Care providers open door to patients with emotionally unstable personality disorder
A hospital’s admission policy may be helping service users to develop more positive coping mechanisms
Emotionally unstable personality disorder (EUPD), previously referred to as borderline personality disorder, is characterised by extreme emotional reactions to everyday events, unstable relationships and deliberate acts of self-harm.
It is thought to affect one in 100 people, and some people who have the disorder may be admitted to hospital regularly after presenting to emergency departments when experiencing a crisis.
'The aims of this policy were to break cycles of self-harm, to teach and build on positive coping mechanisms'
Staff at Mulberry 1, an acute assessment unit at Fulbourn Hospital, Cambridgeshire, wanted to find a more effective way to help people with severe EUPD and to prevent them presenting to emergency departments when in crisis.
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After investigation, they decided on a collaborative open-door policy to offer short-term, two-day admissions for service users with a severe form of the disorder.
The aims of this policy were to break cycles of self-harm, to teach and build on positive coping mechanisms so that service users could mitigate crises, and potentially to reduce further presentations to front-line services.
Alternative for ‘intensive users’
Structured short-term admissions may help service users with the disorder to manage a crisis. In the Netherlands, brief admissions are frequently used as part of a treatment and crisis management approach for those diagnosed with the disorder. Service users there are admitted for a maximum of three nights, and have a clear treatment plan that allows a maximum number of brief admissions over a specified time frame.
A pilot study in the Netherlands evaluated the effectiveness of brief psychiatric admissions for people with severe EUPD. The authors concluded that preventive admissions may be an ‘easy to use’ alternative for those service users diagnosed with a severe form of the disorder who use psychiatric services intensively.
What it should include
After reviewing the literature, staff at Fulbourn Hospital agreed five important factors when offering short, planned, open-door admissions in the Mulberry 1 unit:
- The goal of the brief admission is discussed with the service user before admission.
- The organisation of the brief admission and its duration is written in the treatment plan or crisis management plan.
- The admission procedure is clearly understood by all those involved, particularly the service user.
- Any interventions undertaken during the brief admission are clearly described.
- The conditions for premature discharge, such as self-harming on the ward, are outlined and agreed on.
Criteria for offers
Open-door admissions to the Mulberry 1 unit were to be offered to service users with a formal diagnosis of EUPD who frequently attend front-line services when in crisis and who are linked to a specialist community mental health team with an allocated case worker who can work alongside the ward team to provide support.
The admissions are offered to a service user by the ward consultant after the multidisciplinary team discusses whether they would benefit.
'To qualify for admission, a service user must not have self-harmed in the previous 48 hours; this aims to break the cycle of self-harm'
A treatment plan is then made with the team and the service user before a crisis occurs and it is instigated as soon as the service user feels a crisis is imminent or currently occurring.
If service users want to access another open-door admission, they can tell us by phone on a date agreed at the end of the previous admission. However, they can also call earlier than this and ask to bring the date forward if in crisis.
To qualify for admission, a service user must not have self-harmed in the previous 48 hours; this aims to break the cycle of self-harm and help the person to put healthier coping mechanisms in place.
However, it is possible for the service user to be offered an ordinary admission if in crisis, as each presentation to front-line services is assessed on its own merits and risk assessment. There is an agreement that service users who have been offered open-door admissions can be offered one night if they have self-harmed, and this is agreed with all services working with that service user.
Open-door admissions in the unit were provided as a pilot scheme and were offered only to a small number of service users. The pilot scheme was run at the unit for a year before evaluation. With service users’ informed consent, staff accessed their case notes six months before and after they first attended open-door admissions and assessed the number of admissions they had via the emergency department. Service users were also invited to make a reflective statement of their experience of the scheme.
Of seven service users who were offered open-door admissions over the year, six consented to share their data.
While there was little overall effect of open door on the service users’ presentation to front-line services, three service users had fewer presentations to the emergency department, one had more presentations and two had no change.
Service users’ reflective accounts
Some service users provided reflective statements about their experiences. One cited carer respite as a significant reason for using open-door admissions.
Service user A: ‘Knowing an admission was coming was very comforting’
‘Knowing the criteria for admission was helpful and was comforting; knowing I didn’t need to go to the extreme of taking an overdose as a way of relieving the overwhelming thoughts I was having. The admissions were helpful by using my skills to deal with overwhelming thoughts and having staff on hand to help me with these, and through time my coping skills became easier to use in times of need. My attendance at A&E decreased and knowing an admission was coming was very comforting.
‘It’s very easy to become institutionalised and just depend on the safe environment rather than using skills learnt to deal with difficult situations’
‘At times I found the strict limit of 72 hours – three days and two nights – with no leeway hard to deal with, and it wasn’t until I’d finished using Open Door that I understood why these boundaries were in place. It’s very easy to become institutionalised and just depend on the safe environment rather than using skills learnt to deal with difficult situations.’
Service user E: ‘It meant I could hold out on acting upon self-destructive behaviour
‘At the time, I was unwell and struggling with my mental health. These admissions really helped me in the way that I did not have to go through the accident and emergency process to acquire professional help with my mental health and not having to go through a stressful and anxiety-provoking time to seek help. Also having the knowledge that I had an admission if I needed it meant I could hold out on acting upon self-destructive behaviour as I was then able to get advice, guidance and treatment from professionals.
Service user F: ’I didn't self-harm as much’
‘Throughout the time that I was on the ward, my Open Door helped with my self-esteem, self-harm and my emotional well-being. Having the staff there helped me. Within the 72 hours that I was there for I’d begin to open up on the last day and be around the other people that were staying there. I feel that three days was very short, especially if something had happened and had put me into a major crisis; I needed a bit more time to deal with it as it took a while to gain trust from staff, even if I had been there before using Open Door.
‘The thing I liked about Open Door was that I was able to give myself a place to stay when I was feeling low or in a crisis. I found it useful but there are other times where I felt that I needed longer, and I was still pushed out the door. On the few occasions after I've left on the Open Door from the ward, I had taken overdoses as soon as I left because I didn't feel that three days was long enough, and I needed longer to get the thought of taking my own life out of my head.
‘It helped me make my decisions of when I needed to go into hospital; when I know that I was becoming unwell, it helped me not to take overdoses’
‘Being on the ward, I found it useful to come up with different techniques of what to do when I got out of hospital. I found it interesting with what the staff and I may come up with: such things as mindfulness techniques, getting into college and getting a regular routine, even thinking about dieting or going to the gym. Being in this space gave me the time to think about my future and what I needed to do to make it better.
‘The Open Door is great as it gives you the time to think about what to do next. It also gives you the staff to do some collaborative thinking about where to go from here and what I could do before my next visit or before when I needed to use it.
‘It's good that it helped me make my decisions of when I needed to go into hospital. When I know that I was becoming unwell, it helped me not to take overdoses; I didn't self-harm as much.’
Team members’ experiences
Team members on the unit had different interpretations about how to apply open-door admissions. This led to confusion for service users during the pilot because care was not always consistent.
When the scheme was introduced, staff had individual clinical supervision, but group supervision might have been more helpful in addressing this problem. On reflection, a more robust training package would also have made it clearer to staff what these admissions should look like.
Positive risk assessment and risk-taking form part of the treatment plan agreed with the service user. A time limit for a brief admission remains in place even if discharge is difficult for the service user.
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There is an increased risk of self-harm after discharge, as evidenced in the reflective account of service user F. Staff members must therefore be prepared for open-door admissions to fail or require re-evaluation. However, the team members did not have the confidence to re-evaluate during the pilot.
At times, it was clear that open-door admissions were not helping, because a service user’s crisis presentations increased, but this was not reviewed. After the pilot evaluation, team members believed that reviews of open-door admissions should be made at a senior level, with the ward manager and consultant completing these with the team.
Team members found that service users did not take the initiative and tended to be passive when first offered open-door admissions. However, as they became used to the process, they became more proactive.
Team members found that the admissions played a valuable part in gaining trust and developing therapeutic relationships with service users as a result of the consistent approach over time. The charity, Mind, recommends that engaging with one healthcare professional is helpful for people with personality disorders. This is not possible in a ward environment because of shift patterns and 24-hour care provision, but service users develop relationships with regular team members.
Staff members believe open-door admissions have value and the unit will continue to offer them to a small number of individuals who meet the criteria. It would not be practical or safe, however, to offer them on a larger scale in a busy acute setting.
'The scheme enabled service users to try to develop personal coping strategies and distraction techniques to help them stay out of hospital while knowing they have a safe space to which to return'
Open-door admissions aim to provide an improved patient experience. Most valuable for service users was the provision of a short-term achievable goal, which gives a sense of accomplishment and leads to a longer-term goal of managing their distress in a healthier way.
Positive risk-taking by staff and service users and a sense of working in collaboration to manage these risks provided a sense of autonomy to staff and service users.
The scheme enabled service users to try to develop personal coping strategies and distraction techniques to help them stay out of hospital while knowing they have a safe space to which to return. It is hoped that in the long term they will use these skills in the community without input from inpatient services.
Implications for practice
- Offering open-door admissions may discourage escalation of behaviours to gain admission
- If open-door admissions result in service users having fewer or no long-term admissions, it decreases their dependence on acute inpatient services
- The ward team has better engagement with community teams, improved joint working and continuity of care
- A patient with an open-door admission plan in place gives those working in the community another option to offer
- Chambers M (Ed) (2017) Psychiatric and Mental Health Nursing: The Craft of Caring. Third edition. Routledge, Abingdon.
- Dutch Psychiatric Multidisciplinary Guideline Committee (2008) Dutch Multidisciplinary Guideline for Personality Disorders. Trimbos Institute, Utrecht, the Netherlands.
- Koekkoek B, van der Snoek R, Oosterwijk K et al (2010) Preventive psychiatric admission for patients with borderline personality disorder: a pilot study. Perspectives in Psychiatric Care 46, 2, 127-134.
- Mind (2018) The Consensus Statement for People with Complex Mental Health Difficulties who are Diagnosed with a Personality Disorder.
- Rethink Mental Illness (2017) Borderline Personality Disorder (BPD). Factsheet.
About the authors
Dawn Stewart and Dean Chipps are deputy ward managers, Asha Praseedom is a consultant psychiatrist, Charlie Gale is a modern matron, Eddi Paul is deputy director of nursing and Kyer Hoskin is service user F, all at Fulbourn Hospital, Cambridgeshire and Peterborough NHS Foundation Trust