Borderlines....What a difficult population. I totally agree, with 1:1constant supervision harming borderlines. It does make them helpless and dependent. I have been a psych nurse for 10 years and I have found some little ideas that might help you. I have never heard of DBT but I will certainly look into it.
#1. On admit, tell them what their discharge date and time will be. Your doc has to agree with this of course. Make sure it is no more than 72 hours from admit time. Tell them that you are sure they will become more suicidal at time for discharge but it is a chronic condition and that you provide a service to get them past the immediate crisis and stress they have long term outpatient resources to help them once discharged.
#2. Benign neglect. I love this phrase. Make sure the patient has food, water, proper hygiene, med teaching, assess for side effects and keep sharps out of reach. We place them on a q1hr (five minutes at the most and use a clock) request schedule to their nurse only.
#3. Use staff interactions as a reward. If they are able to comply with no self abusive behavior and can comply with q1hr requests, then at the end of the shift, they earn 15 minutes of 1:1 interaction with their nurse. This really works if they crave staff attention.
#4. Focus on immediate crisis only. Repeat over and over again that everything else is for her to discuss with her outpatient therapist. Explain the reasons why like you would need time to recover from deep therapy issues since they are so emotionally exhausting.
#5. Behavioral contracts. When a patient comes in, be ready for her. I am sure you know your frequent fliers and what their behaviors are. You can explain to them that since what we have done before is not helping you, we have to come up with something else to try to help you. I love to do this. Very simple things can be made into a contract.
List positives like you are expected to eat breakfast, be bathed, take meds and get vs done by 10:00. Attend each group appropriate to you to benefit from treatment. Check in with only your nurse only on the hour.
List negatives like no acting out, no going to other nurses for anything, no cutting. Keep this brief so as to focus on positives.
What is the reward? Interactions with you as her nurse of course.
With our frequent fliers, we kept copies of the contracts so on each admit, we were ready with new copies of old contract. Offer to have her sign it but it is totally not necessary. Have the doc and the nurse sign it and tell her it is being put into place as a part of her treatment plan weather she signs it or not.
#6. Consistency. This is what our staff has the most trouble with and this leads our patients to act out. Put the contract in the patients room for her to have a copy of. Let it be part of the treatment team. Make sure all staff know each and every line of the contract including the secretary.
When we first started doing contracts, our frequent fliers revolted and tested our new system. We had to work out the bugs too. We often had to put patients in locked rooms with nothing but a bare mattress on the floor, blanket, one gown, one pair of footies and undies and lock the bathroom, just until they felt they were in control enough to earn back their clothes and bed linens. If they have prn's, of course, by all means offer it to them.
Another thing that helps is to have a contract presented from the whole treatment team. That way it is not just the evil nurses who are doing this to them.
In my hospital, it seems to work to decrease length of stay, decrease staff burnout and it seems to give everyone a sense of control (even the patient) over a very difficult population. I hope this helps you.