Predictable, Collaborative and Safe: Healthcare Provider Experiences of Introducing Brief Admissions by Self-referral for Self-harming and Suicidal Persons with a History of Extensive Psychiatric Inpatient Care.

People with severe self-harming behavior and histories of lengthy psychiatric inpatient admissions can represent a challenge to care providers. This interview-based study illuminates healthcare provider experiences (n = 12) of Brief Admission (BA) among self-harming individuals, with >180 days of psychiatric admission the previous year. Qualitative content analysis revealed that providers experienced benefits of increased predictability, and a shift from trigger and conflict to collaboration with individuals admitted to BA. Staff participants expressed an increased sense of safety and a strengthened link between inpatient and outpatient caregiving. Results indicated that BA is a promising intervention for self-harming individuals with extensive psychiatric histories.

Individuals' experiences with brief admission during the implementation of the brief admission skåne RCT, a qualitative study.

BACKGROUND: Brief admission (BA) is an adjunctive treatment option for individuals with self-harming behavior, having traits of borderline personality disorder (BPD). It is offered alongside outpatient psychotherapy for the purpose of strengthening autonomy, self-reflection and self-care and to increase the likelihood of being able to stay in therapy by avoiding lengthy inpatient hospitalizations. AIMS: To investigate participants' experiences with BA during the pilot phase of the Brief Admission Skåne Randomized Controlled Trial (BASRCT), in order to detect possible strengths and limitations of the intervention and gain knowledge to facilitate implementation of BA at other treatment centers. METHOD: Eight participants randomized to BA were interviewed to obtain their experience of BA, or alternatively their reasons for choosing not to use BA. Thematic analysis was conducted upon their transcribed interviews. RESULTS: Reported as most helpful by the participants was the structure/routines at the ward and the positive attitudes from the staff. However, some individuals reported problems with perceived negative attitudes from the staff administering BA and negative rumination about themselves. The reported reasons to request BA were: preventing urges to self-harm from escalating; ending isolation; preventing longer admissions and forced admission; feelings of emotional exhaustion, and the need for rest and support in re-creating a daily routine. Reasons for not requesting BA were fear of rejection, questioning the method; presumed room shortage; difficulties in deciding whether one's problems are serious enough; experiencing the situation to be too clinically acute. CONCLUSION: The results from this study indicated the importance of repeated staff education on all aspects of BA when it is being newly implemented, as well as the importance of working with attitudes of staff delivering BA. These were the key ingredients in making BA implementation successful. Our findings may be of value to other treatment centers implementing BA for the first time. TRIAL REGISTRATION: NCT02985047.

Components of Brief Admission as a Crisis Intervention for Patients With a Borderline Personality Disorder: Results of a Delphi Study.

BACKGROUND: Brief admission (BA) is a widely used intervention for patients with a borderline personality disorder but it has not yet clearly defined and still lacks clear operational standards. To fully develop this intervention, the relevant components need to be identified and clearly documented. OBJECTIVE: To obtain consensus on the components of BA as a crisis intervention for patients with a borderline personality disorder. DESIGN: Modified Delphi study. RESULTS: Consensus of 100% was reached for the components: "BA plan must be developed together with the patient"; "The BA intervention should be mentioned in the care plan for the patient"; "Not all behavior on the part of the patient has to be accepted during a BA"; and "The BA can only be offered together with treatment by a community care professional." CONCLUSION: Consensus on the components of BA was reached for 82 of the 90 components. This indicates a substantial degree of agreement on what BA should entail.

A standardized crisis management model for self-harming and suicidal individuals with three or more diagnostic criteria of borderline personality disorder: The Brief Admission Skåne randomized controlled trial protocol (BASRCT).

BACKGROUND: Brief Admission is a crisis and risk management strategy in which self-harming and suicidal individuals with three or more diagnostic criteria of borderline personality disorder self-admit to hospital at times of increasing risk when other efforts to stay safe are failing. Standardized in the current randomized controlled trial, the intensity of Brief Admission Skåne is implemented in durations of three days, with a maximum frequency of three times a month. Brief Admission is integrated into existing treatment plans in advance of crises to prevent reliance on general psychiatric admissions for risk management, as these may be lengthy, unstructured, and of uncertain therapeutic value. METHODS/DESIGN: The overall objective of the Brief Admission Skåne randomized controlled trial is to determine if Brief Admission can replace general psychiatric admission for self-harming and suicidal individuals with complex mental illness at times of escalating risk. Other objectives of the study are to evaluate whether Brief Admission increases daily functioning and enhances coping, reduces psychiatric symptoms including frequency and severity of self-harm and suicidal behaviours. A final objective is to determine if Brief Admission is an effective crisis management model for this population. Participants are randomized at an individual level to either Brief Admission Skåne plus Treatment as Usual or Treatment As Usual. Based on a priori power analyses, N = 124 participants will be recruited to the study. Data collection is in progress, and will continue until June 2018. All participant data are single-blinded and will be handled with intention-to-treat analysis. DISCUSSION: Based on the combined clinical experience of our international research group, the Brief Admission Skåne randomized controlled trial upon which the current protocol is based represents the first initiative to standardize, implement and evaluate Brief Admission amongst self-harming and suicidal individuals, including those with borderline traits. Objectively measuring protocol fidelity and developing English-language Brief Admission study protocols and training materials are implementation and dissemination targets developed in order to facilitate adherent international export of Brief Admission Skåne. TRIAL REGISTRATION: NCT02985047 . Registered November 25, 2016. Retrospectively registered.

Brief Admissions During Prolonged Treatment in a Case Involving Borderline Personality Disorder and Posttraumatic Stress Disorder: Use and Functions.

BACKGROUND: This study describes the use of brief admissions to a psychiatric ward by a single patient across a period of 7 years. The patient suffered from a borderline personality disorder and a complex posttraumatic stress disorder. OBJECTIVE: The purpose of this study was to describe how brief admission may be used during a long-term treatment process. DESIGN: A single-case descriptive study with triangulation of the data was undertaken. Semistructured interviews were conducted with the patient and the patient's spouse, psychiatrist, ward nurse, and community psychiatric nurse. Other data were retrieved from the medical records of the patient. RESULTS: Four phases could be distinguished in the treatment of the patient: crisis, treatment of posttraumatic stress disorder, treatment of borderline personality disorder, and recovery. The use of brief admissions positively influenced the course of treatment. CONCLUSIONS: Brief admissions were initially used to prevent self-harm and suicide. The goals and functions expanded to prevention of prolonged admission, prevention of dropout from evidence-based therapy, and practicing with newly acquired skills and promotion of autonomy.

One-Year Consistency in Lifetime Frequency Estimates and Functions of Non-Suicidal Self-Injury in a Clinical Sample.

Non-suicidal self-injury (NSSI), the direct, deliberate destruction of one's own bodily tissue in the absence of an intent to die, is frequently used for evaluating treatment in clinical care. One instrument for assessing NSSI is the Inventory of Statements About Self-Injury (ISAS). The ISAS is a self-rating measure examining the lifetime frequencies of NSSI behaviors and further exploring NSSI functions. The study aimed to examine the consistency of self-reported lifetime NSSI frequencies and functions (via the ISAS) in a clinical sample of individuals with current self-harm and/or recurrent suicidal behaviors over one year. Fifty-two individuals (84.6% women) completed the ISAS three times over 1 year. We found relatively good test-retest stability for most NSSI behaviors and functions, but the correlation coefficients and frequencies of NSSI behaviors varied substantially. Approximately, 50% of participants reported lower lifetime frequencies of NSSI behaviors at the later time points, with approximately 20% reporting a significant reduction in their lifetime frequencies over one year. This unexpected finding raises concerns about the accuracy of reporting lifetime NSSI frequencies among individuals with multiple psychiatric diagnoses and extensive NSSI behaviors across their lives. Further research is needed to determine more reliable ways of collecting data on the lifetime frequency of NSSI in clinical samples and the accuracy of lifetime NSSI frequency estimates in general.

Brief admission (BA) for patients with emotional instability and self-harm: nurses' perspectives - person-centred care in clinical practice.

Purpose: Emotional instability and self-harm pose major problems for society and health care. There are effective interventions in outpatient care, but when patients need inpatient care, nurses often struggle meeting their patient's needs. Brief admission (BA) is a newly implemented crisis intervention and novel form of inpatient care. The aim of this study is to describe nurses' experiences working with BA related to patients with emotional instability and self-harm. Methods: Eight nurses were interviewed according to a semi-structured interview guide. The data was analysed using qualitative content analysis. Results: Four main categories emerged regarding nurses' experiences with BA: provides security and continuity, fosters caring relationships, shifts focus towards patient's health and empowers the patient. The nurse's role shifted from "handling problems" to establishing caring relationships with a focus on the person's health and possibilities for recovering instead of psychiatric symptoms. Conclusions: Previous studies on patients' perspective of BA describe positive experiences such as increased autonomy and participation in the healthcare process. This study supports those findings, albeit from the perspective of nurses. Our findings suggest that BA may reduce work-related stress experienced by nurses while caring for persons with emotional instability and self-harm. BA may also support nurses in their ability to provide more meaningful and constructive psychiatric inpatient care.

Effect of Brief Admission to Hospital by Self-referral for Individuals Who Self-harm and Are at Risk of Suicide: A Randomized Clinical Trial.

Importance: To our knowledge, there is no consensus regarding when individuals who repeatedly self-harm and are at risk of suicide should be hospitalized. To evaluate a new alternative, we examined the effects of brief admission (BA) to hospital by self-referral. Objectives: To determine the effects of BA on inpatient service use and on secondary outcomes of daily life functioning, nonsuicidal self-injuries, and attempted suicide among individuals who self-harm and are at risk of suicide. Design, Setting, and Participants: The single-masked Brief Admission Skåne Randomized Clinical Trial was conducted from September 2015 to June 2018 at 4 psychiatric health care facilities in southern Sweden. Data were collected 6 months retrospectively at baseline and at 6-month and 12-month follow-ups. Participants were randomized to either BA and treatment as usual (BA group) or treatment as usual (control group). The sample was a referral population, with the most important inclusion criteria being current episodes of self-harm and/or recurrent suicidality, at least 3 diagnostic criteria for borderline personality disorder, and hospitalization in the last 6 months. Interventions: Self-referred BA was offered for 12 months, with standard limits for duration and frequency, after the negotiation of a contract outlining the intervention. Main Outcomes and Measures: Prespecified main outcome measures were days admitted to the hospital, including voluntary admission, BA, and compulsory admission. Results: The 125 participants had a mean (SD) age of 32.0 (9.4) years, 106 (84.8%) were women, and 63 were randomized to the BA group and 62 to the control group. No significant advantage was observed in the number of days in the hospital for the BA group compared with the control group. Within-group analyses demonstrated significant decreases in both groups regarding days admitted to the hospital (BA group: χ2 = 22.71; P < .001; control group: χ2 = 23.01; P < .001) and visits to the emergency department (BA group: χ2 = 13.95; P < .001; control group: χ2 = 21.61; P < .001), but only the BA group showed a reduction in days with compulsory admission (χ2 = 7.67; P = .02) and nonsuicidal self-injuries (χ2 = 6.13; P = .047). The BA group showed significantly greater improvements in the mobility domain of daily life functioning (z = -2.39; P = .02) and significant within-group improvements in 3 other domains (cognition: F = 9.02; P < .001; domestic responsibilities: F = 3.23; P = .049; and participation: F = 3.79; P = .03). Conclusions and Relevance: Brief admission appears no more efficacious in reducing use of inpatient services than usual care for individuals who self-harm and are at risk of suicide. Future studies should explore other possible beneficial effects. Trial Registration: ClinicalTrials.gov identifier: NCT02985047.

Evidence base and components of Brief Admission as an intervention for patients with borderline personality disorder: a review of the literature.

PURPOSE: To review the available evidence-based literature on the components of brief inpatient psychiatric hospital admission as an intervention for patients with borderline personality disorder. DESIGN AND METHOD: Systematic literature search, narrative literature review. Content analysis. FINDINGS: Five key components of brief admission as an intervention were identified: discussion of goals; organization of Brief Admission; clear admission procedure; specification of any other interventions during Brief Admission; and stipulation of conditions for premature (i.e., forced) discharge. RESEARCH AND PRACTICE IMPLICATIONS: Brief Admission can be effectively used to prevent self-harm and suicide in patients with borderline personality disorder. During the Brief Admission, psychiatric nurses can support these patients achieving an active coping in dealing with their symptoms.

Experiences of patients with borderline personality disorder with the brief admission intervention: a phenomenological study.

Brief admission is a crisis intervention for patients with borderline personality disorder (BPD), and refers to a clinical admission at a psychiatric hospital for a period of 1-5 nights. Patients formulate a treatment plan together with their community mental health nurse about the maximum frequency allowed for these brief admissions. The purpose of the study was to describe the lived experiences of patients with BPD with use of the brief admission intervention. The study used a phenomenological approach. Inclusion criteria were a diagnosis of BPD, according to the Diagnostic and Statistical Manual of Mental Disorders-IV criteria; experience with brief admission, and sufficient understanding of the Dutch language. A total of 16 female patients and one male patient participated in the study. Thematic analysis of the transcripts of the interviews revealed four major meaning units: (i) organization of the brief admission; (ii) contact with a nurse; (iii) time out from daily life; and (iv) experienced value for the patient. Patients highlighted the quality of the contact with a nurse as the most important aspect of the brief admission. Nurses should be aware of the importance of connecting with patients who have BPD during a brief admission, particularly in light of the interpersonal hypersensitivity that characterizes these patients.