The management of crises

Principles and general management of crises

maintain a calm and non-threatening attitude



try to understand the crisis from the person's point of view



explore the person's reasons for distress



use empathic open questioning, including validating statements, to identify the onset and the course of the current problems



seek to stimulate reflection about solutions



avoid minimising the person's stated reasons for the crisis



refrain from offering solutions before receiving full clarification of the problems



explore other options before considering admission to a crisis unit or inpatient admission



offer appropriate follow-up within a time frame agreed with the person.



Drug treatment during crises

Short-term use of drug treatments may be helpful for people with borderline personality disorder during a crisis.

Before starting short-term drug treatments for people with borderline personality disorder during a crisis:

ensure that there is consensus among prescribers and other involved professionals about the drug used and that the primary prescriber is identified



establish likely risks of prescribing, including alcohol and illicit drug use



take account of the psychological role of prescribing (both for the individual and for the prescriber) and the impact that prescribing decisions may have on the therapeutic relationship and the overall care plan, including long-term treatment strategies



ensure that a drug is not used in place of other more appropriate interventions



use a single drug



avoid polypharmacy whenever possible.



When prescribing short-term drug treatment for people with borderline personality disorder in a crisis:

choose a drug (such as a sedative antihistamine [ ] ) that has a low side-effect profile, low addictive properties, minimum potential for misuse and relative safety in overdose



use the minimum effective dose



prescribe fewer tablets more frequently if there is a significant risk of overdose



agree with the person the target symptoms, monitoring arrangements and anticipated duration of treatment



agree with the person a plan for adherence



discontinue a drug after a trial period if the target symptoms do not improve



consider alternative treatments, including psychological treatments, if target symptoms do not improve or the level of risk does not diminish



arrange an appointment to review the overall care plan, including pharmacological and other treatments, after the crisis has subsided.



Follow-up after a crisis

After a crisis has resolved or subsided, ensure that crisis plans, and if necessary the overall care plan, are updated as soon as possible to reflect current concerns and identify which treatment strategies have proved helpful. This should be done in conjunction with the person with borderline personality disorder and their family or carers if possible, and should include:

a review of the crisis and its antecedents, taking into account environmental, personal and relationship factors



a review of drug treatment, including benefits, side effects, any safety concerns and role in the overall treatment strategy



a plan to stop drug treatment begun during a crisis, usually within 1 week



a review of psychological treatments, including their role in the overall treatment strategy and their possible role in precipitating the crisis.



If drug treatment started during a crisis cannot be stopped within 1 week, there should be a regular review of the drug to monitor effectiveness, side effects, misuse and dependency. The frequency of the review should be agreed with the person and recorded in the overall care plan.

The management of insomnia

Provide people with borderline personality disorder who have sleep problems with general advice about sleep hygiene, including having a bedtime routine, avoiding caffeine, reducing activities likely to defer sleep (such as watching violent or exciting television programmes or films), and employing activities that may encourage sleep.

Be aware of the potential for misuse of many of the drugs used for insomnia and consider other drugs such as sedative antihistamines.

Discharge to primary care

When discharging a person with borderline personality disorder from secondary care to primary care, discuss the process with them and, whenever possible, their family or carers beforehand. Agree a care plan that specifies the steps they can take to try to manage their distress, how to cope with future crises and how to re-engage with community mental health services if needed. Inform the GP.

Inpatient services

Before considering admission to an acute psychiatric inpatient unit for a person with borderline personality disorder, first refer them to a crisis resolution and home treatment team or other locally available alternative to admission.

the management of crises involving significant risk to self or others that cannot be managed within other services, or



detention under the Mental Health Act (for any reason).



When considering inpatient care for a person with borderline personality disorder, actively involve them in the decision and:

ensure the decision is based on an explicit, joint understanding of the potential benefits and likely harm that may result from admission



agree the length and purpose of the admission in advance



ensure that when, in extreme circumstances, compulsory treatment is used, management on a voluntary basis is resumed at the earliest opportunity.



Arrange a formal CPA review for people with borderline personality disorder who have been admitted twice or more in the previous 6 months.

Ensure that young people with severe borderline personality disorder have access to tier 4 specialist services if required, which may include: