When treating patients with any mental disorder, attention to risk management issues is important and often enhances patient care. Attention to these issues is particularly important when treating patients with borderline personality disorder, given the potential for self-injury, violent behavior, and suicide, as well as impulsivity, splitting, problems with the therapeutic alliance, and transference and countertransference problems (e.g., the mobilization of intense feelings in the clinician). The following are general risk management considerations for patients with borderline personality disorder:

• Good collaboration and communication with other clinicians who are also treating the patient are necessary.

• Attention should be paid to careful and adequate documentation, including assessment of risk, communication with other clinicians, the decision-making process, and the rationale for the treatment used.

• Attention should be paid to any transference and countertransference problems that have the potential to cloud good clinical judgment. The clinician should be especially aware of the potential for splitting to occur and should resist taking on the role of the "all good" or rescuing clinician. In this regard, close collaboration and communication with other team members are important. Keep in mind that different perspectives of different clinicians can be valid, since the patient may act differently with different clinicians.

• Consultation with a colleague should be considered and may be useful for unusually high-risk patients (e.g., when suicide risk is very high), when the patient is not improving, or when it is unclear what the best treatment approach might be. It is important to document the consultation (i.e., that the consultation has occurred, what the recommendations were, whether the recommendations were followed or not, and, if the clinician made a different treatment decision, why the recommendations were not followed).

• Termination of treatment with a patient with borderline personality disorder must be managed with care. Standard guidelines for terminating psychiatric treatment should be followed, even if it is the patient's decision to terminate treatment (133). Careful attention must be paid to timing, transfer, and discussion with the patient. If the treatment termination process is unusually difficult or complex, obtaining a consultation should be considered.

• Psychoeducation about the disorder is often appropriate and helpful from both a clinical and risk management perspective. When appropriate, family members should be included, with attention to confidentiality issues. Psychoeducation should include discussion of the risks inherent in the disorder and the uncertainties of the treatment outcome.

Suicidal threats, gestures, and attempts are very common among patients with borderline personality disorder, and 8%–10% commit suicide. Managing suicide risk therefore poses important clinical and medicolegal challenges for clinicians. However, it can be difficult to address suicide risk in these patients for a number of reasons. First, suicidality can be acute, chronic, or both, and responses to these types of suicidality differ in some ways. Second, given the tendency of patients with borderline personality disorder to be chronically suicidal and to engage in self-destructive behaviors, it can be difficult to discern when a patient is at imminent risk of making a serious suicide attempt. Third, even with careful attention to suicide risk, it is often difficult to predict serious self-harm or suicide, since this behavior can occur impulsively and without warning. Fourth, given the potential for difficulties in forming a good therapeutic alliance, it may be difficult to work collaboratively with the patient to protect him or her from serious self-harm or suicide. Last, even with good treatment, some patients will commit suicide. The following are risk management considerations for suicidal behavior in patients with borderline personality disorder:

• Monitor patients carefully for suicide risk and document this assessment; be aware that feelings of rejection, fears of abandonment, or a change in the treatment may precipitate suicidal ideation or attempts.

• Take suicide threats seriously and address them with the patient. Taking action (e.g., hospitalization) in an attempt to protect the patient from serious self-harm is indicated for acute suicide risk.

• Chronic suicidality without acute risk needs to be addressed in therapy (e.g., focusing on the interpersonal context of the suicidal feelings and addressing the need for the patient to take responsibility for his or her actions). If a patient with chronic suicidality becomes acutely suicidal, the clinician should take action in an attempt to prevent suicide.

• Actively treat comorbid axis I disorders, with particular attention to those that may contribute to or increase the risk of suicide (e.g., major depression, bipolar disorder, alcohol or drug abuse/dependence).

• If acute suicidality is present and not responding to the therapeutic approaches being used, consultation with a colleague should be considered.

• Consider involving the family (if otherwise clinically appropriate and with adequate attention to confidentiality issues) when patients are chronically suicidal. For acute suicidality, involve the family or significant others if their involvement will potentially protect the patient from harm.

• A promise to keep oneself safe (e.g., a "suicide contract") should not be used as a substitute for a careful and thorough clinical evaluation of the patient's suicidality with accompanying documentation. However, some experienced clinicians carefully attend to and intentionally utilize the negotiation of the therapeutic alliance, including discussion of the patient's responsibility to keep himself or herself safe, as a way to monitor and minimize the risk of suicide.

Anger and impulsivity are hallmarks of borderline personality disorder and can be directed at others, including the clinician. This is particularly likely to occur when there is a disruption in the patient's relationships or when he or she feels abandoned (e.g., there is a change in clinicians) or when the patient feels betrayed, unjustly accused, or seriously misunderstood and blamed by the clinician or a significant other. Even with close monitoring and attention to these issues in the treatment, it is difficult to predict their occurrence. Another complicating factor is that the patient's anger or behavior may produce anger in the therapist, which has the potential to adversely affect clinical judgment. The following are risk management considerations for anger, impulsivity, and violence in patients with borderline personality disorder:

• Monitor the patient carefully for impulsive or violent behavior, which is difficult to predict and can occur even with appropriate treatment.

• Address abandonment/rejection issues, anger, and impulsivity in the treatment.

• Arrange for adequate coverage when away; carefully communicate this to the patient and document coverage.

• If the patient makes threats toward others (including the clinician) or exhibits threatening behavior, the clinician may need to take action to protect self or others.

With patients with borderline personality disorder there is a risk of boundary crossings and violations. The following are risk management considerations for boundary issues with patients with borderline personality disorder:

• Monitor carefully and explore countertransference feelings toward the patient.

• Be alert to deviations from the usual way of practicing, which may be signs of countertransference problems—e.g., appointments at unusual hours, longer-than-usual appointments, doing special favors for the patient.

• Always avoid boundary violations, such as the development of a personal friendship outside of the professional situation or a sexual relationship with the patient.

• Get a consultation if there are striking deviations from the usual manner of practice.