The Borderline Patient Who Wants to Stop
A 27-year-old man with borderline personality disorder and a history of two suicide attempts (one by overdose 14 months ago) has been in weekly therapy for 6 months. He arrives saying he has decided to stop all treatment, has been cutting his forearm daily for a week, and states, 'I have a plan this time and I've picked the date - I'm not telling you when.' He refuses to sign a safety plan, says he will not go to the ER, and adds that he has been drinking heavily. He is currently intoxicated (slurred speech, unsteady gait). He lives alone; his only contact is an ex-partner who has asked not to be contacted. His therapist is in solo private practice with no on-call coverage.
1. What is the immediate risk formulation and what actions must the therapist take in this session?
Read the worked answer
This is high acute risk: recent self-harm, a stated plan and date, intoxication (a disinhibitor and independent risk factor), refusal of safety planning, social isolation, and loss of the therapeutic alliance. The therapist cannot rely on outpatient management alone.
Immediate actions: (1) Do not let him leave while acutely intoxicated and refusing safety measures - assess capacity and medical stability; intoxication may warrant a medical evaluation for the self-harm and alcohol. (2) Call emergency services or arrange emergency psychiatric evaluation; in most U.S. jurisdictions, imminent risk with a plan permits emergency detention or a crisis evaluation, though the therapist should follow local law and consult. (3) Contact the ex-partner only if permitted by law and clinically necessary to prevent harm - generally a last resort, and document the rationale. (4) Do not attempt to 'contract for safety' - safety contracts are not evidence-based and are contraindicated here. (5) Document contemporaneously: statements, plan, intoxication, refusal, actions taken, consultations.
The core judgment: refusal of treatment does not eliminate the duty to act on imminent risk. The therapist's solo status increases, not decreases, the obligation to escalate.
2. The therapist is in solo practice with no on-call coverage. What should happen to the treatment frame going forward if the patient survives and returns?
Read the worked answer
The solo, no-coverage arrangement is itself a risk-management and ethical problem for a patient with recurrent suicidality. Options: (a) arrange formal after-hours coverage (a colleague, a crisis line with a documented agreement, or a covering service); (b) refer to a program with 24/7 access (e.g., DBT with phone coaching) if the patient needs that level; (c) if neither is possible, discuss limits honestly and facilitate transfer.
If he returns: re-engage, re-assess, and consider a higher level of care. Do not simply resume weekly therapy as if nothing happened. Document the coverage plan and any referral. This tests Domain 6 (risk management) and Domain 2 (treatment planning): the level of care must match the risk, and the clinician's practice infrastructure is part of the standard of care.