The Borderline Who Cried Wolf

I recently spent three days in "Crisis Respite" at the hospital. While there, I saw something disturbing--security escorting a patient out of the psychiatric extended observation unit. Due to the confined space and raised voices, I saw a great deal of the drama.

This patient, who may or may not have borderline personality disorder (BPD), refused to follow the program rules. She refused all offers of placement in a halfway house. She even called the suicide hotline, repeatedly saying "They're going to discharge me even though they know I'm going to take my life when I leave here."

Staff called security, who escorted the woman off the unit for her discharge.

Where should one draw the line?

I've mentally replayed this incident several times. I want to believe staff knew what they were doing. But was it the right thing to do? I don't know.

In the staff's defense, she wouldn't follow program rules or accept help. She'd been evaluated by two psychiatrists, including one who is an expert in BPD--they'd recommended discharge. What more could the staff have done?

However, the situation brought back memories. When I was a patient at Richmond State Hospital in Richmond, Ind., I went through a severe suicidal crisis. The staff ignored me, as well as multiple other patients and my mother. After I recovered from the attempt, the psychiatrist explained "We had another borderline here, and every other word out of her mouth was 'suicide', so we assumed you were the same way."

On very rare occasions, a person will fake a suicidal crisis, and in these rare occasions BPD is almost always a factor. However, Suicide Prevention 101 teaches "Never take a suicide threat lightly." Where should the mental health system draw the line?

The case for automatic hospitalization

We can argue that all suicide threats result in immediate hospitalization. That's basically what the law is now. Psychiatrists are human and make mistakes, but a human life is too great a gamble.

It's a myth that someone talking about suicide won't do it. That's why mental health professionals are trained to take all talk of suicide seriously. Individuals in a suicidal crisis are the psychiatric equivalent of a person with crushing chest pain and difficulty breathing: there's a chance it's not anything serious, but the symptoms should be treated as life-threatening until proven otherwise.

The case for physician discretion

People with BPD are often considered manipulative. Although rare--I've run into only two people who've exaggerated their symptoms--it does happen. While not all people with BPD do this, almost all people who do this have a diagnosis of BPD.

When I was a patient on the borderline unit at LaRue D. Carter Memorial Hospital in Indianapolis, staff were trained to triage our distress levels. While all threats of self-harm were taken seriously, our baseline was used to determine symptom severity.

For example, Patient N often self-reported her distress level as 8 out of 10. As long as it was at that, she was treated as distressed but not in imminent danger. Patient B, whose distress level averaged around 4, was treated as in severe danger when she self-reported a distress level of 8.

Staff knew our history and had special training in working with patients with BPD. They used discretion to determine which patient needed what protective measures.

A no-win situation

The mental health system has limited resources. Treatment should go to those most in need. How that is determined, however, is difficult. The system risks overextending if all threats result in immediate hospitalization. However, when human life is at stake, we can not ethically deny treatment just because of an extremely rare chance someone might be faking.

It's a classic no-win situation. What should we as a society do?