I am calling this borderline patient client one to protect identity. ‘Client-One’ refers to the fact that she is perhaps our most prominent client. This note addresses two concerns. The first is placement on 1:1 staffing. There are two aspects of this concern. Who should do the 1:1 and should there be a 1:1? Star security had been providing 1:1 (street clothes.) Further, how should the 1:1 be done (given the decision to 1:1.) Perhaps, the 1:1 should be ‘loose.’ However, given the non-risk taking approach that seems to be desired, I have formulated a protocol that addresses ‘no-risk.’ The concern appears to require immediate address but is not particularly interesting. The second concern is long term treatment. This is the more interesting aspect of this note

Staffing for One-One Observation

Problem

Has been creating difficulties with scheduling, creating problems on floor when experienced staff are engaged in 1:1 (including diminished attention / care for other patients,) will result in staff burnout (signs are already present; in past years there had been severe burnout; star does not face this since they have no other duties and do not have limit setting or therapeutic roles).

Observation

The problem with 1:1 staff has not been the fault of the star. The problems seem to be (1) How meds are given, (2) Protocol (1:1 during shower and restroom visits had not been set up,) (3) Inadequate training / instruction of star (star not told that they need to follow client to nursing station or wherever she goes).

Solution

Meds crushed; must have female 1:1 for shower, restroom.

Write up protocol and orient every 1:1 (including nurses) each shift.

Problem—In the past, client has deceived staff

Client is cunning (apparently with volition) and even states she enjoys deceiving us. (Her behavior appears to improve at times but she has not demonstrated that full trust can be placed in what she says in any circumstances.) In the past when SV staff has been 1:1 they have been deceived and client has cut, made ropes etc. even when monitored by SV staff. Therefore, everyone (star, staff) is being placed at risk by having them do 1:1; this is because the approach focuses on preventing acting out instead of preventing / removing access to materials. We are engaged in risk avoidance, not in problem solving. The current situation may be seen as splitting at all levels (this statement need not be in the final version).

Concern

Do we really want to give this client huge amounts of attention? Is it helping her improve? From time to time there is apparent improvement but I don’t see any permanent improvement. Is the attention itself part of the problem? What if she were not on 1:1? She has not so far ever actually carried out a suicide attempt / gesture to completion on the unit or in the community. She invariably asks for help. Not having her on 1:1 runs the risk that the attempt / gesture might be successful but is, perhaps, among other interventions or diminished intervention, the path to health or, at least, to the solution of the intense problem of this client.

Solution

This solution ignores the concern (reasons already stated) and focuses on the risk. It is to do a room search and complete search every shift and as needed while the client is on 1:1 with star (or staff) as available; schedule rotation of 1:1’s to minimize burnout.

Some Afterthoughts

This client continues to split – with and without intent; continues to contribute to staff burnout; continues to drain resources away from other clients; continues to be a huge drain on resources; continues to hold us captive.

Question

Is she holding us captive? Are we letting ourselves be held captive?

Solution 1. Attitude Adjustment by Staff

Problem: of course an attitude adjustment might help individual staff; however, not every staff member has the ability to do this; counter-transference issues have traditionally been held to require training. Therefore to suggest this as a solution is to ignore the problem of staff burnout.

Solution 2. Training

Minimal training would involve (1) insight into the nature of the personality disorder (staff who become the most burnt out appear to be those who have empathy and also expect the personality disordered client to behave normally; note that I am here talking of general burnout and not of the issue of 1:1 staffing,) (2) achieving a better balance between involvement and disengagement.

Client-One and Borderline Personality Disorder

Long Term Prospect and Concern

The main purpose of this section is to assess the prospect of the particular client and to see how the prospect of BPD clients in general may be assessed. The conclusions are stated at the end of this section. Along the way, a variety of treatments is considered; it is not the objective to be final or complete with regard to the treatments; their consideration, though of independent interest, is subservient to the primary function. A more complete review of the treatments and their indications will be taken up later.

This particular client has been diagnosed with Borderline Personality Disorder. However, there appears to be a layer of willful behavior that suggests Antisocial traits; additionally, from time to time Avoidant and Negativistic traits appear to manifest. These comments are not intended as diagnostic; the intent is to underline the difficulty of treating the client. The client is intelligent and this has been seen as contributing to the therapy defeating behavior and the consequent consumption of personnel and economic resources.

The client continues to consume resources without any apparent progress. We have been hesitant to consider more expensive but short term solutions or to take a risk and in doing so we have, perhaps, been abandoning our responsibility to the client (in perpetuating her condition,) to the community (especially other clients,) and to ourselves.

The consideration of solution ideas that follows has two objectives, (1) as a source of ideas and, more importantly, (2) as preliminary to an assessment of a good long term plan.

Solution ideas

Dialectical Behavior Therapy

Dialectical behavior therapy is a form of cognitive-behavioral therapy. There are a number of therapies available. Sharon Crockett has incorporated elements of DBT into this client’s program. It might save expense in the long term to invite Marsha Linehan or someone from her team to train staff in DBT – or to have select staff attend a training program. It is not clear that DBT would help this treatment refractory client; it is not a short term therapy and it has not as yet received ranking as ‘best practice;’ any decision to seek training in and to deploy the DBT model should be carefully considered. The saving in expense might also apply to other personality disordered clients.

Electro-convulsive Therapy

ECT has been demonstrated to have a 20% success rate with depressive borderlines. Even though the success rate is low, the expected saving (= probability of success x savings if successful = 0.2 X Cost per year X Remaining life expectancy of client – Cost of ECT) is high. Therefore, ECT deserves consideration.

Other therapies

There is variety of experimental treatments including novel application of medications; these deserve consideration for the present and other clients.

Placement

Specialty programs: a survey of costs and screening criteria suggests that this is not a particularly viable option; deserves further research and cost-benefit analysis.

Consultation

We might consider psychological, psychiatric, legal options. A possibly viable option to placement in a specialty program. What would we seek? From the psychological and psychiatric option: diagnostic and therapeutic recommendation. This would provide legal confidence even in the absence of legal consultation. Have we sought input from County Counsel?

Hiring for expertise

Along these lines, what would be the expense of hiring one additional MD / LCSW with a proven track record in treatment of personality disordered clients? How might that compare with long term savings? How much might that contribute to client, community, agency, and staff welfare?

Experimental options

Walter Wilcox, MD, a Sempervirens Staff psychiatrist in the early 1990’s and retired military psychiatrist, suggested that, in his experience, military service was the most effective ‘therapy’ BPD that he had seen. This suggests that there are novel solutions (the military environment, its structure, provision of purpose is but an example.) Can a small county undertake such options? Are they viable in the present social climate (essentially coddling?) Are there any existing experimental options – preferably low cost? As an example, would it be viable to involve the client in community service? What can we do? What do we want to do? (The general problem of individual action in a large, complex, modern society.)

Observation. The problem is not merely psychiatric but has obvious economic, political and community dimensions. What can we do about this? (Again, the general problem of individual action in a large, complex, modern society.)

Placement again

We have had little success with placement options. Perhaps it is time to consider community placement. Problem: in addition to risks, this would likely involve cycling in and out of SV but may reduce long term cost. Benefit: except for the risks, this may well be the least expensive option; it may also be in the client’s best interest, be her best prospect for a life in which she realizes her potential, overcomes her disability. Are we denying her this possibility by continued hospitalization? If we are willing to take the risk, pending further research, may well be the best option, even the most humanistic one.

Solution Ideas

Summary and conclusion. There is no guarantee that investment in the treatment options described above will pay off. The risk of the least expensive option, that of community placement, cannot be eliminated. However, it is probable that without either investment in treatment options or placement risk, the long term costs of the borderline client will continue to be an unnecessary and enormous drain on human and financial resources. Assessment of the prospect of any personality disordered client is not a single step process. This requires psychological assessment and, typically, a number of treatment trials before a picture of the client profile can be build up to a degree that assessment of prospect may be reliable. Potentially, community placement (with comprehensive treatment planning and safeguards) may well be the most therapeutic and most humanistic option.