing suicidal behavior and to promote coping with suicidality in the natural environment.18,24 Also take into account acute exacerbation of comorbid Axis I diagnoses when determining the duration of hospitalization.
‘No-suicide’ contracts. Be careful not to rely on “no-suicide” contracts. They have no legal standing and may give you a false sense of security. Clearly, a patient may attempt suicide despite promising not to do so.
Asking if the patient can commit to staying safe for a specified time can be useful in assessing his/her level of suicidality and motivation to behave safely, but this is no substitute for a thorough clinical evaluation. Consider increasing the level of care and degree of monitoring or hospitalization if other suicide risk factors are elevated, even if the patient has “contracted for safety.”
Validated psychotherapies
Psychotherapy is the primary treatment for BPD, according to American Psychiatric Association (APA) guidelines.1 DBT,21-22 transference-focused therapy,25 and mentalization-based therapy26 are 3 validated psychotherapeutic approaches for BPD that have been shown to reduce suicide attempt rates in randomized clinical trials (RCTs). DBT has the greatest number of RCTs supporting its efficacy. We advise clinicians who work frequently with BPD patients to become familiar with these effective, empirical treatments.
A recent open trial of cognitive therapy for BPD demonstrated a decrease in self-harm behaviors.27 Cognitive therapy for recent suicide attempters—including those with BPD—decreased subsequent suicide attempts by approximately 50% over 18 months of follow-up in a RCT.28
Target suicidality. For all patients with a recent suicide attempt, make suicidal behavior the primary treatment target.18-20 Work with the patient on skills to reduce suicidal behavior, rather than assuming the behavior will resolve after you treat the psychiatric disorder (such as depression or BPD).
Throughout treatment, make suicidality or NSIB the priority in sessions whenever it occurs.18 This ensures that self-harm behavior is adequately addressed and provides an aversive consequence for this behavior. The patient cannot talk about other topics he/she might want to discuss until the suicidal behavior is addressed.18
Also target risk factors for suicidal behavior, such as depression, hopelessness, substance abuse, impulsivity, affective instability, social adjustment, and social problem-solving skills.
Teach coping skills. Because suicide attempts and NSIB in BPD often occur as maladaptive means of coping with distress, teach your patient alternatives such as distraction and self-soothing techniques, relaxation, positive self-statements, problem-solving skills, and how to use social support.18-20 The patient is likely to be flooded with affect when suicidal, so teach simple, easy-to-perform coping skills. Because self-harm behaviors in BPD patients often occur impulsively, create a written safety plan in advance. A “hope kit” can be an extremely useful part of the safety plan ( Box 2 ).18,18,27