Paradoxes in the management of suicidality in borderline patients

The risk of completed suicide in DSM-III borderline patients (BPD) equals that of manic-depressive patients. But BPD patients are also notorious for making manipulative suicide threats and gestures--"false positives" that do not foretell of imminent danger of death. BPD patients will often engage in deceitful, paradoxical behavior, attempting to make a fool of the therapist (often seen transferentially as a disparaged parent on whom the patients seeks revenge) either by escalating to serious suicidality, if a threat is not adequately heeded, or by angry criticism, if the therapist insisted on hospitalizing (as though such intervention were quite unnecessary). To deal effectively with such paradoxical behavior, therapists need to develop ever better "risk-thermostats" (in effect, "street smarts") for parrying the patients' thrusts: when to go out of one's way to be helpful, when to put responsibility on these patients, when to hospitalize, etc. There are no convenient algorithms to simplify the task. The ultimate choice of intervention shares aspects with chaos theory and weather prediction, and is sensitively dependent on initial conditions and on the idiosyncrasies and peculiarities of each member of the therapist-patient dyad. A number of general guidelines are offered in the paper, along with several illustrative cases.