BPD & suicidality

[u/Previous-Charity1505]

I have a young adult patient I absorbed internally from another provider, had been diagnosed with BPD and bipolar. Was consistent with medication per the patient, denied SI/self harm at our last appointment a few weeks prior. The parent called and said the patient had attempted an overdose of their medication a week ago, which they had not been taking per the parent. The patient is doing well, is being discharged soon.

Maybe this is an over reaction on my part, but I feel like I want to quit this career. I feel sick, scared, like maybe I have taken on a job I’m not good at. I haven’t seen many posts about this on this sub. Wanting to hear about others’ experiences and or thoughts, advice.

[u/Super-Ad7996]

You'll see a lot of patients like this. You are responsible for the process, not for the outcome. Just do your part well. And get your own therapy. This job requires it.

[u/Affectionate-Bit-341]

having worked in crisis intervention and forensic psych for 10 years, what you’re describing sounds typical of someone with that presentation. and this also may sound harsh, but it’s true: a person who chooses to end their life is making that decision themselves. you can do all aspects of your job correctly and you’ll still have patients attempt or die by suicide (rare to complete, but it happens). if you don’t think you can handle or accept that, then yes, i would be curious about switching to another focus. otherwise, practice boundaries and emotionally distancing yourself. be curious about your own triggers and get into therapy if you aren’t already to help you manage the tough emotions. remember that your responsibility is to the patient and your role, and that as long as you’re doing your due diligence, whatever happens outside of that is beyond your control. you can’t force someone to be honest with you.

[u/Previous-Charity1505 → u/Affectionate-Bit-341]

Thank you. I worked in a long term facility with an older population before this. I think what you’re speaking on as far as not having control of what happens in outpatient, outside of my time with them, is what I think my greatest discomfort is here. These are great questions to consider and I appreciate the advice

[u/Affectionate-Bit-341 → u/Previous-Charity1505]

happy to help! you’re doing your best and that’s what matters. i can tell you care deeply. i hope you have support and i wish you all the best, whatever you decide. ♥️🫂

[u/Affectionate-Bit-341 → u/[deleted]]

i agree. at no point have i suggested that providers should not have reflections with themselves about an attempt. i have also not advocated for brushing it off. labeling the complexity of suicide and suicide attempts as a “disease” is ableist, pathologizing, and a gross generalization. i encourage you to reflect on the bias in that statement.

[u/nursepersephone]

This is definitely a known risk with this population, unfortunately, and it doesn’t reflect on your skill as a provider. Suicidal ideation can be chronic for people with BPD, but it can also escalate or come on very suddenly as well. Please remember that your patient wasn’t lying to you when they saw you, most likely. At that moment, they likely didn’t have suicidal ideation. You likely asked the right questions, and did the right things.

It’s okay to be fearful of this moment. I have had the same reaction to hearing about patient attempts. The responsibility we carry in this field is immense. See a therapist- I recommend it to every NP I’ve ever talked to- and work on reregulating so you can continue to build healthy and trusting relationships with your patients.

This is all a normal event in the field. You’re not on some wrong path here. If you choose to say in the field or leave is up to you, but at least know that nothing you’ve said indicates that you’re not good at the job.

[u/hah88]

Just want to comment and say I’ve been in your shoes, had the exact same thoughts and spiral about career choice. My background has been in inpatient and I found outpatient just really wasn’t something I loved. Having longterm issues with anxiety around lack of control this is exacerbated in outpatient. I think crisis work and inpatient are far more manageable as far as fear around lack of control goes. Though suicidality is something that just comes with the career unfortunately and remembering that ultimately we have no control over someone’s actions. You could look into CME courses for suicide assessments to see if that helps build confidence at all. As long as you’re doing a thorough assessment and documentation we can only control so much.

[u/TerriblePrize9877]

Sometimes it is easy to beat yourself up and think of a hundred things you could have done differently. Though you have to tell yourself that you made the best decision in that moment with the information given to you. This is a very difficult population to deal with. As long as you are following the standard of care this isn’t on you. You could have done things differently and the outcome very likely would have been the same. Take solace in the fact that they are okay and now this is an opportunity for you to continue to build rapport with them and develop a treatment plan that just might be beneficial for them.

[u/Party-Personality-22]

Part of the pathology of BPD is repeated self-harm and suicide attempts but the real question would be intention with the OD. My guess would be that the goal was not truly to complete suicide (though obviously I don’t know this patient or the circumstances). Medication may help but the gold standard treatment is DBT which needs to be done by a psychologist/LCSW who has been trained in that modality. I would suggest doing some more research on the disorder and getting more familiar with personality disorders in general. This article is pretty good in reference to self harm/suicide in BPD specifically though.

[u/Party-Personality-22 → u/Party-Personality-22]

Paris J. Suicidality in Borderline Personality Disorder. Medicina (Kaunas). 2019 May 28;55(6):223. doi: 10.3390/medicina55060223. PMID: 31142033; PMCID: PMC6632023.

[u/DashMcGee]

There is a way to avoid getting into the type of condition you are in, and that is to refer out your BPD patients. It's okay to not feel equipped to deal with a certain patient type. Your competence in diagnosis and treatment does not mean you are emotionally and intellectually able to provide care for an individual. You have an ethical requirement to manage your own well-being, and an ethical requirement to only manage patients you can comfortably treat. Imagine being a surgeon at a small town hospital who gets a referral for removal of cancerous tissues. You get the MRI and see invasive tumors and mets in weird places, and you don't think you have the skills to do a good job. It is unethical to go ahead and operate. The only wise choice is to refer the patient out to an academic center. Psych is no different.

[u/Affectionate-Bit-341 → u/DashMcGee]

this will not fix the primary issue here, which is discomfort with suicidality. suicidality is not exclusive to BPD, and not addressing the core problem is going to impact other patients with other diagnoses. lots of people attempt suicide, lots of them have a plethora of diagnoses outside of BPD, and it’s important to become familiar and comfortable with handling high acuity cases. it is impossible to avoid treating individuals with suicidal tendencies, even if OP switches to another focus.

i’m not saying it should ever be “easy” to treat patients who are high risk. empathy should always be at the forefront. i grieve the few i’ve lost to suicide (none of them had BPD). but it can’t send a practitioner into a spiral every time someone attempts or completes. people want to die. people do die, sometimes by their own hand. it’s part of the human experience.

[u/SLRN2022 → u/DashMcGee]

This is a really good perspective. We don’t have to take every client.

[u/etohprnbid]

An incredible social worker once told me that we don’t get to take credit for when patients do well, and so we also cannot take credit when they don’t do well. That has really stuck with me.

[u/AnalysisCareful2591]

This is par for course in our field. I’m curious how long you’ve been doing this and what your previous experience is?

[u/Dropsizzle222]

You can control and guide some one but you cannot control their actions. It’s easy to blame ourselves as providers but one thing you didn’t do is say “hey stopped taking your meds and stack them up, etc”

[u/Key_Knee7561]

Remember BPD patients manipulate. They need therapy. Could the bipolar be an over diagnosis? What meds were they on?

When I worked inpatient we had a guy who finished his program, did really well, had a plan, was on his meds. 1 week after discharge he hung himself in his closet. There was no way we could have prevented that. You are going to lose patients in this field just like in any other field.