Is the client at risk for suicide?

Question

DSM Diagnosis
301.83 Borderline Personality Disorder
Phase of Life Problem: Difficulty making the transition from college to professional life.
Housing problems: Temporary housing with sister, who has asked her to move out within six weeks.
Economic problems: Client is dependent on mother and father for support. Father has stopped supporting her and her mother is threatening to do so as well.
Access to health care: Client has no health insurance with her part-time job.

Rationale
According to the DSM-5, an individual must meet at least five of the nine criteria for the diagnosis of borderline personality disorder, and Erica meets the minimum criteria:
1. She reports needing to be in an intimate relationship or with friends partying and clubbing all the time in a pattern that seems to represent an effort to avoid feelings of abandonment.
2. She has a pattern of unstable and intense interpersonal relationships as seen in her choice of boyfriends and the way she idealizes men of questionable character. She also swings back and forth in how she sees her father – he is good when he pays for her, but “Castro” when he does not.
3. She has a fragmented sense of self and low self-esteem. She admits to low self-esteem, and has a disjointed self-appraisal. She describes herself both as “passive” and “extroverted and social.” In another statement, she is “too generous and kind,” but she has strong expectations for what others should do for her in exchange. For instance, she willingly lives off of other people’s money (her father, mother, and sister and fiancé). Additionally, Erica identity concerns; she received a degree in Criminal Justice but is only waitressing part-time. She admits that her values and goals change from day to day depending with whom she has been talking.
4. The client is impulsive with sex, spending (from which she has always been protected because her father pays the bills), and substance abuse.
5. Erica talks about feeling “empty” when she is alone.

Additional Information Required
Erica needs a full medical examination to rule out any physical condition that might be contributing to her presentation. Further assessment of her current substance is also required. Although she denies current drug use, it remains to be seen how she defines “social drinking.” Inquiry about manic or hypomanic episodes would rule out a bipolar diagnosis.

Risk and Resilience Assessment
Onset
Erica has a number of biological risk influences. She is female, presents with interpersonal sensitivity, and her mother had an episode of major depression, which means that Erica may be at genetic risk. Her parents’ divorce and the shared custody arrangement in which she lived growing up may have exacerbated her predisposing factors.
Regarding protective mechanisms for onset, the client did not experience any physical or sexual abuse, and she appears intelligent. She also seems to have a close relationship with her mother. Further, her family maintained an upper socioeconomic status.

Course
Erica has dropped out of therapy several times in the past, and treatment for Borderline Personality Disorder requires a long-term (at least a year) commitment. Erica also continues to have conflict with her father. She has depended on her parents for all of her financial support until recently and seems ill-equipped to support herself.
Regarding protective influences, Erica meets only minimal criteria for borderline personality disorder and is without the self-injury and suicidal ideation that characterizes many people with the disorder. Erica maintains a close relationship with her mother and ties to a supportive peer group. She has some structure in her life by being employed, although not in her chosen career. Erica’s goals for herself include being in a healthy relationship and becoming self-sufficient.

What techniques could be used to elicit additional strengths?
Education and career:
? How was Erica able to graduate from college? What strengths, qualities, and supports did she draw upon to achieve this?
Substance use:
? How did she come to the decision to stop using drugs and to curtail her drinking? How was she able to do this once she made the decision?
Exception-finding:
? Have Erica identify a time she was able to feel all right when she was alone. What was she doing differently? What was she saying to herself?
Future without the problem:
? What will Erica’s life be like as a result of coming to treatment? What will she be feeling/doing/saying? What will being in a healthy relationship and supporting herself look like? What will other people notice that is different about her?
Decisional balance about her involvement with unsuitable partners:
? What does she get (e.g., revenge at her father, excitement, doesn’t feel alone and empty) doesn’t have to commit to anyone)?
? What does she lose (e.g., self-respect, long-term security, sexual health, a mutual relationship)?

Treatment
With the number of sessions the client has canceled and rescheduled, as well as her history of moving, it looks doubtful that Erica would commit to a one-year course of Dialectical Behavior Therapy, including individual and group therapy, although the therapist would explore with her this treatment option. In addition, Erica will be referred to the agency’s vocational services to help her formulate career goals and to find employment in her chosen field.

Critical Perspective
As discussed, Erica meets only the minimum criteria for Borderline Personality Disorder, and she does not seem to present with the affective stability and self-injurious behavior of many people with this disorder. The heterogeneity of the disorder is considerable, and different people with the disorder might look very different in presentation.
Although Erica’s patterns seem to be long-term in nature stemming back to high school, Erica is only 23 years old at this time. Many of her current problems could be attributed to a phase of life or an identity problem (both v codes) and may resolve once she is more accountable for herself and her family is not paying her way.

Answer 1

Erica has fleeting thoughts of not being alive but doesn’t have recurrent thoughts or a plan.