1. General Considerations

  • Collaborate and communicate with other treating clinicians.

  • Provide careful and adequate documentation, including assessment of risk, communication with other clinicians, the decision-making process, and the rationale for the treatment approach.

  • Attend to problems in the transference and countertransference and be alert for splitting.

  • Consider consultation with a colleague for unusually high-risk patients, when a patient is not improving, or when the best treatment approach is unclear.

  • Follow standard guidelines for terminating treatment.

  • Consider providing psychoeducation about the disorder (e.g., risks of the disorder and uncertainties of treatment outcome).

  • Assess the risk of suicide; the potential for angry, impulsive, or violent behavior; and the potential for boundary violations.


2. Suicide

  • Monitor the patient carefully for suicide risk and document these assessments.

  • Actively treat comorbid axis I disorders, with particular attention to those that may contribute to or increase the risk of suicide.

  • Take suicide threats seriously and address them with the patient.

  • Consider consultation and/or hospitalization.

  • In the absence of acute risk, address chronic suicidality in the therapy.

  • Consider involving the family when the patient is either chronically or acutely suicidal.

  • Do not allow a "suicide contract" to substitute for a careful and thorough clinical evaluation of the patient's suicidality.


3. Anger, Impulsivity, and Violence

  • Monitor the patient carefully for impulsive or violent behavior.

  • Address abandonment/rejection issues, anger, and impulsivity in the treatment, because they may be triggers of violence.

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

  • If threats toward others or threatening behavior is present, action may be necessary to protect self or others.


4. Potential Boundary Violations

  • Monitor carefully and explore countertransference feelings toward the patient.

  • Be alert to deviations from the usual way of practicing (e.g., appointments at unusual hours), which may be signs of countertransference problems.

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

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


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