Further reading - an overview of the evidence

Best available evidence suggests that, on the whole, acute in-patient care is at best neutral and at worst damaging to the long term recovery of people with personality disorder. However, there will of course be occasions when inpatient care can be life-saving in the short term if used judiciously.

Long term specialist residential placements also fail to show positive long term benefits. This suggests that the problem is not due to a lack of specialist skills, knowledge or attitudes within acute ward staff. One study showed that a short stay in a specialist residential unit followed by long term outpatient treatment had significantly better outcomes in a variety of indicators than long stay specialist residential treatment. Severity of personality disorder also appears to be a negative predictor of outcome for inpatient treatment, but this does not seem to be the case for outpatient treatment.

There appears to a principle of “less is more” as regards inpatient treatment. The benefit of “less” may be explained by the incremental accrual of skills by managing emotional crises in the everyday interpersonal and social contexts in which they arise. This contrasts with a pattern of avoiding such situations by admission to hospital, which inhibits in vivo skills development. Admitting a dysregulated, emotionally sensitive individual to a highly emotionally-charged environment, where staff may have different views on the appropriateness of the admission and respond differently to the patient as a result, can have significant dysrregulating effects.

Many people with borderline personality disorder are likely to be particularly sensitive to real or perceived disapproval from staff and/or other patients. This increased emotional sensitivity, and sensitivity to rejection in particular, can lead to an emotional response of intolerable intensity. Very often, the only strategies available to the patient to modify such unpleasant emotional states are unhelpful, for example self-harm, use of drugs or alcohol etc. Use of such strategies in the inpatient setting is often viewed negatively by staff, and any disapproval or even gentle challenging of the behaviour may be experienced by the patient as a rejection, leading to a further intolerable emotional response, which in turn may lead to more unhelpful behaviour in an
attempt to feel better, with further challenges by staff, and so on.