What do we do about the frequent flyer borderline who refuses DBT on multiple occaisions? Continue to offer it until they move through the stages of contemplation?
Wow, now that's a different problem. Where I did my training, many of the patient would've jumped at DBT if you told them it was the right treatment and why they haven't gotten better in years.
If they refuse DBT, then you got to set boundaries. If what they want is not therapeutic, you shouldn't offer it. E.g. Ativan, Xanax, etc.
If they meet commitment criteria and refuse DBT, and it's an extreme (I'm talking parasuicidal to the point where they truly are in danger of suicide), then you admit them. If you're hospital doesn't offer DBT, perhaps long term care does (but then again maybe not).
DBT, mind you, if done properly would offer 24 hour support services for the more extreme patients, and in several of those cases, the patients have been put in a situation where they don't have many other options. E.g. someone who is in mental health court has to get treatment or they could go to jail. Others may have been literally told several times that medication is not the appropriate treatment and if seen on the inpatient unit, they will be discharged immediately.
(Heh, reminds me of an attending I had in residency. The second he saw a borderline he discharged them. Most of the borderlines were hospitalized for less than 12 hours and when he showed up in the morning---OUT! As cruel as that sounds, that actually in many cases is not off with what DBT recommends. The problem was that the patients had no place to go to get DBT once they were discharged.)
But aside from DBT, my opinion stated above is for several patients who don't need what the hospital provides. E.g. welfare drug addicts who only go to the hospital because they've spent all their money on drugs for the month and they claim to be suicidal but are really seeking 3 hots and a cot, institutionalized former criminals who don't want to go to prison but want someone to take care of them, women who claim to be suicidal only because they wanted attention from their boyfriend, etc.
The program you are in needs to develop a strategy to deal with these people without them ripping off the system but at the same time, in a non-judgmental manner, direct them to what they really need. Unfortunately that direction may not exactly seem compassionate to the patient at that time.
The problem is that several programs label someone and medicate when that is often not the right answer.
The worst extreme case I had was a homosexual man who felt he was in man-heaven in the inpatient unit. This particular individual had histrionic personality disorder but was diagnosed with bipolar disorder and he did not have this disorder, or at least did not have a depressive, mixed, or manic episode while in the hospital for 2 months. I told him I was going to discharge him and he told me the second he'd get out of the hospital he was going to cause a public disturbance to get back in. Thankfully, being that I work in a forensic psychiatric unit, we had another forensic psychiatrist do an assessment corroborating my opinion and the guy was discharged against his will. The guy caused a scene (exposed his penis at the first mom and pop store he could get to), the prosecutor ordered his records from the hospital, they read my report and the other doctors report, and instead of being sent back to the hospital, he was sent to jail.
What most places would've done would've been to keep this guy in the hospital.......indefinitely, even though no one believed he had an Axis I disorder, but someone would've written down Mood DO NOS, or Psychosis NOS when they didn't even believe in that diagnosis.
That is by no means a salutation on myself. I was only able to get to this point by doing forensic fellowship, knowing the laws inside out, knowing how the mental health court works, and being able to have a forensic psychiatric consult available. Most places don't have these things available to them.