Borderline personality disorder (BPD) is one of the most misunderstood and contested diagnoses in mental health. Characterised by emotional dysregulation, unstable relationships, and self-harming behaviours, people with BPD often experience repeated crises and high-risk situations.
Previous Mental Elf blogs have explored widespread misunderstandings of the BPD label, diagnostic overlap with other conditions and the relationship between BPD criteria and suicidality.
Recently Dan Warrender blogged about a systematic review of an approach known as Brief Admission; a structured approach to hospital admission for this population, describing promising but inconsistent results. This blog builds on this body of commentary by reflecting on new longitudinal evidence from Daukantaitė et al. (2025), examining four years of Brief Admission self-referral for people with a BPD diagnosis.
My reflections are informed by multiple perspectives. Professionally, I have worked within a specialised BPD service in the UK and have seen first hand the challenges of balancing risk management with person-centred, trauma-informed care. Personally, I am a brother and son to family members who access secondary and tertiary mental health services, which deepens my appreciation of the lived realities behind clinical presentations. From this combined lens, I tend to foreground relational approaches, self-empowerment, and autonomy rather than purely medicalised interventions.
BPD remains highly stigmatised within services, with subjective risk assessments, staff burnout, and service-led interventions often limiting client agency. In this context, brief admission, which allows self-referral, short-term respite, and a focus on self-care rather than medical treatment, represents a promising alternative.
Balancing risk management with trauma informed care for people with a BPD diagnosis is challenging
Methods
The study employed a mixed-methods convergent parallel design, in which quantitative and qualitative data were collected simultaneously, analysed separately, and integrated during the discussion (Daukantaitė et al, 2025). Participants were drawn from a previous randomised controlled trial on Brief Admission for individuals with borderline personality disorder (BPD) and self-harm, conducted between 2015 and 2018 (Westling et al, 2019). This follow-up study (2018–2022) examined long-term utilisation and experiences of Brief Admission among this cohort.
A total of 125 individuals from four psychiatric inpatient units in southern Sweden were eligible, all with a history of recurrent suicidality or self-harm and at least three diagnostic criteria for BPD. Eighty-one participants consented to the follow-up, and 62 completed all four years.
- Implementation of Brief Admission followed a structured manual.
- Each participant negotiated an individualised contract allowing self-referral for up to three nights, a maximum of three times per month.
- Stays were nurse-led, focused on autonomy and self-care, and did not include medical or psychological treatment on the ward.
Data sources included medical records and a four-year follow-up survey. Medical records provided data on Brief Admission days and hospital admissions at six-month intervals. The survey measured functioning (WHODAS-II), non-suicidal self-injury (ISAS), and satisfaction (CSQ-8), and invited open-ended responses.
Quantitative analyses were conducted, with k-means cluster analysis to identify patterns of Brief Admission utilisation. This method is used to group similar sets within data. Qualitative analysis was also applied with content analysis used to code and categorise responses relating to experiences and factors influencing Brief Admission use.
Results
Over the four-year follow-up, patterns of Brief Admission utilisation varied considerably among participants, revealing both declining trends in overall use and distinct engagement profiles. When examining mean levels across the sample, Brief Admission use averaged approximately eight days per six-month period in the initial stages following access, but gradually declined to three to four days per six-month period by the end of the four years.
The k-means cluster analysis identified three distinct utilisation profiles:
- The largest group, Cluster 1 (n=40), exhibited consistently low Brief Admission usage across all time points.
- Cluster 2 (n=14) represented participants who initially engaged more frequently but whose Brief Admission use declined gradually over time.
- In contrast, Cluster 3 (n=8) consisted of individuals with high and sustained engagement, maintaining frequent Brief Admission use throughout the four-year period.
The distribution of former intervention and control participants was even across clusters, indicating that assignment in the original RCT did not influence long-term usage patterns.
When comparing demographic and clinical characteristics, no statistically significant differences emerged across clusters, though several trends were observed:
- Participants in Cluster 1 were younger on average (mean age 31.2 years) than those in Clusters 2 (38.1 years) and 3 (34.6 years).
- Women represented the majority in all clusters (75–86%).
- Functional assessments (WHODAS-II) revealed that individuals in Cluster 3 reported the highest functional impairment, particularly in self-care, domestic responsibilities, and participation, suggesting that those with greater daily life challenges were more likely to maintain long-term engagement with Brief Admission.
- Recent non-suicidal self-injury (NSSI) was most prevalent in Clusters 2 (36%) and 3 (43%), compared to only 3% in Cluster 1.
- Lifetime suicidal behaviour was high across all clusters (≥86%), reflecting the high-risk profile of the sample.
- While differences in psychiatric hospitalisations and emergency visits were not statistically significant, Cluster 3 participants tended to have slightly higher numbers of hospital days, medication support, and social service involvement.
Findings on Participants’ experiences and satisfaction:
- Those in Cluster 3 consistently reported the most positive perceptions, with 75% holding a current Brief Admission contract, 87.5% having used Brief Admission in the past year, and 62.5% being “very satisfied.” In this group, half rated the quality of Brief Admission as excellent, and most reported that Brief Admission met most or all of their needs and significantly helped them manage their problems.
- In contrast, participants in Cluster 1 were less engaged and less likely to respond to questions about satisfaction, suggesting a weaker connection to the intervention.
- Cluster 2 participants reported moderate engagement and satisfaction.
The qualitative content analysis of open-ended survey responses further illuminated these quantitative findings, identifying five overarching categories that explained variations in Brief Admission use:
- No need – reflected recovery, stability, or alternative support reducing reliance on Brief Admission.
- Resistance – involved ambivalence, prior negative care experiences, or reluctance to seek admission.
- Individual factors – personal circumstances that either supported the individual’s process of recovery, that is, contributed to lessening the need for Brief Admission, or were described as personal hurdles to using Brief Admission.
- The central role of mental health workers – Positive and negative experiences with mental health workers were seen as pivotal in shaping participants’ trust and continued engagement.
- The care system – systemic factors such as limited bed availability, staff shortages, and integration issues with emergency services were reported to either facilitate or hinder Brief Admission use.
Overall, while most participants’ use of Brief Admission decreased over time, a small subgroup (cluster 3) with enduring functional impairments continued to rely on it heavily, describing Brief Admission as a vital safety net providing structure, autonomy, and emotional security.
Three distinct groups were identified in the data with one benefitting most from Brief Admission.
Conclusions
The authors argue that Brief Admission:
emerges as a promising, person-centred self-care option that consistently promotes autonomy over time for individuals with severe mental health conditions—particularly those experiencing significant functional impairments and facing barriers to accessing traditional psychiatric services.
They note that concerns among stakeholders that Brief Admission might “lead to overcrowded wards or excessive healthcare use appear to be unsupported by the data,” as continued use was “limited to a small subgroup of participants with the most severe psychiatric symptoms.” For these individuals, Brief Admission “likely functions as a substitute for other, often more resource-intensive forms of care, rather than adding to the overall service burden.”
Finally, they conclude that:
successful and sustainable implementation of Brief Admission requires ongoing efforts to overcome structural and organisational barriers, [such as] negative or sceptical clinician attitudes, limited availability of beds, and restricted access to emergency services.
Strengths and limitations
This study demonstrates several methodological strengths. It addresses a clearly focused research question, exploring long-term utilisation patterns and experiences of Brief Admission among individuals with borderline personality disorder (BPD) and self-harm. A strength is the use of objective medical record data, collected every six months across a four-year period, to measure Brief Admission days and psychiatric admissions. This approach reduced recall bias and ensured consistency in data collection. However, it does not discuss standardisation of how records are written which can often differ between healthcare practitioner and provider. Inclusion of validated self-report measures added rigour and reliability to outcome measurement.
The study also benefits from its transparent reporting of attrition, missing data, and analytic procedures. Taking a mixed methos approach with the inclusion of both quantitative (cluster analysis, descriptive comparisons) and qualitative (content analysis) approaches enriched the findings and allowed the researchers to explore not only how Brief Admission was used, but why. The qualitative strand, though limited in depth, contextualised the statistical results and illuminated key factors influencing Brief Admission use—such as personal motivation, perceived need, the role of staff relationships, and systemic barriers.
However, several limitations affect the confidence we can have in the findings. The most significant limitation was high attrition, with only 62 of the 125 original participants completing all four years. The authors acknowledge that this loss “limits the representativeness of the findings and increases the risk of bias”. The small sample size, particularly in the smallest utilisation cluster (n=8), also reduces statistical power and the stability of identified patterns.
Furthermore, although the study compared demographic and clinical variables across clusters, there was minimal adjustment for confounding factors, with analyses largely descriptive. The qualitative component was based on brief open-ended survey responses rather than interviews, limiting depth and nuance. Finally, as the authors note, findings are most applicable to specialist psychiatric settings in southern Sweden, and may not generalise to other healthcare systems or models of crisis intervention.
Overall, despite these constraints, the study provides valuable longitudinal and mixed-methods evidence supporting Brief Admission as a feasible, person-centred model that promotes autonomy for individuals with complex mental health needs, while transparently acknowledging its exploratory scope and contextual limitations.
Using mixed methods enriched the findings.
Implications for practice
This study highlights that Brief Admission’s structured, self-referral, nurse-led model promotes autonomy, self-management, and person-centred care. By allowing clients to initiate their own admissions, Brief Admission reduces the power traditionally exercised by care teams through gatekeeping. This approach positions the client as the expert in their own life, enhancing trust in services, validating lived experience, and fostering collaborative relationships. It also facilitates co-production of care plans, with clients actively negotiating individualised contracts and participating in decisions about the frequency and nature of their admissions. These are all significant factors that are often missing for clients with BPD within current mental health teams.
A key insight from the study is the importance of relational, skills-focused support. Traditional psychiatric wards are often not experienced as therapeutic environments for individuals in crisis, with the clinical nature of care sometimes exacerbating distress or reducing engagement. My feeling is that framing Brief Admission as a short-term ‘respite’ option creates an opportunity to reduce the overtly clinical atmosphere and prioritise relational support. Within such settings, staff could provide more intensive guidance on self-care, autonomy, and coping strategies. This environment could create skill-building in daily functioning and emotional regulation, rather than focusing solely on risk containment or medicalisation.
Addressing staff stigmatisation remains essential. Training in trauma-informed care, education about the evidence base for Brief Admission, and reflective practice around biases toward self-harm or BPD can help staff view Brief Admission as a supportive intervention rather than indulgent. Further research will be needed on how best to support this since positive staff engagement is crucial for sustaining trust, ensuring consistent delivery, and supporting long-term participation.
In the UK context, the scarcity of psychiatric beds for voluntary or self-referral admissions (Kings Fund, 2025) presents a significant barrier for BPD clients in crisis. Implementation of Brief Admission would require investment in alternative infrastructure, such as crisis houses, step-down units, or community-based respite facilities. These settings are better suited to relational, skills-based support and align with trauma-informed, person-centred principles. Framing Brief Admission as ‘respite’ may also facilitate commissioning and funding through community mental health budgets or charitable partnerships.
There are large disparities and inequities throughout the UK in how mental health services operate (Emsley et al, 2022). With this in mind, further research is required to determine which type of mental health team or service model is best suited for Brief Admission to understand how it should be implemented. Whether this would fit within a generic ‘Recovery’ model, or if a more specialist BPD service with a greater understanding of trauma-informed approaches would maximise client autonomy and engagement. Finally, understanding how multidisciplinary team composition, skill mix, and organisational culture influence outcomes will be essential for safe and effective implementation.
This approach could build autonomy and coping skills.
Links
Primary paper
, , , and . (2025). Brief Admission by Self-Referral: A 4-Year Follow-Up on Utilisation Patterns and Experiences. International Journal of Mental Health Nursing 34, no. 4: e70091. https://doi.org/10.1111/inm.70091
Other references
Westling, S. , Daukantaitė D., Liljedahl S. I., 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, no. 6: e195463. 10.1001/jamanetworkopen.2019.5463.
