Using this model of suicide risk assessment, Anita clearly demonstrated an acute-on-chronic risk for suicide, as indicated by high levels of hopelessness, recent alcohol(Drug information on alcohol) and drug abuse, recent discharge from hospital, several recent negative life events, and a perception that her support system had given up on her. If the patient is at an elevated risk, the next question is whether hospitalization will be helpful or harmful. When considering this question for Anita, we suggest that you consider some common myths about admitting the patient with BPD.
Myth 1: Hospitalization is never useful for patients with borderline personality disorder. Hospitalizations and multiple service contacts are part of the expected course of this disorder (Bender et al., 2001; Zanarini et al., 2004). It would be fallacious to argue that patients with BPD should never be hospitalized. There is little empirical evidence about whether hospitalization prevents suicide for these or any other patients at risk, and such tenets are difficult to prove primarily because suicide is a rare outcome.
Myth 2: Patients with BPD will regress during their inpatient stay. With the reality of only brief hospitalizations, patients who show disruptive and unsafe behaviors, including self-harm behaviors, during an inpatient stay are likely continuing in a long-standing pattern of impulsive aggressiveness rather than regressing to behaviors not typical of their repertoire (Boggild et al., 2004). Patients with few external sources of support or those without housing are at increased risk for disruptive behavior during a hospitalization (Boggild et al., 2004). Patients with BPD may be disruptive and demonstrate unsafe behavior during a hospitalization. However, being disruptive does not necessarily mean that these patients have not derived benefit from their inpatient stay. Discussions of personal safety as a mutual responsibility for the patient, other patients and staff should be an integral part of therapy, both in and out of the hospital.
Myth 3: The patient's crisis has to do with their doctor being "fed up" with them. Countertransferential and transferential problems are characteristic of therapy, and it is to be expected that such issues will lead to crises and presentations to the emergency department. Crisis services and hospital inpatient services can have an important and sometimes life-saving role in resolving or attenuating these crises.
Anita was admitted to the hospital for a few days. Rather than perceiving her admission as a therapeutic setback, we noted that this presentation was one of the only times she had presented without first cutting herself deeply. Her story is continuing, but she is alive and still insisting on our help and understanding.