‘Borderline personality disorder’ (‘BPD’) is a controversial psychiatric diagnosis, argued to be misunderstood by many, plagued with problems of comorbidity and misdiagnosis, as well as being stigmatising and overshadowing the trauma which may people with the label have experienced. For these reasons, to acknowledge the degree of disagreement and debate, I have used inverted commas when referring to the diagnosis in all my own writing for the last few years and will do so here.
Despite disagreement around appropriate labels and ways of understanding distress, there does nonetheless exist a group of people who experience crisis and often need help. The most prominent symptoms of ‘BPD’ are an instability in interpersonal relationships, emotional dysregulation and impulsivity (American Psychiatric Association 2013). People diagnosed with ‘BPD’ have been linked with recurrent crisis, which is a subjective and multidimensional experience (Warrender et al 2021). This crisis can lead to self-harm and attempting suicide, with ‘BPD’ strongly linked to risk of suicide.
Crisis can understandably lead to high contact with mental health services (Lewis et al 2019, Smith et al 2024), however hospital admission has been argued to be unproductive, or even counterproductive (Livesley 2003, Paris 2019). However, the evidence for brief admission, a structured approach to hospital admission and described in the results section of this blog, has been growing over the last few years. This study sought to ask the question ‘is brief admission effective for people diagnosed with borderline personality disorder when they are in crisis’?
Brief admission is a structured approach to hospital admission which has been growing in evidence over the last few years.
Methods
This was a systematic review, which updates a previous systematic review published in 2014 (Helleman et al 2014).
The study followed PRISMA guidelines, a recognised standard for reporting systematic reviews. It searched four electronic databases (Medline, CINAHL, PsychInfo and Cochrane library) using synonyms to ‘suicide’, ‘self-harm’, ‘BPD’ and ‘crisis admission’, and capturing papers published after January 2011, which related to people diagnosed with ‘BPD’ aged between 18 and 64. Brief hospital admission was capped at five days, with papers excluded where they exceeded this timescale.
Two reviewers screened 4465 papers. 1195 duplicates were excluded, with the remaining 3270 abstracts screened. 3250 more papers were excluded following inclusion and exclusion criteria. Full text was reviewed for 20 articles, with six papers meeting eligibility criteria. Given the heterogeneity of papers, which were both qualitative and quantitative, they did not conduct a meta-analysis.
The Mixed Methods Appraisal Tool (MMAT) was used on all papers to assess quality, with each of the six studies having a clear research question, and collecting data appropriate to answering that question.
Results
A total of six studies were included in this review. This included one randomised controlled trial (RCT), two non-RCT quantitative studies and three qualitative studies. Each of these studies took place in European countries (one in Netherlands, one in Switzerland and four in Sweden). Participants in these studies had a mean age of 32 to 42.1 years. Only five of six studies reported the gender of participants, though these returned as 80% female. Studies included between 15 and 200 participants.
Qualitative studies all used semi-structured interviews, with sample sizes between 15 and 17, and developed results into thematic analyses. Helleman (2014b) found the average use of brief admission was 12 times over a three year period, and Eckerstrom (2020) reported an average use of 3.64 times, but did not report a timescale. One study (Enoksson et al 2021) interviewed participants who had and had not experienced brief admission, though each of them had it available to them through their treatment plan.
Brief admission was used as an adjunct to ongoing outpatient treatment. The content of the brief admission intervention was consistent for five of six studies. It included:
- Formulation of a care plan between the person diagnosed with ‘BPD’, inpatient and community mental health staff
- This care plan detailed admission goals, admission duration, and admission frequency
- People diagnosed with ‘BPD’ would initiate their admission by contacting the ward directly, without needing to go through any other service
- As inpatients, people self-managed their own medication, did not have contact with a Psychiatrist, or any structured therapy
- Admissions would last up to three days.
There was one exception to this general description (Berrino et al 2011), where:
- Admission was initiated through referral through the emergency department
- Admission included intensive treatment including interpersonal interventions which included families, and significant others and families developing coping strategies
- During admission there was assistance offered through visual observation and medication-management
- Admission lasted up to 5 days
- People diagnosed with ‘BPD’ were assigned further treatment on discharge.
Quantitative and qualitative papers were analysed independently, then integrated into a narrative summary. The outcome measures of studies included rates of self-harm, rehospitalisation, presentation to emergency department and quality of life.
One randomised controlled trial (Westling et al. 2019) compared rates of self-harm and rehospitalisation between those experiencing brief admission and those who did not, finding no significant difference between groups. Furthermore, brief admission had no effect on subsequent use of inpatient service either on a voluntary or involuntary basis. However, over a 3-month follow up, Berrino et al (2011) saw a reduction in relapse through self-harm and rehospitalisation in those who experienced brief admission vs those who did not (8% and 8% vs 17% and 56%). Eckerstrom et al (2022) noted improvements in symptoms following brief admission, particularly anxiety and depression.
Qualitative studies showed people were satisfied with the collaborative care planning which formed part of their admission, appreciating the opportunity to take “time out” from daily life, and a positive approach from staff. Daily interactions with nursing staff were also highly valued, but added to feelings of loneliness when absent. The choice and ability to use brief admission was valued and added to a sense of security and also increased motivation to try and solve problems at home. Where brief admission was used, it was less disruptive to people’s lives, given they had choice and control to come and go as they pleased, and could plan ahead, being aware of when admission and discharge would be.
There were some struggles contacting wards to initiate admission, communicating over the phone, and issues with bed occupancy. Some suggestions for improvement included alternative means of contacting wards, increasing the number of beds available, and improving staff contact through increased training.
People diagnosed with ‘BPD’ were satisfied with collaboration in their care planning.
Conclusions
Overall, this systematic review showed some promising, but inconsistent results.
Quantitative papers indicated brief admissions could reduce depression and anxiety, and also increase quality of life, although hospital readmission and self-harm rates were inconsistent.
Qualitative studies showed brief admission was valued in terms of having choice and a sense of security, but experiences were not consistently good.
The paper does show that brief admission can have value, although it is worth noting in all studies brief admission was an adjunct to community treatment, and occurred as well as, not instead of it. Also, while there was more choice and autonomy, there could still be issues accessing care.
This review showed some promising (but inconsistent) results for brief admission as a way of helping people with BPD in crisis.
Strengths and limitations
This study took a focused and robust approach to reviewing relevant literature, developing a solid search strategy, adhering to PRISMA guidelines, including both quantitative and qualitative data, and utilising the MMAT to assess the quality of included studies. The MMAT is appropriate given the inclusion of different types of study. Results from the review were appropriately combined into a narrative.
A limitation of the study, not a fault of the authors, but rather the combination of research, was that included qualitative and quantitative research measured different things, limiting the development of overarching themes. What may be lacking from this review is a real sense of ‘what happens’ whilst people are experiencing brief admission, absent, in particular, from quantitative studies. Some studies said there was no contact with psychiatrist or therapy, which indicated it may be no more than physical containment, although qualitative studies did discuss daily interactions with nursing staff being valued. Future research may be wise to explore in more depth the content and structure to these daily interactions in terms of psychotherapeutic process. The study also notes the majority of participants were female, and it is unclear if findings can be generalised to males diagnosed with ‘BPD’.
A further limitation is that the brief intervention in one study seemed inconsistent with the other five. Berrino et al (2011) described an admission lasting five days. While this is longer than the three days in the other included studies it is still consistent with the inclusion criteria for this review. However, other differences may have had more of an impact on outcome which were worthy of consideration. For example, having an additional service (the emergency department) act as gatekeeper to admission, including intensive treatment during admission, and offering treatment on discharge. This perhaps suggests that there is more work to do to better define the intervention before we can be confident of its effect. However, it is also reflective of a general lack of evidence in the field for effective interventions. As is so often the case, more research is badly needed.
The review offers the summary of results that “brief admission as a crisis management tool is acceptable and can be effective”. Whilst deemed acceptable, as some service users valued it, there is often a limitation in what we count as ‘effective’, where one of these studies did appear to offer additional support. Are we measuring the timescale of admission, or what happens during it?
What may be lacking from this review is a real sense of ‘what happens’ whilst people with a ‘BPD’ diagnosis are briefly admitted to hospital.
Implications for practice
Given there can be reluctance in offering hospital admission to people diagnosed with ‘BPD’, this study shows that it can have some value. Whilst objective outcomes were inconsistent, they showed some subjective value for people. Of note, these studies were retrieved from Netherlands, Switzerland and Sweden, with none from elsewhere, and this may link to issues of culture where this model has been deemed more acceptable. It would be useful for this to be explored in the UK and other settings and ensuring a clearly defined intervention.
Some people interviewed in these studies, had not used brief admission, but it had been made available to them. This may be an important point, as the knowledge that help is available may create a sense of safety and reassurance, which decreases the likelihood of admission being used. My own research has found that struggling to access care increases distress (Warrender et al 2021, Warrender 2024), and it follows that knowing help will be available, may mitigate. Given mental health services can lack resources, there can become a “siege mentality” where it can appear that the role is gatekeeping and keeping people out, rather than finding a way to let them in. In these circumstances, service users can feel invalidated and left alone, or left with family, or become the responsibility of other services such as the police. Whilst there is a reality to limited resources, I feel at the very least there could be more honesty about this predicament, and clinicians can at least empathise and validate distress, whilst being honest about their own position in having limited resources, competing demands, and difficult decisions to make. Ultimately, what may be needed are radically different responses to crisis, e.g. crisis cafes which are more accessible.
Whilst participants noted a positive approach from staff, I wonder if this is helped by staff having a clear sense of the purpose and structure of admission. My own study from 2015 found staff describe feeling frustrated, drained and tired, saying “sometimes we get people in and they come in for two days, then they go home for a week, then they come in for three days and it’s just back forth back forth back forth back forth, that you just, you don’t know what you’re doing with them anymore” (Warrender 2015). One must wonder if a clear focus and understanding between patient and professional may also help relationships, and reduce likelihood of stigma, poor attitudes and iatrogenic harm which we hear about so prevalently for this group of people.
A useful avenue for further research would be who makes decisions around access to care and discharge, and how this power dynamic influences therapeutic relationships. It may be that staff who have more direct influence on admission time, may feel more invested in contributing to what happens during that time.
Finally, whilst brief admission is being explored here, admission is no more than going to a particular place for a certain number of days, and people are such that we are influenced by many human variables. Perhaps it is not brief admission itself that is important, but the human interactions that occur within and around it. Qualitative research exploring these complex issues will always be better able to detail any mechanism of change. Brief admission may be a worthwhile intervention, but it is done in the context of human relationships, and this (for all of us) is usually what matters.
Perhaps it is not the brief admission in itself that is important, but the human interactions that occurs within and around it.
Statement of interests
I have also conducted research into crisis and crisis intervention for people diagnosed with ‘borderline personality disorder’, and sit on the executive committees for the Scottish Personality Disorder network and the British and Irish Group for the Study of Personality Disorder.
Links
Primary paper
Tan, S.-Y. and Hope, J. (2025), Is Brief Admission Effective for Individuals With Lived Experience of Borderline Personality Disorder (BPD) When Experiencing Crisis? A Mixed Systematic Review. Int J Mental Health Nurs, 34: e13503. 10.1111/inm.13503
Other references
Eckerström J, Allenius E, Helleman M, Flyckt L, Perseius KI, Omerov P. Brief admission (BA) for patients with emotional instability and self-harm: nurses’ perspectives – person-centred care in clinical practice. Int J Qual Stud Health Well-being. 2019 Dec;14(1):1667133. https://doi.org/10.1080/17482631.2019.1667133
Eckerström, J., A. Carlborg, L. Flyckt, and N. Jayaram-Lindström. 2022. “Patient-Initiated Brief Admission for Individuals With Emotional Instability and Self-Harm: An Evaluation of Psychiatric Symptoms and Health-Related Quality of Life.” Issues in Mental Health Nursing 43: 593–602. https://doi.org/10.1080/01612840.2021.2018530
Eckerstrom, J., L. Flyckt, A. Carlborg, N. Jayaram-Lindstrom, and K.-I. Perseius. 2020. “Brief Admission for Patients With Emotional Instability and Self-Harm: A Qualitative Analysis of patients’ Experiences During Crisis.” International Journal of Mental Health Nursing 29: 962–971. https://doi.org/10.1111/inm.12736
Enoksson, M., S. Hultsjo, R. E. Wardig, and S. Stromberg. 2021. “Experiences of How Brief Admission Influences Daily Life Functioning Among Individuals With Borderline Personality Disorder (Bpd) and Self-Harming Behaviour.” Journal of Clinical Nursing 31: 2910–2920. https://doi.org/10.1111/jocn.16118
Helleman, M., P. J. Goossens, A. Kaasenbrood, and T. van Achterberg. 2014a. “Evidence Base and Components of Brief Admission as an Intervention for Patients With Borderline Personality Disorder: A Review of the Literature.” Perspectives in Psychiatric Care 50: 65–75. https://doi.org/10.1111/ppc.12023
Helleman, M., P. J. J. Goossens, A. Kaasenbrood, and T. van Achterberg. 2014b. “Experiences of Patients With Borderline Personality Disorder With the Brief Admission Intervention: A Phenomenological Study.” International Journal of Mental Health Nursing 23: 442–450. https://doi.org/10.1111/inm.12074
Lewis, K. L., M. Fanaian, B. Kotze, and B. F. S. Grenyer. 2019. “Mental Health Presentations to Acute Psychiatric Services: 3-Year Study of Prevalence and Readmission Risk for Personality Disorders Compared With Psychotic, Affective, Substance or Other Disorders.” BJPsych Open 5: e1. https://doi.org/10.1192/bjo.2018.72
Livesley, W. J. 2003. Practical Management of Personality Disorder. New York: Guilford Press.
Monk-Cunliffe J, Borschmann R, Monk A, O’Mahoney J, Henderson C, Phillips R, Gibb J, Moran P. Crisis interventions for adults with borderline personality disorder. Cochrane Database of Systematic Reviews 2022, Issue 9. Art. No.: CD009353. DOI: 10.1002/14651858.CD009353.pub3.
Paris, J. 2019. Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice. New York: Guilford Publications.
Smith, D., P. Cammell, M. Battersby, D. Bartsch, J. Stevenson, and T. Bastiampillai. 2024. “Recurrent Mental Health Presentations to Public Hospital Services: A Focus on Borderline Personality Disorder.” Primary Care Companion for CNS Disorders 26: 23m03559. https://pubmed.ncbi.nlm.nih.gov/38228069/
Warrender, D. (2015), Staff perceptions of MBT-S for BPD in acute mental health. J Psychiatr Ment Health Nurs, 22: 623-633. https://doi.org/10.1111/jpm.12248
Warrender, D. (2024). A “fireball of emotion”: a qualitative case study exploring the experiences of crisis and crisis intervention for people diagnosed with ‘borderline personality disorder’, their family and friends, and professionals who work with them. [PhD thesis, Robert Gordon University]. Available online
Warrender D, Bain H, Murray I, Kennedy C. Perspectives of crisis intervention for people diagnosed with “borderline personality disorder”: An integrative review. J Psychiatr Ment Health Nurs. 2021; 28: 208–236. https://doi.org/10.1111/jpm.12637
Westling, S., D. Daukantaite, S. I. Liljedahl, et al. 2019. “Effect of Brief Admission to Hospital by Self-Referral for Individuals Who Self-Harm and Are at Risk of Suicide: A Randomized Clinical Trial.” JAMA Network Open 2: e195463. https://doi.org/10.1001/jamanetworkopen.2019.5463
