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.”

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David 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.