A useful strategy for reducing the need for emergency in-patient admissions is to construct alternative interventions around the patient. Safe, predictable and accessible follow-up is important.
The treatment offered in an in-patient unit is often unsatisfactory, and many patients report little benefit from hospitalisation. There is a risk of patients only being 'stored' in the unit. However, it is possible to change this by, for example, clarifying which issues need to be addressed during their stay. A key factor is staff competence (15). A literature review of qualitative studies showed that patients viewed being listened to, talking to staff and fellow patients, getting a break from daily life and gaining a sense of safety and control as positive experiences. Negative experiences were attributed to lack of contact, negative attitudes and lack of knowledge among staff, sectioning and poor preparation for discharge (16).
Admission to an emergency unit can be incorporated into a patient's treatment programme, but this requires the practitioners in the emergency unit and outpatient clinic to reach a consensus on how the patient should be treated (17). It is also recommended that agreement is reached with the patient on a clear goal for the stay, including how long it should last, and that a well-defined follow-up plan is in place at the time of discharge (4). The work in the ward must be carried out according to well-defined and well-structured parameters, and as well as having clear boundaries, these must be transparent and predictable (4). The staff must have up-to-date knowledge about borderline personality disorder so that they can treat the patients with respect, and show interest and understanding. Through guidance, they can be trained to be aware of their own responses and not let them impact on the patients.
The symptoms of borderline personality disorder usually diminish somewhat over time. This particularly applies to dramatic factors such as self-harm and suicide attempts (18). If patients exhibit a severe level of self-harm or are acutely suicidal, it is important to help them survive the crisis (4). Helping patients in crisis situations, whilst simultaneously limiting their period of hospitalisation without rejecting them is a balancing act.
A study in Switzerland showed how a five-day period of hospitalisation, which entailed psychodynamic therapy for patients with borderline personality disorder in an acute suicidal crisis, led to a significant reduction in subsequent re-admissions within a three-month follow-up period (19). This general hospital ward has eight beds and is an example of how it is possible to tailor hospital stays for this patient group.
The attention should be focussed on the interpersonal circumstances that triggered the crisis as well as the patient's feelings and thoughts about them. The systematic treatment of the personality disorder should be based on outpatient care, and emergency stays should aim to help patients regain their emotion regulation and ability to think more flexibly about themselves and their relationships with others (mentalisation) (5). Attempts must be made to maintain contact with the responsible outpatient practitioner during the patient's stay in hospital.