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Background: Extensive psychiatric hospitalization due to repeated severe self-harm (SH), is a poorly researched area, but a challenge within health services (HS). Recent studies have demonstrated high levels of involuntary treatment among patients with severe personality disorder (PD) and complex comorbidity. Keeping focus on extensively hospitalized SH patients, this study aimed to investigate patients' and clinicians' evaluation of HS and treatment alliance. Method: A cross-sectional study with an inpatient sample (age >18 years) with frequent (>5) or long (>4 weeks) psychiatric hospital admissions last year due to SH or SA recruited from 12 hospitals across health regions (N = 42). Evaluation included patient and clinician report. Results: A minority of the patients (14%) were satisfied with HS before the current admission, 45% (patients) and 20% (clinicians) found the current admission helpful, and 46% (patients) and 14% (clinicians) worried about discharge. Treatment complaints were received in 38% of the cases. Outpatient mental HS were available after discharge for 68% and a majority of clinicians indicated satisfactory contact across HS. More intensive or specialized formats were unusual (structured outpatient treatment 35%, day treatment 21%, ambulatory services 32%, planned inpatient services 31%). Mutual problem understanding, aims, and confidence in therapists during the hospital stay were limited (patient-rated satisfactory mutual problem understanding: 39%, aims of stay: 50%, confidence: 50%). Patient and therapist alliance-ratings were in concordance for the majority. Conclusion: The study highlights poor HS satisfaction, poor patient–therapist coherence, limited treatment alliance and limited follow-up in structured treatments addressing SH or intermediary supportive ambulatory/day/inpatient services. [ABSTRACT FROM AUTHOR]

Social media use is an integrated part of youth's social life, enabling access to knowledge and social exploration, but it also increases the risk of experiencing online child sexual abuse (OCSA). Quantitative reviews of OCSA provide insights into prevalence, risk factors, and mental health outcomes, but we have limited knowledge about how youth experience OCSA. This study aims to synthesize qualitative studies on youth's (12–24 years of age) first‐person experiences of OCSA. We conducted a systematic database search and included 16 studies. The meta‐synthesis resulted in three meta‐themes: (1) "Navigating in a digital world – feeling safe and understood," (2) "Being lured, tricked, and caught up in online child sexual abuse," and (3) "Facing the consequences – feeling powerless and blaming oneself." Although the studies included most females, findings apply to all genders and across ages. The results highlight how online sexual engagement is a way to explore social and sexual relationships and address a basic need to be understood and supported. However, when trust is misused, developmental tasks related to autonomy and agency may be shattered, replaced with shame and self‐blame. These findings point to the need to openly and nonjudgementally address OCSA so that it can be disclosed, and the psychological impact can be addressed. [ABSTRACT FROM AUTHOR]

Studies report an increase in self‐harm, and engagement in risk content online has gained growing attention. This study aims to synthesize qualitative studies on youths' (12–25 years of age) engagement in self‐harm content online (SCO). We conducted a systematic database search of studies on first‐person experience and included 16 studies. The meta‐synthesis resulted in two meta‐themes: 1) "Belonging to a community – online engagement with peers who self‐harm" and 2) "Self‐development – online engagement to get to know myself". Following Winnicott's (1953) thinking, digital activity is discussed as an extended peer arena with a "transitional" quality – neither completely internal, nor external, and potentially bridging an inner and outer world. Engagement in SCO is discussed as a transitional object or activity that enables relatedness and self‐definition – important developmental experiences for the exploration of social roles, borders between self and others and self‐identity during adolescence. However, engagement in SCO comes with a risk for deterioration of mental health. Clinicians should ask directly about digital activity and meet those engaged in digital risks with respect. [ABSTRACT FROM AUTHOR]

Self-harm is a major problem among young adults, and many do not seek help from health care services. Little is known about how patients who harm themselves experience positive encounters with health care workers. Blogs are a way of communicating personal experiences to a broader public and may provide an immediate expression of such experiences. We conducted a thematic analysis of blog entries written by ten patients who carry out self-harm, in order to answer the question: How do young adults who blog about their self-harming describe positive encounters with health care workers? The analysis revealed four meta-themes: 1) I feel cared for, 2) I am treated like a fellow human, 3) I can talk about everything, and 4) I feel that the helper takes charge. Emotion regulation skills emerged as the most valued specific therapeutic ingredient. These findings are relevant for making young adults who self-harm feel understood and cared for. [ABSTRACT FROM AUTHOR]

Patients with personality disorders (PDs) often have insecure attachment patterns and may be especially vulnerable to abrupt treatment changes. Patients with borderline PD (BPD) are often considered vulnerable to treatment interruption due to chronic fear of abandonment. Nonetheless, other PDs are poorly investigated. In the first Covid-19 wave in Norway, in-person treatment facilities and group treatments were strongly restricted from March 12th until May/June 2020. To examine and compare changes in outpatient treatment for patients with avoidant (AvPD) and BPD during the first Covid-19 wave in Norway, and patients' reactions to these changes. The study is based on a cross-sectional survey distributed to 1120 patients referred to 12 different PD treatment units on a specialist mental health service level within the Norwegian Network for Personality Disorders. The survey included questions on treatment situation, immediate reactions, and changes during the crisis. From 133 responders (response rate 12%), 40 patients reported BPD and 30 AvPD as diagnosis. All patients were followed up from their therapist after March 12th. Almost all patients in both groups expressed satisfaction under the new circumstances. Both groups experienced the same regularity as before, but more AvPD patients reported less than weekly consultations. AvPD patients reported more negative feelings about changes in therapy, and missed the therapy and group members more than the BPD group. After the lockdown, BPD patients received a closer follow-up than AvPD patients, and the latter reported more negative feelings related to change in their treatment situation. [ABSTRACT FROM AUTHOR]

Treatment irregularity may complicate therapy for patients with personality disorders (PD). In Norway, Covid-19 restrictions led to a shutdown of outpatient mental health services from March 12th, 2020. The article aims to investigate how patients with PD experience Covid-19 related changes in their everyday life and treatment. A multi-center survey was performed in June–October 2020 at 12 PD treatment units. Thematic analysis was chosen for data-analysis of the open questions. Data-analysis resulted in two meta-themes: 1) Treatment changes as good enough emergency solutions – continuing personal change and care during the crisis, and 2) An overwhelming experience of unpredictability in everyday life and treatment – a feeling of being lost and lonely. The two meta-themes encompass themes organized to show diverse experiences of changes in social contact, treatment adjustments, and mental health problems. The two meta-themes could be understood along a dimension of "safety – vulnerability" more than separated experiences. The experiences are discussed concerning technological, social, and individual resources and vulnerability. The therapist should explore the patient's experience of the treatment adjustments several times through the treatment process during a crisis to increase safety and continue treatment. [ABSTRACT FROM AUTHOR]

This article aims to explore how young adults (18–23) who have a history of self‐harm experienced involvement in self‐harm content online during adolescence. The qualitative data analysis follows the steps of Interpretative phenomenological analysis and resulted in four meta‐themes: (1) 'Solitude during adolescence—finally found a place to fit in', (2) 'Tempting but dangerous—a game that never should end', (3) 'Searching for self—it was like an online diary' and (4) 'No one in charge'. Each superordinate theme characterizes essential features of subjective reasons for becoming involved in and their way out of self‐harm content online. Digital involvement is discussed in light of developmental challenges during adolescence—such as exploration of borders, autonomy and self‐identity formation. For lonely people, online involvement with self‐harm content may enable 'a potential space' in between reality and fiction sufficient for relational and personal exploration. Involvement in self‐harm content online may cover a need to belong, to express and share problems, and for support. This knowledge should inform clinicians to ask patients about involvement in risk content online and motivate decision‐makers to develop ways to detect and support vulnerable adolescents online and offline. [ABSTRACT FROM AUTHOR]

Relational and emotional problems, dysregulation, self-harming or substance abuse often characterize personality disorders (PD). In Norway, COVID-19 restrictions led to an abrupt shutdown of services from 12 March 2020 also including specialized PD treatments. The objective of this study was to investigate social and mental distress among patients with PDs during the first COVID-19 wave. A survey was distributed after the first COVID-19 wave (June–October 2020) among 1120 patients from 12 PD treatment units. The response rate was 12% (N = 133). The survey reflected impairment of occupational activity (53% <50% activity last 6 months), life quality (EQ-5D-VAS: 56, SD 19), and personality functioning (LPFS-BF ≥12: 81%, 35% avoidant PD, 44% borderline PD) and high levels of depression and anxiety (PHQ-9 ≥ 10: 84%, GAD-7 ≥ 10: 68%), 49% with health-related anxiety. Problem increase was reported for anxiety (28%), depression (24%), aggression (23%), substance use (14%), and 70% of parents had more child-care difficulties. Self-destructive behaviors (26%) did not increase. The majority (78%) reported increased or unchanged social isolation and loneliness. Occupational activity declined with negative effects on part-time jobs/rehabilitation. Therapist contact was mainly telephone-based (63% ≥ weekly contact). More severe personality problems, current depressive symptoms, and self-harming before 12 March were associated with more frequent consultations. The survey confirms severe, enhanced levels of mental distress among patients receiving telephone-based consultations as the main alternative to specialized PD treatment during the COVID-19 shutdown. The most vulnerable patients received more frequent consultations and self-destructive actions did not increase. [ABSTRACT FROM AUTHOR]

The societal shutdown due to the Covid-19 pandemic involved mental health services for personality disorder (PD) and was introduced from 12 March 2020 in Norway. Rapid implementation of treatment modifications was required for patients typically characterized by insecure attachment and vulnerability to separation. To investigate immediate reactions to the shutdown of services; alternative treatment received; and differences related to age in a clinical sample of patients with PD. A survey performed from June to October 2020 (after the first Covid-19 wave) among 1120 patients from 12 units offering comprehensive group-based PD programs. The response-rate was 12% (N = 133). Negative feelings of anxiety, sadness, and helplessness were noteworthy immediate reactions, but the dominating attitude was accommodation. Younger patients (<26 years) reported more skepticism and less relief. Modified treatment was mainly telephone therapy. Digital therapy was less available, but was more frequent among younger patients. A minority received digital group therapy. Most patients rated the frequency and quality of modified treatments as satisfactory in the given situation, but also worried about own treatment progress, lack of group therapy, and 47% missed seeing the therapist when having telephone consultations. The survey confirms a radical modification from comprehensive group-based PD programs to telephone consultations, low availability of digital consultations and group treatments. Taking a short-term, first wave perspective, the survey indicates a noteworthy capacity among poorly functioning patients for accommodating to a clearly challenging situation, as well as considerable concern about treatment progress. [ABSTRACT FROM AUTHOR]

Self-harm is associated with mental illness and suicide risk. The present study aims to increase knowledge of adolescent girls' pathways into and out of self-harm. The participants were 19 girls, 13 to 18 years of age, who were strategically selected from an outpatient care unit. A naturalistic multiple case study was done with personal interviews. The interviews were analyzed using Interpretative Phenomenological Analysis, and the capacity for "mentalization"—representation of behavior in terms of mental states—was measured with the Reflective Functioning Scale. The analysis of the topic "beginning self-harm" resulted in two meta-themes: (a) beginning self-harm as a way to handle difficult feelings and relational problems and (b) becoming influenced by peers to experiment with self-harm. The analysis of the topic "quitting self-harm" resulted in three meta-themes: (a) ambivalence toward help, treatment, and ending self-harm; (b) finding one's own way of quitting self-harm; and (c) exploring self-harm together with the therapist. Three case stories illustrate variations in trajectories of change and capacity for mentalization. The findings suggest that self-harm may be a way of handling developmental challenges in autonomy and identity formation during adolescence. Adolescents need an opportunity to discover their own way of quitting self-harm. Variations in mentalization may provide for different pathways. [ABSTRACT FROM AUTHOR]