Academic journal article American Journal of Psychotherapy

Patients with Borderline Personality Disorder Who Are Chronically Suicidal: Therapeutic Alliance and Therapeutic Limits

Academic journal article American Journal of Psychotherapy

Patients with Borderline Personality Disorder Who Are Chronically Suicidal: Therapeutic Alliance and Therapeutic Limits

Article excerpt

Therapeutic work with patients who are chronically suicidal and have borderline personality disorder (BPD) is challenging, and clinicians often resort to setting firm limits or excessively cautious interventions in efforts to prevent manipulation, regression, or over-dependence. Litigation and malpractice fears reinforce these stances, and reduced compensation for additional time and energy devoted to patients adds further disincentives to sole providers. However, elements of the working alliance and therapeutic limits are within the therapist's control. A case vignette illustrates an individual therapist's modification of usual therapeutic limits while working with a chronically suicidal patient with BPD within a dialectical behavior therapy (DBT) framework over a 16-week period. Discussions regarding the case, interventions used, DBT, and legality concerns follow.

KEYWORDS: Borderline Personality Disorder; suicide; phone coaching; therapeutic alliance

INTRODUCTION

Clinicians are often warned about therapeutic work with patients who have personality disorders, particularly patients who are chronically suicidal and have borderline personality disorder (BPD). We are cautioned that certain boundaries and clear parameters must be established in order to prevent calamity. This may include "setting clear limits," such as adhering to strict payment and scheduling policies or practicing complete lack of personal disclosure. These measures provide unwavering and consistent messages to patients, limiting interaction to time-limited and focused intervals to prevent regression and overdependence. Litigation and malpractice are additional real-world fears reinforcing these stances. Furthermore, therapists face pressures from third-party payers and are awarded reduced, if any, compensation for additional time devoted to patients. These variables-complex psychopathology, poor reimbursement, and a legal culture of caution-support the splintering of services and prevent sole providers from engaging in comprehensive care of chronically suicidal BPD patients. As such, it seems the days are dwindling for therapists in private practice to single-handedly manage patients who repeatedly self-injure and wish for death.

This shiftseems inevitable as standards of care change; interdisciplinary approaches, including dialectical behavior therapy (DBT), are increasingly popular. However, the manner in which individual therapists approach such complex patients remains relevant as DBT and other multipronged approaches may not be readily available to certain patients or in particular regions. The following case vignette illustrates an individual therapist's modification of usual therapeutic limits within a DBT framework while working with a chronically suicidal BPD patient. Discussion regarding the case and interventions follows.

CLINICAL VIGNETTE

Mrs. A1 was in her late 30s, residing in a suburban home with her husband (of nearly 20 years) and three children. At the time of treatment, she was employed full time in a healthcare setting. She was voluntarily admitted to an inpatient psychiatric unit after an overdose of 69 tablets of her antihypertensive (hydrochlorothiazide) medication. According to Mrs. A, this ingestion was intended to end her life and it had occurred within the context of her upcoming birthday and her husband's attempt to leave her. Her admission was facilitated by a mobile outreach team that she called one day after she ingested the pills; when she realized she did not die, she feared she may have caused irreversible organ damage. There were no medical consequences to the ingestion and she was cleared for psychiatric evaluation.

During initial evaluations Mrs. A was described as cooperative but guarded and less than elaborative. History revealed that for several months she had experienced low mood, poor energy, impaired sleep, feelings of hopelessness and helplessness, social withdrawal, irritability, and multiple instances of suicidal ideation, with plans and intent to overdose on medication. …

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