Patient safety of the borderline personality on the crisis unit.
Subject: Borderline personality disorder (Diagnosis)
Borderline personality disorder (Care and treatment)
Health care industry (Quality management)
Patients (Care and treatment)
Patients (Health aspects)
Patients (Analysis)
Author: Mead, Robert, Jr.
Pub Date: 09/22/2010
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Fall, 2010 Source Volume: 13 Source Issue: 3
Topic: Event Code: 353 Product quality Computer Subject: Health care industry
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 242897540

As mental health professionals, when we hear the diagnosis of borderline personality disorder, it is enough to make us shudder. That particular diagnosis can feel like the kiss of death to those who work with the mentally ill population. We are aware that those with borderline personality disorder can be like emotional vampires, draining every ounce of emotion from the provider before leaving the husk and moving on to the next individual. They are very manipulative, drain resources to an alarming degree, and are frequently successful at suicide, with women attempting to harm themselves up to three times more often than men (Sneed, Balestri, & Belfi, 2003).

It is estimated that approximately 19% of psychiatric inpatients meet the criteria for borderline personality disorder, with a high disproportionate rate of emergency room utilization (Marshall & Serin, 1997). They are usually well known in the local emergency rooms, and more often than not when they are coming into the inpatient unit, or the crisis unit, it is due to a serious attempt at harming themselves in any number of ways. They are adept at using sharp objects or even plastic to cut any body part they can reach. They may bite or scalp themselves or attempt an overdose on medications mixed with alcohol or street substances. A determined borderline patient may insert pencils, or any other object he can get hold of, into body orifices so that he can continue with the self-injurious behavior on the inpatient unit.

This type of individual presents many problems on a crisis unit that will need to be dealt with in order to provide a sense of safety and structure to the inpatient unit. The following recommendations are just that: recommendations that this writer has found effective on an inpatient unit, based on studies showing how dialectical behavior therapy has been successfully utilized for treatment of borderline personality disorder (see Linehan, 1993; Sneed, Balestri, and Belfi, 2003; and Paris, 2008 for a more complete review). All of the treatment modalities are geared toward California law.

After working in a crisis unit for an extended period of time, you will become familiar with the more extreme borderline patients and hopefully will have built up some kind of rapport with them. Once you have established a rapport, you will know how best to approach an individual patient when he or she begins to act out.

For example, one patient has a history of hiding razors or pieces of razors in her vagina, bra, or panties. When left alone, she will cut and later be found bleeding out on the floor of the bathroom or bedroom. For this individual, the standard procedure when she is brought into the crisis unit is to be strip-searched by female staff and scanned with a handheld metal detector. Her clothes are taken away, and she is given hospital-issue gowns and panties. One staff member is assigned to watch her.

Having worked with this individual extensively, I can almost predict when she will begin to choke and/or bite herself. This will result in her being placed in automatic 5-point restraints and given IM emergent medications. I have found that while she is restrained, if I keep up a running commentary to her, pointing out that she will only act like this when she and her teenage daughter are having difficulties, and maintain eye contact with her, she will usually slow down enough to allow the medications to work and get some sleep. By doing this, I am building trust with her, empathizing with her, and laying the foundation for further psychotherapy in the near future. Linehan discusses the six levels of validation, the first being listening and observing, then proceeding through the other five levels of validation: accurate reflection, interpretation, causes of behavior, empathy and finally, radical genuineness (Sneed, Balestri, and Belfi, 2003).

After she has had some sleep, I begin the process of contracting with her to remove the restraints from one body part at a time in 20-minute intervals, with the caveat that if she does anything that can be construed as self-injurious behavior, the 5 points go back on and we start over. Of course, she will test, and I have to be consistent with what I say. After her second visit to our crisis unit, she has become compliant and will work her way out of the restraints with minimal problems. This process demonstrates to her, first, that someone does care; second, that she is in a safe environment; and third, that she can make good choices regarding her behavior. This technique has been used with both male and female borderline patients, regardless of the severity of their behavior.

The primary goal is to teach these patients that the behavior cannot be tolerated; that they can be and will be held accountable for their behavior; and that they can make better choices as to how to deal with what, to them, are overwhelming emotions and a sense of abandonment.

Returning to our female patient: once she has contracted out of the restraints, she is given a one-to-one mental health worker, chosen specifically to work with the patient and keep that consistency going. With this arrangement, the patient cannot staff split or create chaos on the unit and will get the undivided attention that he or she is so desperately seeking. If necessary, until she can completely contract out of restraints, walking restraints may be called for. Once the patient can verbalize that she can be trusted with the removal, the 20-minute rule applies. The patient is then monitored during showers and given finger foods so that she has no access to plastic utensils until she can prove she is trustworthy.

In working with this population, I have found that by showing them I am consistent in what I say, and following through with what I say will happen, I also give them the chance to build trust with me by allowing them to show that I can trust them as well. When speaking with them, especially in the beginning, I am careful to use all the tools available to me as a therapist: tone of voice, speaking about expectations, setting the tone for them to make choices, and assisting them if they are unable to make those decisions.

It is also important, and I cannot emphasize this enough, to have the team on the crisis unit follow my lead in dealing with the situation--from the moment the patient walks through the door, to the application of restraints, to talking with the patient while he or she is in the restraints--as well as having the psychiatrist on board with what I am doing and why. The staff members are generally appreciative when they do not have to respond to the crisis, and there is a tendency on people's part to overreact to the patient's behavior.

A male borderline took great delight in shocking workers by inserting pencils into his abdomen, leaving only a small portion showing. He would walk up to the counter and show the unsuspecting staffers, who reacted exactly as he wanted, screaming and showing disgust. This individual fully admitted that he did it because it gave him a thrill, as well as "proving" he was crazy so that he could manipulate his way into a state hospital.

If you can get a thorough history on the patient, it is very helpful when dealing with them psychotherapeutically. The aforementioned male borderline patient was a very interesting case with his history and quite articulate in what he wanted to do and why he did it. I have found most self-injurious borderlines are bright and, for the most part, willing to work on their issues. Expect an increase in behavior like a child will do until they are able to integrate the work they are doing into new behaviors. The female patient discussed earlier has actually decreased her inpatient stay in crisis from what was every other day to having an almost 4-month break in admissions.

In conclusion, the main goals of this type of intervention are multipurpose. There is the need to establish safety for the patient and the staff involved in treating this type of patient, as well as the safety of milieu. This is accomplished by establishing rapport with the patient, being very clear with boundaries of both the person and the unit, and engaging the patient in his own treatment. By having patients become responsible for their behavior, they are now actively engaging in their own treatment, whether they acknowledge this fact or not. Giving them clear choices, a specific time frame for making that decision, and--a very key point here--following through with what you, as the clinician, have stated will go a long way in having the buy-in of the patients in regard to their treatment. It is mixing behavior modification principles with psychotherapeutic principles to create change and empower the patient as well as beginning the process of retraining their thinking that they can take with them when they go to an outpatient clinic.


Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: The Guilford Press. Retrieved January 24, 2010 from

Marshall, W. & Serin, R. (1997). Personality disorders. In Sm.M. Turner & R. Hersen (Eds.), Adult psychopathology and diagnosis (3rd ed.) (pp. 508-543). Hoboken, NJ: John Wiley & Sons, Inc.

Paris, J. (2008). Treatment of borderline personality disorder: a guide to evidence-based practice. New York: The Guilford Press.

Sneed, J. R., Balestri, M., & Belfi, B. J. (2003). The use of dialectical behavior therapy strategies in the psychiatric emergency room. Psychotherapy: Theory, Research, Practice, Training, 40, 265-277. doi: 10.1037/0033-3204.40.4.265

By Robert Mead, Jr.

LMFT, BCPC, DAPA, doctoral intern

ROBERT MEAD, Jr. has been working in the field of inpatient/outpatient psychotherapy for the past 20 years. He is a licensed MFT and is currently finishing up his hours as a doctoral intern. Mead has extensive history in working with children, child protective services, adjudicated sex offenders, adolescents and adults, inpatient hospitals-adults, crisis units-children and adults, and is currently working with wards in a juvenile facility. Due to budget constraints in the county where he works, he is now being transferred back to a outpatient clinic.
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