Personality and Mental Health (2012) Published online in Wiley Online Library (wileyonlinelibrary.com) DOI 10.1002/pmh.1214
Working with borderline personality disorder: A small-scale qualitative investigation into community psychiatric nurses’ constructs of borderline personality disorder
JAMES STROUD1 AND RACHEL PARSONS2, 1Hafan Hedd Resource Centre, Adpar, Newcastle Emlyn, SA38 9NS, UK; 2Cardiff University, 11th Floor, Tower Building, 70 Park Place, Cardiff, CF10 3AT, UK ABSTRACT Borderline personality disorder (BPD) is a complex presentation that can have a significant impact upon the individual and on his or her quality of life. BPD has often been associated with negative connotations (e.g. ‘manipulative’, ‘attention seeking’). The aim of the current study was to gain a fuller understanding of how community psychiatric nurses (CPNs) make sense of the diagnosis of BPD and how their constructs of BPD impact their approach to this client group. Four CPNs, three women and one man, were interviewed using a semi-structured interview schedule. The data were analysed using interpretative phenomenological analysis, to reveal over-arching and sub-themes. The results indicated that participants attempted to ascribe meaning to the client’s presentation ‘in the moment’. When they had a framework to explain behaviour, participants were more likely to express positive attitudes. When they did not have such a framework, participants could view clients in more pejorative terms. As participants were deriving meaning ‘in the moment’, there could be fluidity with regards to participants’ attitudes, ranging from ‘dread’ to a ‘desire to help’. This could lead to participants shifting between ‘connected’ and ‘disconnected’ interactions with clients. The limitations and implications for clinical practise will also be considered. Copyright © 2012 John Wiley & Sons, Ltd. Introduction Borderline personality disorder (BPD) is defined by the Diagnostic and Statistical Manual–fourth edition (American Psychiatric Association, 2000) as ‘a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood’. Estimates suggest that the prevalence of BPD in the general population is between 1.1% and 3% and can vary within clinical settings from 10% in
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outpatients to 15–50% in inpatient samples (Arntz & van Genderen, 2009; Stuart & Laria, 2005; Swartz, Blazer, George, & Winfield, 1990; Widgier & Weissman, 1991). Ensuring individuals with a diagnosis of BPD have appropriate treatment is paramount for many reasons. Firstly, evidence suggests that 8–10% of individuals with a diagnosis of BPD may die through suicide (Adams, Bernat, & Luscher, 2001; Paris, 1993). Secondly, individuals with BPD can often require hospitalization or inpatient admissions
(2012) DOI: 10.1002/pmh
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because of the severity of their difficulties. Thirdly, the complex presentation of BPD can have a profound effect upon the individual’s social, educational, vocational functioning and general quality of life. Treatments of BPD have suggested that a number of factors are important in the aetiology of BPD. These include the individual’s temperament, exposure to trauma and environmental factors (e.g. parental influences, exposure to invalidating environments, the individual’s core emotional needs being unmet; Arntz & van Genderen, 2009; Linehan, 1993; Young, Klosko, & Weishaar, 2003). As a result of these factors, treatments for BPD (dialectical behavioural therapy (DBT) and schema therapy) emphasize the primacy of the therapeutic relationship between the client and therapist. For example, schema therapy (Young et al., 2003) places at its core the relationship between the therapist and the client, with prominence on creating a safe and trusting relationship. The importance of the therapeutic relationship is also reinforced within National Institute for Health and Clinical Excellence (NIHCE, 2009) guidelines. Given the traumatic experiences that individuals with BPD have often had, and the importance placed upon the therapeutic relationship with clients, it is clearly essential to ensure that staff have a good understanding of BPD, and their attitudes/ beliefs are conducive to the development of a strong therapeutic relationship. For example, DBT emphasizes ‘phenomenological empathy’, where the clinicians attempt to search for empathic, non-judgemental explanations for a client’s presentation (Swales & Heard, 2009). Despite this, there is evidence to suggest that health professionals can often hold negative attitudes towards people with BPD. Westwood and Baker (2010) reviewed the literature on registered mental nurses (RMNs) attitudes towards clients with BPD. Findings indicated that RMNs were often ‘socially distant’ towards BPD clients, compared with clients with other mental illnesses and expressed more negative attitudes and perceptions towards BPD. Westwood
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and Baker (2010) suggested that negative attitudes and ‘social distancing’ may be driven by the staff members’ knowledge and understanding of the BPD presentation. Similarly, Purves and Sands (2009) found that increased level of education related to more positive attitudes towards clients with BPD. Although they acknowledge that this may, in part, relate to willingness to disclose negative attitudes, they also suggest that education can provide a conceptual framework for understanding the individual’s behaviour. In a recent study, Bodner, Cohen-Fridel, and Iancu (2011) found that attitudes differed between professional groups with psychiatric nurses and psychiatrists holding more ‘antagonistic judgements’ than psychologists. The nurses within the sample also expressed less empathy towards this client group, compared with other professionals. Consistent with previous research, Bodner et al. (2011) found that the less negative the evaluations, the higher the empathy expressed towards BPD clients. Westwood and Baker (2010) acknowledged that in two of the reviewed studies, RMNs held positive attitudes about working with clients with BPD (Cleary, Siegfried, & Walter, 2002; James & Cowman, 2007). James and Cowman (2007) found that optimism is growing because staff are perceiving clients as ‘treatable’. Consequently, there was willingness for nurses to work with people with BPD and a desire to improve the services that they receive. Research from the client’s perspective has also demonstrated the importance of staff knowledge and attitudes. A common theme is that clients can view the diagnosis negatively, as it has been associated with ‘untreatability’ (Horn, Johnstone, & Brooke, 2007), which in the past has resulted in the individual being denied services (Crawford, Rutter, Price, et al., 2007). Studies have also demonstrated that some clients perceived the label negatively, that it carried stigma and they were ‘stereotyped’ by professionals (Crawford et al., 2007; Haigh, 2002; Horn et al., 2007; Nehls, 1999; Stalker, Ferguson, & Barclay, 2005). Other clients perceived the label as accurate and felt that
(2012) DOI: 10.1002/pmh
Professional’s knowledge and attitudes towards borderline personality disorder
it was useful to help them make sense of their difficulties; nevertheless, research participants emphasized the importance of staff being sensitive and respectful to their needs, and to consider the impact of the diagnosis (Crawford et al., 2007; Haigh, 2002). The existing research indicates that it is important to obtain a fuller understanding of how frontline mental health professionals understand the presentation of BPD and to consider how the professionals’ constructs may influence their attitudes and, subsequently, the individual’s care. It is important to acknowledge that there is a paucity of research in this area, and the literature focuses on professionals working within inpatient settings. As there is an emphasis on community-based services, and staff working in inpatient settings are likely to be working with clients with more severe presentations, the aim of the current study was to begin to understand community psychiatric nurses’ (CPNs) knowledge, attitudes and approach to clients with BPD. Methodology Design The current research was a qualitative design, using a semi-structured interview schedule to gain a deeper understanding of how CPNs conceptualize BPD and how this may impact upon the client’s care. Participants Four registered CPNs were recruited from a Community Mental Health Team (CMHT). The sample comprised of three female and one male
CPNs. All participants had considerable experience working with clients with BPD. Only one participant (participant 4) had received specific training in working with BPD (DBT), since qualifying as a nurse. Table 1 provides further demographic information. Inclusion/exclusion criteria. As the aims of the research were to understand CPNs’ knowledge and attitudes of BPD, the researchers only included nurses in the study. Inclusion of participants was based on them working within a CMHT setting, having a clinical role and working directly with BPD clients. CPNs were excluded from the study if they were employed in a non-clinical capacity or if they did not have direct experience working with clients with a diagnosis of BPD. Recruitment. Initially, one of the researchers (trainee clinical psychologist) met with CPNs within a CMHT to discuss the research proposal and to enquire about which staff had experience of working with clients with BPD. The professionals were given an information sheet, which provided further details of the research. Team members were asked to read the information sheet in order to make an informed decision about participating in the research. Approximately 48 h later, team members were contacted, and the trainee arranged to meet individually with professionals who consented to take part in the research. The purpose of the research was discussed again, and any questions were answered. During this meeting, if the participant was agreeable to participate, written consent was obtained. Throughout the
Table 1: Demographic information Participant (age range) and gender Time worked as Time working in mental Frequency of contact Time spent working a CPN (years) health field (years) with clients with BPD with BPD (years) Participant Participant Participant Participant
1 (40–49), female 2 (40–49), female 3 (50–59), female 4 (30–39), male
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1–5 6–10 11–15 6–10
1–5 26–30 26–30 6–10
Daily 1–2 times a week Daily Daily
1 5 10 2–3
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recruitment phase, the trainee clinical psychologist met with the CPNs. As the trainee was new to the team (and not a full time member), it was felt that this may ensure that CPNs did not feel pressured into participating in the research. This was also considered when reinforcing to the CPNs, whose participation was voluntary, that they could withdraw at anytime and that they did not have to answer anything that they did not feel comfortable answering (this information was also incorporated in the information sheet). Four out of seven (57%) CPNs that were eligible to take part in the study consented. Data collection Data were collected using a semi-structured interview schedule. The researchers reviewed a semistructured interview schedule, previously used in an inpatient research study. The researchers modified this schedule to ensure that it was appropriate to a community setting. During this process, the researchers were mindful to ensure that the aims of the research were closely adhered to. As part of the modification of the semi-structured interview, the researchers consulted with colleagues to ensure ‘face validity’ of the interview schedule. Key questions from the interview schedule are outlined in Table 2. Interviews were conducted individually with participants in January and February 2011. The interviews were conducted by a trainee clinical psychologist and lasted between 50 and 60 min. Data analysis Data were analysed using interpretative phenomenological analysis (IPA). IPA was chosen over other forms of qualitative methodology because it is concerned with trying to understand ‘lived experience’ and how individuals make sense of their experiences. IPA attempts to explore an individual’s personal perception as opposed to attempting to produce an objective record of the event or state itself (Smith & Osborn, 2003); therefore, IPA was felt to be appropriate to the aims of the study.
Copyright © 2012 John Wiley & Sons, Ltd.
Table 2: Examples of core questions from the semi-structured interview How would you describe a client with borderline personality disorder? What behaviours are common for this diagnosis? Clients with BPD can experience a wide range of symptoms. How do you make sense of these symptoms/changes in symptoms? When you hear the term ‘borderline personality disorder’, what comes to your mind? What are your initial reactions? Without disclosing identifiable information about a particular client, could you tell me about a client that you have worked with that, to you, captures someone with BPD? Could you describe a memorable experience of working with a client with BPD? Thinking about the above event from the person with BPD’s perspective, what do you think was the function of the behaviour? Thinking about yourself, can you tell me about how well equipped you feel you are to work with clients with BPD? What do you think that you do well when working with these clients? Is there anything that you feel you would like to do better/ change when working with these clients?
The analysis of the data followed the steps set out by Smith, Jarman, and Osborn (1999). Initially, each recorded interview was transcribed verbatim. During this process, any personally identifiable information was removed. The researchers read and re-read the transcript to immerse themselves in the participants’ narratives. The researchers used the left-hand margin of the transcript to document any thoughts, feelings and emerging themes. As the researchers re-read the text, they consolidated the ideas from the left-hand margin and documented the emerging themes in the right-hand margin of the text. Once this process was completed, the themes were listed from the whole transcript. These themes were grouped into a table of super-ordinate and sub-themes. This process was completed for each interview transcript to develop super-ordinate and sub-themes from all the interviews. To ensure validity of the analysis, both researchers completed the aforementioned process separately
(2012) DOI: 10.1002/pmh
Professional’s knowledge and attitudes towards borderline personality disorder
and compared the themes once the analysis was completed. This process informed the final results. Ethical considerations A number of ethical issues were considered. Firstly, it was acknowledged that participants may have experienced distressing incidents working with people with BPD. Participants were informed both verbally and within the information sheet that they could withdraw from the study at any time, that they did not have to answer any questions that they did not feel comfortable in answering and/or they could speak with the researchers at anytime to address any issues that arose. Secondly, participants were made aware that if any information of a serious nature was disclosed (e.g. wilful abuse or neglect), the interview would be stopped and the researchers would have a duty of care to take action (e.g. to inform the team manager). Approval for this research project was granted from the local research ethics committee and the Health Board’s Research and Development Department (January 2011). Results On the basis of the analysis of participant’s transcripts, a number of super-ordinate and subordinate themes emerged. These are summarized in Table 3 and will be expanded upon later. Direct quotations from participants, to support the themes, are also provided. Knowledge of BPD CPNs who had not had specific training in BPD appeared to have a limited knowledge base relating to the presentation of BPD: Participant 1: ‘[when asked about how to describe someone with BPD] Good question I should have read up a bit more. . .My understanding of borderline personality is something that is very close to bipolar. They can be up and down and there is a fine line between [the two diagnoses].’
Copyright © 2012 John Wiley & Sons, Ltd.
Table 3: Table of themes Super-ordinate themes
Sub-themes
Knowledge of BPD
Presence/lack of a conceptual framework Links between past and present? Attitudes towards BPD Dread vs. desire to help A process of making sense Interactions with clients Connected vs. disconnected Service context Support and supervision Competing demands and litigation Need for a specialist service
Participant 3: ‘[when asked about understanding of symptoms of BPD] I leave all that to the psychiatrist. I’ve done a lot of research in the past about different things but borderline personality disorder is not one of my fortes.’ All participants acknowledged the importance of negative early life experiences including trauma experienced by clients with BPD. However, when participants appeared to lack a knowledge framework for BPD, the link between past traumas and current difficulties could fluctuate: Participant 1: ‘A really bad childhood into teenage [years], extremely shocking the sexual abuse. Became a drug addict who masked the feelings, not being able to cope with what happened. . .She’s can be quite devious, saying one thing to you and then something different to someone else. The participant who had specific training of DBT had a strong knowledge base to understand BPD, and there appeared to be less fluctuation in the links between past and present: Participant 4: ‘[the client is] more biologically vulnerable to being emotional and as they are growing up they are in an invalidating environment which means that they then have difficulties identifying their own emotions or start to invalidate their own emotions and they become increasingly dysregulated which results in impulsive behaviours to try and regulate their own emotions.’
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Attitudes towards clients with BPD Feelings of ‘dread’ towards working with clients with BPD were frequently expressed. This was often related to the complexity of clients, the longevity of input required and the demands placed upon the CPN: Participant 1: ‘My immediate reaction is “oh no” because they are a really difficult client group to work with.’ Participant 2: [Immediate reaction is] ‘Oh God, here we go again. . .its challenging they are so complex. . .I just found myself exhausted because of the challenges and the behaviours.’ Although clients with BPD were perceived as challenging and complex, it appeared as if the participant’s knowledge base further influenced perceptions of BPD. Participants who lacked a framework appeared to be more likely to use pejorative terms to explain clients’ behaviours: Participant 1: ‘They are telling you one thing, then when you are putting into place the plan they are not seeing it through. . .quite a few of them don’t want to change, perhaps they are scared of change but I think they are also hiding behind it. . .can be quite devious.’ Participant 2: ‘Trying to split people [in teams] up. . .they will try and exploit areas to get you worried.’ Participant 4: ‘The traditional view is about them being very manipulative and attention seeking, but in DBT I have not really found that. It is just about the distress they are in. . .you would look at it in terms of the client is trying to cope.’ Similarly, when participants did not have a clear framework to explain a client’s behaviour, they could hold conflicting explanations, as a way of trying to make sense of the individual’s presentation. As a result, there could be clear shifts in staff attitudes:
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Participant 1: ‘[following a client taking an overdose] I would certainly say that it was a cry for help, but she told me with a smile on her face, so there must have been some idea of gain from it. . .it gave me the idea that she might have been enjoying telling me. She might have been testing me, to see my reactions.’ Despite there being evidence of some negative attitudes towards clients with BPD, all participants had a strong desire to help. This may be linked to the participant’s personal values. Consequently, attitudes could shift between ‘dread’ and ‘a desire to help’: Participant 1: ‘I think the initial “oh no” reaction really quickly envelops into “well they still need help”.’ Participant 2: ‘I feel really sorry for them, where they are [in their lives], but because of the challenges and the behaviours it’s very difficult. . .I think they have got real problems and I think some of them have got more problems than a lot of people.’ Interaction with clients Participants’ interaction with clients could be conceptualized on a continuum of ‘connected’ to ‘disconnected’. When participants were ‘disconnected’ with the client, they may withdraw emotionally, put up a ‘professional front’, suppress their own emotions and form rigid boundaries: Participant 3: ‘It’s a nurse–patient relationship and nobody ever steps over to this side. . .There are boundaries and they don’t step over them. A lot of staff have got [work] phones [that they give clients direct contact numbers] there’s no way [they will have my direct number]. . .they can change their care co-ordinator when they like so they can dismiss you as well, which is good.’ Participant 2: ‘[at the beginning] you don’t know how to trust them and it makes you more aware because she could lie about me for all I know, so it does make you quite tender-footed.’
(2012) DOI: 10.1002/pmh
Professional’s knowledge and attitudes towards borderline personality disorder
When participants were ‘connected’ with the client, they saw the client as a person and engaged with them on a human and emotional level. Although boundaries were still seen as important, they were there explicitly for the clients’ benefit: Participant 4: ‘You are more yourself in DBT, more open. . .[it is important] being genuine, validating the client and the distress or difficulty they are having. . .I think just being respectful, pleasant and interested.’ Participant 2: ‘I think at the beginning what I found frustrating was these sort of pushing, pushing, pushing. . .I don’t think she trusted me at that time. She would say a few lies, yeah, which I caught her out on. I did challenge that because, to me, if you can’t be honest and open then we’re not getting very far are we? I think its got to work both ways. . .Rewarding, was her being able to open up and say to me, “yeah I’ve fallen off the wagon again and I’ve been doing this”. To me that was a big reward because she’d have never done that before.’ The ‘connected’ or ‘disconnected’ approach could be fluid and appeared to be influenced by the participant’s attempts to make sense of the client’s behaviour and prevailing attitudes: Participant 1: ‘[talking about her response to a client who overdosed] I felt glad that I had spent the time with her in Casualty, rather than just putting her on the ambulance. . . If I had phoned 999 and got the ambulance out then that probably would have been a better thing to do because it would not have been reinforcing her behaviour. . .Thinking back, I shouldn’t have spent the time with her, but then I was glad I had because she was okay, so its difficult. . .’ Participant 2: ‘Before having the knowledge I’ve got now I would have said “they are getting on my bloody nerves, I don’t know what to do with them”. . .Over the years you gain knowledge and change your outlook.’
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Participant 4: ‘[In the past] not give anything away but trying to pick inconsistencies in their statements [to] prove that they are not suicidal or not imminent risk. In DBT you are more relaxed and more real and I don’t try to mask, its just more open and it is more helpful to clients and whilst at the same time working to boundaries. . .You don’t need to go in there like a shield so things bounce off.’ Constraints/impact of service context A number of service-related issues appeared to impact upon knowledge, attitudes and approach to clients. Firstly, participant 4 acknowledged the importance of training and regular supervision in DBT as paramount in the therapeutic work with this client group. This enabled the individual to ventilate feelings, maintain focus on the model and discuss the best avenues for treatment (within the DBT framework). Although other participants mentioned ‘informal’ arrangements (e.g. discussions with colleagues), the lack of formal supervision often left them feeling frustrated and helpless about working with this client group. Participant 1: (In response to the question: can you tell me about how equipped you feel to work with clients with borderline personality disorder?) ‘I kind of feel that I am not, but on the other hand I must be doing something right to be working with so many borderline personality disorders, so I must be doing something right, although I think maybe I’m not. . .the help that I am giving is the nursing basis rather than any kind of schema therapy or DBT skills, because I haven’t got any of those skills. . . [what I need is] having a presentation from psychology or whoever, that either reinforces what I am doing or gives me hints and tips of how to manage some of the behaviours, so that would certainly help. Even to know that what I am doing is the right thing that would give me confidence.’ Participant 2: ‘I find that I’ve got to go through a process, a sort of reflection thing in my head [laughs]. I do reflect a lot . . .and sometimes you need to do it because you think to yourself ‘did I say the right thing then or didn’t I?’
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Participant 4: (when asked about what staff ‘communicate’ when they talk about BPD) ‘These clients are [often seen as] a drain on resources, they waste time and shouldn’t be treated by the mental health team and they should sort themselves out and take responsibility for their behaviour. That is the main gist really, but I can also see how the frustration can manifest in the conversations that staff have as you get a lack of support and a lack of training. Even in DBT you can feel frustrated with clients but in DBT you have a team approach, like there is six people all working on somebody’s treatment, as a CPN you might not have that. It is much more difficult and much more stressful.’ Secondly, it was noted by participants that services demands, such as high caseloads and the focus on completing documentation (e.g. risk assessments, care plans) and the risk of litigation, could be additional factors in mediating the participants’ approach to clients. Participant 1: (when asked about the impact of work): [following a phone call from a client with BPD] ‘you think “oh God I don’t want a complaint made against me”. I won’t say that I go home and catastrophise about it, but I guess I do [laughs]. But I don’t want to lose my job.’ Participant 3: ‘it’s all to do with risk. That’s all we are being embroiled in at the moment is risk. Nothing else just risk and litigation. A big part of it, we’ve got to cover ourselves really. . . I switch off as soon as they’ve [the client] gone out of the room I don’t worry. If my risk assessment is tight that’s fine by me.’ Participant 4: ‘As a CPN if something goes wrong then the buck stops with you and then I think that does not help staff to take positive risks. Staff are very defensive in their practice and very risk adverse and in DBT it is about accepting that this is a risky client group and if we wrap them up in cotton wool all the time that is not treating them and I think it is about having a service that is prepared to take well thought out positive risks and I don’t think we are there yet. Because I think staff are so scared of things going wrong and them getting the blame and being sued it is very hard to allow clients to have some responsibility.’
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On the basis of the participants’ accounts, the service structures and demands were a further factor that may impact upon the professional’s approach to the client. Discussion A key finding of the current research is the link between CPNs’ knowledge and attitudes towards clients with BPD. Although it was noted that participants could at times express negative views, this was not a static concept, and attitudes could shift between ‘dread’ and a ‘desire to help’. Participants were constantly trying to ascribe meaning to the client’s changeable presentation; however, developing a coherent meaning could be problematic when the client’s presentation was frequently shifting or conflicting (e.g. smiling whilst talking about an overdose). The researchers hypothesized that the participants’ attitudes could be affected by their knowledge of BPD and by how knowledge was applied ‘in the moment’. Consequently, to understand the participants’ attitudes, there is a need to consider the framework (or lack of) that the participant applies to understand the client’s behaviour at the time. For example, when participants perceived current behaviour to be a consequence of negative early life experiences, participants were more positive/nurturing towards clients. When participants did not link current behaviours with the past, or did not have a framework to explain a current behaviour, participants could view behaviour in more pejorative terms (e.g. ‘manipulative’, ‘attention seeking’). Similarly, participant 4, who had a strong conceptual framework to explain BPD, held the most consistently positive attitudes. This link between application of knowledge (‘in the moment’) and attitudes is crucial for a number of reasons. Firstly, previous (quantitative) research has often categorized professionals as having either positive or negative attitudes (James & Cowman, 2007; James & Cowman, 2007; Purves & Sands, 2009; Westwood & Baker, 2010). The current investigation highlights that CPNs’ attitudes cannot be
(2012) DOI: 10.1002/pmh
Professional’s knowledge and attitudes towards borderline personality disorder
viewed as static, but rather as a product of how they understand the client’s presentation, ‘in the moment’. This can provide a synthesis to explain previous research that shows a polarized view of staff attitudes. Bodner et al. (2011) found that psychologists held less ‘antagonistic judgements’ compared with psychiatrists and mental health nurses. Although it could be argued that nurses are often on the ‘front line’, so exposed to more challenging behaviour, this finding may support the current research about application of knowledge ‘in the moment’. Bodner et al. (2011) suggested that psychologists may be more likely to ‘accept, empathise and understand patients as opposed to the authoritarian and limit-setting style of the other professionals’. As psychologists often develop a formulation (framework) to conceptualize the development and maintenance of an individual’s difficulties, this formulation may help the psychologist to understand the individual’s presentation ‘in the moment’ and maintain an empathic stance. In contrast, psychiatrists and mental health nurses can often focus upon the individual’s diagnosis (medical model), which may not contextualize the person’s ‘in the moment’ presentation in relation to their early life experiences and history. Previous studies have suggested that positive attitudes towards clients may be mediated by education and experience (Bodner et al, 2011; Purves & Sands, 2009; Westwood & Baker, 2010). This is partly supported by the current research, as staff members who have a clear conceptual framework to explain a client’s behaviour were less pejorative and viewed the client in more nurturing terms. Bodner et al. (2011) proposed that the more experience (‘seniority’) a clinician had working with this client group, the less negative these patients were viewed. Although the current sample is too small to generalize from, what is indicated is that seniority/experience may be less important in understanding attitudes than knowledge base. For example, participants 2 and 3 had worked in mental health settings for up to 30 years, but where they did not have a
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basis to explain a client’s presentation, they could express negative attitudes. As well as the participant’s conceptual framework being crucial to the understanding and subsequent attitudes towards clients, this needed to be considered in relation to service context. Within the current research, supervision was seen as a key factor in facilitating the understanding of a client’s presentation and maintaining adherence to a model/therapeutic approach. The need for good supervision in developing/maintaining knowledge is supported within previous research (Purves & Sands, 2009; Westwood & Baker, 2010). Purves and Sands (2009), citing references by Gilbert (2001) and Bland and Rosen (2005), acknowledged that ‘clinical supervision provides support for professionals to maintain compassion, therapeutic optimism and prevent “burn out”’. Supervision is just one aspect of the service context. What is also highlighted within the current study is the impact on staff attitudes from the ‘prevailing culture’. For example, overt focus on risk and litigation appeared to result in more guarded attitudes towards the client and detract from patient care. The participant within DBT services emphasized that experiencing a service culture that drew upon a conceptual model and took ‘positive risks’ facilitated working with this client group. Service context and culture are crucial in understanding staff attitudes towards this client group and go beyond education, training and supervision. Similarly, it could be proposed that a ‘service culture’ where there is little education, training or supervision around BPD may foster negative attitudes within a staff team. The researchers hypothesized that knowledge, attitudes and service context were all inextricably related to each other and could impact upon the participant’s approach to the clients. The participant’s approach towards clients was conceptualized on a continuum of ‘connectedness’ (‘connected’– ‘disconnected’). This is supported by a number of strands of previous research. Firstly, Westwood and Baker (2010) found that where RMNs expressed negative attitudes towards this client group, they were also more ‘socially distant’
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(akin to ‘disconnected’). The author proposed that this was also related to a lack of knowledge about BPD. Similarly, Bodner et al. (2011) found that ‘the less negative the practitioners’ evaluations, the higher the empathy towards the client’. When also considering therapeutic approaches towards clients with BPD, both DBT and Schema therapy place the therapeutic relationship at the centre of treatment. For example, at the heart of schema therapy is ‘limited reparenting’ (Young et al., 2003). Effective ‘limited reparenting’ is characterized by warmth, genuineness, connection with the client, (appropriate) selfdisclosure, nurturance, setting limits and so forth. All of these characteristics are consistent with the ‘connected’ concept that was apparent within participants’ narratives. In order to develop an effective therapeutic relationship with clients, it is important to have a framework to understand the individual’s presentation and a service culture that supports this. Limitations of the current study The study has identified a number of emerging themes that have been posited to be inter-related (e.g. knowledge, attitudes, service context and approach to clients). It is not possible to attribute causality to these factors from the study. For example, it cannot be determined whether positive attitudes towards clients with BPD lead participants to ‘seek out’ knowledge or whether increased knowledge leads to changes in attitudes. Although participant 4’s narrative provided some initial support for the view that increased knowledge leads to changes in attitudes, it is possible that this individual’s underlying attitudes may have led to him seeking out further training. The current study utilized a semi-structured interview. Although this allowed detailed exploration of the participants’ views and experiences, one criticism is that the analysis can be subject to the researchers’ interpretation, culture, values and beliefs. Attempts were made to control for this by analysing the results separately and utilizing a
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researcher with less experience of BPD, to try and minimize the impact of preconceived ideas on the research. It should also be acknowledged that participants may want to present themselves in the best light when discussing their experiences of working with clients. As a result, it may be that their true attitudes or values are not fully revealed during the interview. This limitation may be applicable to any form of research in this area. The current researchers attempted to address this by ensuring clients were at ease during the research. There are also a number of limitations with regards to sampling. Firstly, despite the sample size being appropriate for a qualitative methodology (Smith et al., 1999), it is too small to draw firm conclusions from. Secondly, the researchers only included participants who had experience working with clients with BPD as it was felt that they would provide a rich source of data. It may be that CPNs who have limited contact with clients with BPD do so because of their attitudes. This should be an area for further investigation. Future research On the basis of the current research, a number of avenues can be considered for future research. Firstly, as outlined earlier, the sample size was relatively small. Therefore, replicating the study with a larger sample may be beneficial. In addition, widening the sample to extend beyond nurses with direct contact with clients with BPD may also be important. Secondly, as it has been hypothesized that staff may take either a ‘connected’ or ‘disconnected’ approach to clients with BPD, it may be valuable to conduct research from the client’s perspective to find out if this is supported by their experiences. Furthermore, investigating how the staff’s approach impacts upon the client may shed light on the reciprocal relationship between staff and clients. As the service context appears to be an influential factor in participants’ acquisition of knowledge, attitudes and approach to clients, further research into how these factors vary in
(2012) DOI: 10.1002/pmh
Professional’s knowledge and attitudes towards borderline personality disorder
different context would be enlightening. Similarly, changing the ‘service context’ (e.g. providing more training, support and supervision) would allow future research to investigate the impact on the professional and the approach they take with the clients.
Funding This research received no specific grant from any funding agency in the public, commercial or non-profit sectors.
Implications of the current research
References
It is paramount to ensure that staff working with this client group have appropriate training in a theoretical framework in order to understand the individual’s often rapidly changing presentation. Staff working with such a complex client group need regular clinical supervision. This would ensure that they are providing the best evidence-based treatment and that they are adhering to a framework that maintains their understanding of BPD and to help to prevent ‘burn out’. In addition, this may help staff to approach clients in a ‘connected’ way, which may help to improve the service the individual receives. The current research raises the implications for the service context in which the clients are seen. It was highlighted within the participants’ narratives that they were under pressure with high caseloads, lack of support and considerable documentation, and there was often a fear of litigation. These factors may overshadow the needs of the clients, reinforcing the sense of invalidation. Therefore, the service context needs to be carefully considered to allow staff to work with this client group effectively.
Adams, H.E., Bernat, J.A., & Luscher, K.A. (2001). Borderline personality disorder: an overview. In P.B., Sutker, & H.E. Adams. (Eds.). Comprehensive handbook of psychopathology (3rd Edition). New York: Kluwer Academic/Plenum Publishers. American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders text revision, 4th Edition (DSM-IV). Washington DC: American Psychiatric Association. Arntz, A., & van Genderen, H. (2009). Schema therapy for borderline personality disorder. Chichester: Wiley-Blackwell Publishers. Bland, A.R., & Rosen, E.K. (2005). Clinical supervision of nurses working with patients with borderline personality disorder. Issues in Mental Health Nursing, 26, 507–517. Bodner, E., Cohen-Fridel, S., & Iancu, I. (2011). Staff attitudes toward patients with borderline personality disorder. Comprehensive Psychiatry, 52, 548–555. Cleary, M., Siegfried, N., & Walter, G. (2002). Experience, knowledge and attitudes of mental health staff regarding clients with a borderline personality disorder. International Journal of Mental Health Nursing, 11, 186–191. Crawford, M., Rutter, D., Price, K., Weaver, T., Josson, M., Tyrer, P., Gibson, S., Gillespie, S., Faulkner, A., Ryrie, I., Dhillon, K., Bateman, A., Fonagy, P., Taylor, B., Moran, P., Beckett, J., Blackwell, H., Burbridge, C., Coldham, T., Gould, D., Imlack, S., Parfoot, S., Sheldon, K., Sweeney, A., & Taylor, E. (2007). Learning the lessons: A multimethod evaluation of dedicated community-based services for people with personality disorder. National co-ordinating centre for NHS service delivery and organization. London. Gilbert, T. (2001). Reflective practice and clinical supervision: Meticulous rituals of the confessional. Journal of Advanced Nursing, 36, 2, 199–205. Haigh, R. (2002). Services for people with personality disorder: The thoughts of service users. Available at: http://www.dh. gov.uk/en/Publicationsandstatistics/Publications/Publications PolicyAndGuidance/DH_4009546 Horn, N. Johnstone, L., & Brooke, S. (2007). Some service user perspectives on the diagnosis of borderline personality disorder. Journal of Mental Health, 16, 255–269. James, P.D., & Cowman, S. (2007). Psychiatric nurses’ knowledge, experience and attitudes towards clients with
Acknowledgements The researchers would like to thank the participants for taking the time to assist us with this study. Thank you to Dr Bethan Lloyd (Consultant Clinical Psychologist) who supported this project. Conflict of interests No conflict of interest has been declared by the authors.
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borderline personality disorder. Journal of Psychiatric and Mental Health Nursing, 14, 670–678. Linehan, M. M. (1993). Cognitive-behavioural treatment of borderline personality disorder. New York: The Guildford Press. National Institute for Health and Clinical Excellence NIHCE. (2009). Borderline personality disorder: Treatment and management. London: National Institute for Health and Clinical Excellence. Nehls, N. (1999). Borderline personality disorder: The voice of patients. Research in Nursing and Health, 22, 285–293. Paris, J. (1993). The treatment of borderline personality disorder in light of the research on its long-term outcome. Canadian Journal of Psychiatry, 38, 1, 28–34. Purves, D., & Sands, N. (2009). Crisis and triage clinicians’ attitudes towards working with people with personality disorder. Perspectives in Psychiatric Care, 45, 3, 208–215. Smith, J.A., & Osborn, M. (2003). Interpretative phenomenological analysis. In Smith, J.A. (ed.). Qualitative psychology: A practical guide to research methods. London: Sage Publishers. Smith, J.A., Jarman, M., & Osborn, M. (1999). Doing interpretative phenomenological analysis. In M. Murray, & K. Chamberlain (Eds.). Qualitative health psychology: Theories and methods. London: Sage Publishers. Stalker, K., Ferguson, I., & Barclay, A. (2005). It is a horrible term for someone: Service user and provider
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perspectives on personality disorder. Disability and Society, 20, 359–373. Stuart, G.W., & Laria, M.T. (2005). Principles and practice of psychiatric nursing (8th edition). Missouri: Elsevier Mosby Inc. Swales, M.A, & Heard, H.L. (2009). Dialectical behaviour therapy: The CBT distinctive features series. Routledge: Taylor & Francis Group. East Sussex/New York. Swartz, M., Blazer, D, George, L., Winfield, E. (1990). Estimating the prevalence of borderline personality disorder in the community. Journal of Personality Disorders, 4, 3, 257–272. Westwood, L., & Baker, J. (2010). Attitudes and perceptions of mental health nurses towards borderline personality disorder clients in acute mental health settings: A review of the literature. Journal of Psychiatric and Mental Health Nursing, 17, 657–662. Widgier, T.A., & Weissman, M.M. (1991). Epidemiology of borderline personality disorder. Hospital & Community Psychiatry, 42, 1015–1021, Young, J., Klosko, J.S., & Weishaar, M.E. (2003). Schema therapy: A practitioner’s guide. New York: The Guildford Press.
Address correspondence to: Dr James Stroud, Hafan Hedd Resource Centre, Adpar, Newcastle Emlyn, SA38 9NS, UK. Email: [email protected]
(2012) DOI: 10.1002/pmh
Working with borderline personality disorder: A small-scale qualitative investigation into community psychiatric nurses’ constructs of borderline personality disorder
JAMES STROUD1 AND RACHEL PARSONS2, 1Hafan Hedd Resource Centre, Adpar, Newcastle Emlyn, SA38 9NS, UK; 2Cardiff University, 11th Floor, Tower Building, 70 Park Place, Cardiff, CF10 3AT, UK ABSTRACT Borderline personality disorder (BPD) is a complex presentation that can have a significant impact upon the individual and on his or her quality of life. BPD has often been associated with negative connotations (e.g. ‘manipulative’, ‘attention seeking’). The aim of the current study was to gain a fuller understanding of how community psychiatric nurses (CPNs) make sense of the diagnosis of BPD and how their constructs of BPD impact their approach to this client group. Four CPNs, three women and one man, were interviewed using a semi-structured interview schedule. The data were analysed using interpretative phenomenological analysis, to reveal over-arching and sub-themes. The results indicated that participants attempted to ascribe meaning to the client’s presentation ‘in the moment’. When they had a framework to explain behaviour, participants were more likely to express positive attitudes. When they did not have such a framework, participants could view clients in more pejorative terms. As participants were deriving meaning ‘in the moment’, there could be fluidity with regards to participants’ attitudes, ranging from ‘dread’ to a ‘desire to help’. This could lead to participants shifting between ‘connected’ and ‘disconnected’ interactions with clients. The limitations and implications for clinical practise will also be considered. Copyright © 2012 John Wiley & Sons, Ltd. Introduction Borderline personality disorder (BPD) is defined by the Diagnostic and Statistical Manual–fourth edition (American Psychiatric Association, 2000) as ‘a pervasive pattern of instability of interpersonal relationships, self-image and affects, as well as marked impulsivity, beginning by early adulthood’. Estimates suggest that the prevalence of BPD in the general population is between 1.1% and 3% and can vary within clinical settings from 10% in
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outpatients to 15–50% in inpatient samples (Arntz & van Genderen, 2009; Stuart & Laria, 2005; Swartz, Blazer, George, & Winfield, 1990; Widgier & Weissman, 1991). Ensuring individuals with a diagnosis of BPD have appropriate treatment is paramount for many reasons. Firstly, evidence suggests that 8–10% of individuals with a diagnosis of BPD may die through suicide (Adams, Bernat, & Luscher, 2001; Paris, 1993). Secondly, individuals with BPD can often require hospitalization or inpatient admissions
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because of the severity of their difficulties. Thirdly, the complex presentation of BPD can have a profound effect upon the individual’s social, educational, vocational functioning and general quality of life. Treatments of BPD have suggested that a number of factors are important in the aetiology of BPD. These include the individual’s temperament, exposure to trauma and environmental factors (e.g. parental influences, exposure to invalidating environments, the individual’s core emotional needs being unmet; Arntz & van Genderen, 2009; Linehan, 1993; Young, Klosko, & Weishaar, 2003). As a result of these factors, treatments for BPD (dialectical behavioural therapy (DBT) and schema therapy) emphasize the primacy of the therapeutic relationship between the client and therapist. For example, schema therapy (Young et al., 2003) places at its core the relationship between the therapist and the client, with prominence on creating a safe and trusting relationship. The importance of the therapeutic relationship is also reinforced within National Institute for Health and Clinical Excellence (NIHCE, 2009) guidelines. Given the traumatic experiences that individuals with BPD have often had, and the importance placed upon the therapeutic relationship with clients, it is clearly essential to ensure that staff have a good understanding of BPD, and their attitudes/ beliefs are conducive to the development of a strong therapeutic relationship. For example, DBT emphasizes ‘phenomenological empathy’, where the clinicians attempt to search for empathic, non-judgemental explanations for a client’s presentation (Swales & Heard, 2009). Despite this, there is evidence to suggest that health professionals can often hold negative attitudes towards people with BPD. Westwood and Baker (2010) reviewed the literature on registered mental nurses (RMNs) attitudes towards clients with BPD. Findings indicated that RMNs were often ‘socially distant’ towards BPD clients, compared with clients with other mental illnesses and expressed more negative attitudes and perceptions towards BPD. Westwood
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and Baker (2010) suggested that negative attitudes and ‘social distancing’ may be driven by the staff members’ knowledge and understanding of the BPD presentation. Similarly, Purves and Sands (2009) found that increased level of education related to more positive attitudes towards clients with BPD. Although they acknowledge that this may, in part, relate to willingness to disclose negative attitudes, they also suggest that education can provide a conceptual framework for understanding the individual’s behaviour. In a recent study, Bodner, Cohen-Fridel, and Iancu (2011) found that attitudes differed between professional groups with psychiatric nurses and psychiatrists holding more ‘antagonistic judgements’ than psychologists. The nurses within the sample also expressed less empathy towards this client group, compared with other professionals. Consistent with previous research, Bodner et al. (2011) found that the less negative the evaluations, the higher the empathy expressed towards BPD clients. Westwood and Baker (2010) acknowledged that in two of the reviewed studies, RMNs held positive attitudes about working with clients with BPD (Cleary, Siegfried, & Walter, 2002; James & Cowman, 2007). James and Cowman (2007) found that optimism is growing because staff are perceiving clients as ‘treatable’. Consequently, there was willingness for nurses to work with people with BPD and a desire to improve the services that they receive. Research from the client’s perspective has also demonstrated the importance of staff knowledge and attitudes. A common theme is that clients can view the diagnosis negatively, as it has been associated with ‘untreatability’ (Horn, Johnstone, & Brooke, 2007), which in the past has resulted in the individual being denied services (Crawford, Rutter, Price, et al., 2007). Studies have also demonstrated that some clients perceived the label negatively, that it carried stigma and they were ‘stereotyped’ by professionals (Crawford et al., 2007; Haigh, 2002; Horn et al., 2007; Nehls, 1999; Stalker, Ferguson, & Barclay, 2005). Other clients perceived the label as accurate and felt that
(2012) DOI: 10.1002/pmh
Professional’s knowledge and attitudes towards borderline personality disorder
it was useful to help them make sense of their difficulties; nevertheless, research participants emphasized the importance of staff being sensitive and respectful to their needs, and to consider the impact of the diagnosis (Crawford et al., 2007; Haigh, 2002). The existing research indicates that it is important to obtain a fuller understanding of how frontline mental health professionals understand the presentation of BPD and to consider how the professionals’ constructs may influence their attitudes and, subsequently, the individual’s care. It is important to acknowledge that there is a paucity of research in this area, and the literature focuses on professionals working within inpatient settings. As there is an emphasis on community-based services, and staff working in inpatient settings are likely to be working with clients with more severe presentations, the aim of the current study was to begin to understand community psychiatric nurses’ (CPNs) knowledge, attitudes and approach to clients with BPD. Methodology Design The current research was a qualitative design, using a semi-structured interview schedule to gain a deeper understanding of how CPNs conceptualize BPD and how this may impact upon the client’s care. Participants Four registered CPNs were recruited from a Community Mental Health Team (CMHT). The sample comprised of three female and one male
CPNs. All participants had considerable experience working with clients with BPD. Only one participant (participant 4) had received specific training in working with BPD (DBT), since qualifying as a nurse. Table 1 provides further demographic information. Inclusion/exclusion criteria. As the aims of the research were to understand CPNs’ knowledge and attitudes of BPD, the researchers only included nurses in the study. Inclusion of participants was based on them working within a CMHT setting, having a clinical role and working directly with BPD clients. CPNs were excluded from the study if they were employed in a non-clinical capacity or if they did not have direct experience working with clients with a diagnosis of BPD. Recruitment. Initially, one of the researchers (trainee clinical psychologist) met with CPNs within a CMHT to discuss the research proposal and to enquire about which staff had experience of working with clients with BPD. The professionals were given an information sheet, which provided further details of the research. Team members were asked to read the information sheet in order to make an informed decision about participating in the research. Approximately 48 h later, team members were contacted, and the trainee arranged to meet individually with professionals who consented to take part in the research. The purpose of the research was discussed again, and any questions were answered. During this meeting, if the participant was agreeable to participate, written consent was obtained. Throughout the
Table 1: Demographic information Participant (age range) and gender Time worked as Time working in mental Frequency of contact Time spent working a CPN (years) health field (years) with clients with BPD with BPD (years) Participant Participant Participant Participant
1 (40–49), female 2 (40–49), female 3 (50–59), female 4 (30–39), male
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1–5 6–10 11–15 6–10
1–5 26–30 26–30 6–10
Daily 1–2 times a week Daily Daily
1 5 10 2–3
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recruitment phase, the trainee clinical psychologist met with the CPNs. As the trainee was new to the team (and not a full time member), it was felt that this may ensure that CPNs did not feel pressured into participating in the research. This was also considered when reinforcing to the CPNs, whose participation was voluntary, that they could withdraw at anytime and that they did not have to answer anything that they did not feel comfortable answering (this information was also incorporated in the information sheet). Four out of seven (57%) CPNs that were eligible to take part in the study consented. Data collection Data were collected using a semi-structured interview schedule. The researchers reviewed a semistructured interview schedule, previously used in an inpatient research study. The researchers modified this schedule to ensure that it was appropriate to a community setting. During this process, the researchers were mindful to ensure that the aims of the research were closely adhered to. As part of the modification of the semi-structured interview, the researchers consulted with colleagues to ensure ‘face validity’ of the interview schedule. Key questions from the interview schedule are outlined in Table 2. Interviews were conducted individually with participants in January and February 2011. The interviews were conducted by a trainee clinical psychologist and lasted between 50 and 60 min. Data analysis Data were analysed using interpretative phenomenological analysis (IPA). IPA was chosen over other forms of qualitative methodology because it is concerned with trying to understand ‘lived experience’ and how individuals make sense of their experiences. IPA attempts to explore an individual’s personal perception as opposed to attempting to produce an objective record of the event or state itself (Smith & Osborn, 2003); therefore, IPA was felt to be appropriate to the aims of the study.
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Table 2: Examples of core questions from the semi-structured interview How would you describe a client with borderline personality disorder? What behaviours are common for this diagnosis? Clients with BPD can experience a wide range of symptoms. How do you make sense of these symptoms/changes in symptoms? When you hear the term ‘borderline personality disorder’, what comes to your mind? What are your initial reactions? Without disclosing identifiable information about a particular client, could you tell me about a client that you have worked with that, to you, captures someone with BPD? Could you describe a memorable experience of working with a client with BPD? Thinking about the above event from the person with BPD’s perspective, what do you think was the function of the behaviour? Thinking about yourself, can you tell me about how well equipped you feel you are to work with clients with BPD? What do you think that you do well when working with these clients? Is there anything that you feel you would like to do better/ change when working with these clients?
The analysis of the data followed the steps set out by Smith, Jarman, and Osborn (1999). Initially, each recorded interview was transcribed verbatim. During this process, any personally identifiable information was removed. The researchers read and re-read the transcript to immerse themselves in the participants’ narratives. The researchers used the left-hand margin of the transcript to document any thoughts, feelings and emerging themes. As the researchers re-read the text, they consolidated the ideas from the left-hand margin and documented the emerging themes in the right-hand margin of the text. Once this process was completed, the themes were listed from the whole transcript. These themes were grouped into a table of super-ordinate and sub-themes. This process was completed for each interview transcript to develop super-ordinate and sub-themes from all the interviews. To ensure validity of the analysis, both researchers completed the aforementioned process separately
(2012) DOI: 10.1002/pmh
Professional’s knowledge and attitudes towards borderline personality disorder
and compared the themes once the analysis was completed. This process informed the final results. Ethical considerations A number of ethical issues were considered. Firstly, it was acknowledged that participants may have experienced distressing incidents working with people with BPD. Participants were informed both verbally and within the information sheet that they could withdraw from the study at any time, that they did not have to answer any questions that they did not feel comfortable in answering and/or they could speak with the researchers at anytime to address any issues that arose. Secondly, participants were made aware that if any information of a serious nature was disclosed (e.g. wilful abuse or neglect), the interview would be stopped and the researchers would have a duty of care to take action (e.g. to inform the team manager). Approval for this research project was granted from the local research ethics committee and the Health Board’s Research and Development Department (January 2011). Results On the basis of the analysis of participant’s transcripts, a number of super-ordinate and subordinate themes emerged. These are summarized in Table 3 and will be expanded upon later. Direct quotations from participants, to support the themes, are also provided. Knowledge of BPD CPNs who had not had specific training in BPD appeared to have a limited knowledge base relating to the presentation of BPD: Participant 1: ‘[when asked about how to describe someone with BPD] Good question I should have read up a bit more. . .My understanding of borderline personality is something that is very close to bipolar. They can be up and down and there is a fine line between [the two diagnoses].’
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Table 3: Table of themes Super-ordinate themes
Sub-themes
Knowledge of BPD
Presence/lack of a conceptual framework Links between past and present? Attitudes towards BPD Dread vs. desire to help A process of making sense Interactions with clients Connected vs. disconnected Service context Support and supervision Competing demands and litigation Need for a specialist service
Participant 3: ‘[when asked about understanding of symptoms of BPD] I leave all that to the psychiatrist. I’ve done a lot of research in the past about different things but borderline personality disorder is not one of my fortes.’ All participants acknowledged the importance of negative early life experiences including trauma experienced by clients with BPD. However, when participants appeared to lack a knowledge framework for BPD, the link between past traumas and current difficulties could fluctuate: Participant 1: ‘A really bad childhood into teenage [years], extremely shocking the sexual abuse. Became a drug addict who masked the feelings, not being able to cope with what happened. . .She’s can be quite devious, saying one thing to you and then something different to someone else. The participant who had specific training of DBT had a strong knowledge base to understand BPD, and there appeared to be less fluctuation in the links between past and present: Participant 4: ‘[the client is] more biologically vulnerable to being emotional and as they are growing up they are in an invalidating environment which means that they then have difficulties identifying their own emotions or start to invalidate their own emotions and they become increasingly dysregulated which results in impulsive behaviours to try and regulate their own emotions.’
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Attitudes towards clients with BPD Feelings of ‘dread’ towards working with clients with BPD were frequently expressed. This was often related to the complexity of clients, the longevity of input required and the demands placed upon the CPN: Participant 1: ‘My immediate reaction is “oh no” because they are a really difficult client group to work with.’ Participant 2: [Immediate reaction is] ‘Oh God, here we go again. . .its challenging they are so complex. . .I just found myself exhausted because of the challenges and the behaviours.’ Although clients with BPD were perceived as challenging and complex, it appeared as if the participant’s knowledge base further influenced perceptions of BPD. Participants who lacked a framework appeared to be more likely to use pejorative terms to explain clients’ behaviours: Participant 1: ‘They are telling you one thing, then when you are putting into place the plan they are not seeing it through. . .quite a few of them don’t want to change, perhaps they are scared of change but I think they are also hiding behind it. . .can be quite devious.’ Participant 2: ‘Trying to split people [in teams] up. . .they will try and exploit areas to get you worried.’ Participant 4: ‘The traditional view is about them being very manipulative and attention seeking, but in DBT I have not really found that. It is just about the distress they are in. . .you would look at it in terms of the client is trying to cope.’ Similarly, when participants did not have a clear framework to explain a client’s behaviour, they could hold conflicting explanations, as a way of trying to make sense of the individual’s presentation. As a result, there could be clear shifts in staff attitudes:
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Participant 1: ‘[following a client taking an overdose] I would certainly say that it was a cry for help, but she told me with a smile on her face, so there must have been some idea of gain from it. . .it gave me the idea that she might have been enjoying telling me. She might have been testing me, to see my reactions.’ Despite there being evidence of some negative attitudes towards clients with BPD, all participants had a strong desire to help. This may be linked to the participant’s personal values. Consequently, attitudes could shift between ‘dread’ and ‘a desire to help’: Participant 1: ‘I think the initial “oh no” reaction really quickly envelops into “well they still need help”.’ Participant 2: ‘I feel really sorry for them, where they are [in their lives], but because of the challenges and the behaviours it’s very difficult. . .I think they have got real problems and I think some of them have got more problems than a lot of people.’ Interaction with clients Participants’ interaction with clients could be conceptualized on a continuum of ‘connected’ to ‘disconnected’. When participants were ‘disconnected’ with the client, they may withdraw emotionally, put up a ‘professional front’, suppress their own emotions and form rigid boundaries: Participant 3: ‘It’s a nurse–patient relationship and nobody ever steps over to this side. . .There are boundaries and they don’t step over them. A lot of staff have got [work] phones [that they give clients direct contact numbers] there’s no way [they will have my direct number]. . .they can change their care co-ordinator when they like so they can dismiss you as well, which is good.’ Participant 2: ‘[at the beginning] you don’t know how to trust them and it makes you more aware because she could lie about me for all I know, so it does make you quite tender-footed.’
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Professional’s knowledge and attitudes towards borderline personality disorder
When participants were ‘connected’ with the client, they saw the client as a person and engaged with them on a human and emotional level. Although boundaries were still seen as important, they were there explicitly for the clients’ benefit: Participant 4: ‘You are more yourself in DBT, more open. . .[it is important] being genuine, validating the client and the distress or difficulty they are having. . .I think just being respectful, pleasant and interested.’ Participant 2: ‘I think at the beginning what I found frustrating was these sort of pushing, pushing, pushing. . .I don’t think she trusted me at that time. She would say a few lies, yeah, which I caught her out on. I did challenge that because, to me, if you can’t be honest and open then we’re not getting very far are we? I think its got to work both ways. . .Rewarding, was her being able to open up and say to me, “yeah I’ve fallen off the wagon again and I’ve been doing this”. To me that was a big reward because she’d have never done that before.’ The ‘connected’ or ‘disconnected’ approach could be fluid and appeared to be influenced by the participant’s attempts to make sense of the client’s behaviour and prevailing attitudes: Participant 1: ‘[talking about her response to a client who overdosed] I felt glad that I had spent the time with her in Casualty, rather than just putting her on the ambulance. . . If I had phoned 999 and got the ambulance out then that probably would have been a better thing to do because it would not have been reinforcing her behaviour. . .Thinking back, I shouldn’t have spent the time with her, but then I was glad I had because she was okay, so its difficult. . .’ Participant 2: ‘Before having the knowledge I’ve got now I would have said “they are getting on my bloody nerves, I don’t know what to do with them”. . .Over the years you gain knowledge and change your outlook.’
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Participant 4: ‘[In the past] not give anything away but trying to pick inconsistencies in their statements [to] prove that they are not suicidal or not imminent risk. In DBT you are more relaxed and more real and I don’t try to mask, its just more open and it is more helpful to clients and whilst at the same time working to boundaries. . .You don’t need to go in there like a shield so things bounce off.’ Constraints/impact of service context A number of service-related issues appeared to impact upon knowledge, attitudes and approach to clients. Firstly, participant 4 acknowledged the importance of training and regular supervision in DBT as paramount in the therapeutic work with this client group. This enabled the individual to ventilate feelings, maintain focus on the model and discuss the best avenues for treatment (within the DBT framework). Although other participants mentioned ‘informal’ arrangements (e.g. discussions with colleagues), the lack of formal supervision often left them feeling frustrated and helpless about working with this client group. Participant 1: (In response to the question: can you tell me about how equipped you feel to work with clients with borderline personality disorder?) ‘I kind of feel that I am not, but on the other hand I must be doing something right to be working with so many borderline personality disorders, so I must be doing something right, although I think maybe I’m not. . .the help that I am giving is the nursing basis rather than any kind of schema therapy or DBT skills, because I haven’t got any of those skills. . . [what I need is] having a presentation from psychology or whoever, that either reinforces what I am doing or gives me hints and tips of how to manage some of the behaviours, so that would certainly help. Even to know that what I am doing is the right thing that would give me confidence.’ Participant 2: ‘I find that I’ve got to go through a process, a sort of reflection thing in my head [laughs]. I do reflect a lot . . .and sometimes you need to do it because you think to yourself ‘did I say the right thing then or didn’t I?’
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Participant 4: (when asked about what staff ‘communicate’ when they talk about BPD) ‘These clients are [often seen as] a drain on resources, they waste time and shouldn’t be treated by the mental health team and they should sort themselves out and take responsibility for their behaviour. That is the main gist really, but I can also see how the frustration can manifest in the conversations that staff have as you get a lack of support and a lack of training. Even in DBT you can feel frustrated with clients but in DBT you have a team approach, like there is six people all working on somebody’s treatment, as a CPN you might not have that. It is much more difficult and much more stressful.’ Secondly, it was noted by participants that services demands, such as high caseloads and the focus on completing documentation (e.g. risk assessments, care plans) and the risk of litigation, could be additional factors in mediating the participants’ approach to clients. Participant 1: (when asked about the impact of work): [following a phone call from a client with BPD] ‘you think “oh God I don’t want a complaint made against me”. I won’t say that I go home and catastrophise about it, but I guess I do [laughs]. But I don’t want to lose my job.’ Participant 3: ‘it’s all to do with risk. That’s all we are being embroiled in at the moment is risk. Nothing else just risk and litigation. A big part of it, we’ve got to cover ourselves really. . . I switch off as soon as they’ve [the client] gone out of the room I don’t worry. If my risk assessment is tight that’s fine by me.’ Participant 4: ‘As a CPN if something goes wrong then the buck stops with you and then I think that does not help staff to take positive risks. Staff are very defensive in their practice and very risk adverse and in DBT it is about accepting that this is a risky client group and if we wrap them up in cotton wool all the time that is not treating them and I think it is about having a service that is prepared to take well thought out positive risks and I don’t think we are there yet. Because I think staff are so scared of things going wrong and them getting the blame and being sued it is very hard to allow clients to have some responsibility.’
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On the basis of the participants’ accounts, the service structures and demands were a further factor that may impact upon the professional’s approach to the client. Discussion A key finding of the current research is the link between CPNs’ knowledge and attitudes towards clients with BPD. Although it was noted that participants could at times express negative views, this was not a static concept, and attitudes could shift between ‘dread’ and a ‘desire to help’. Participants were constantly trying to ascribe meaning to the client’s changeable presentation; however, developing a coherent meaning could be problematic when the client’s presentation was frequently shifting or conflicting (e.g. smiling whilst talking about an overdose). The researchers hypothesized that the participants’ attitudes could be affected by their knowledge of BPD and by how knowledge was applied ‘in the moment’. Consequently, to understand the participants’ attitudes, there is a need to consider the framework (or lack of) that the participant applies to understand the client’s behaviour at the time. For example, when participants perceived current behaviour to be a consequence of negative early life experiences, participants were more positive/nurturing towards clients. When participants did not link current behaviours with the past, or did not have a framework to explain a current behaviour, participants could view behaviour in more pejorative terms (e.g. ‘manipulative’, ‘attention seeking’). Similarly, participant 4, who had a strong conceptual framework to explain BPD, held the most consistently positive attitudes. This link between application of knowledge (‘in the moment’) and attitudes is crucial for a number of reasons. Firstly, previous (quantitative) research has often categorized professionals as having either positive or negative attitudes (James & Cowman, 2007; James & Cowman, 2007; Purves & Sands, 2009; Westwood & Baker, 2010). The current investigation highlights that CPNs’ attitudes cannot be
(2012) DOI: 10.1002/pmh
Professional’s knowledge and attitudes towards borderline personality disorder
viewed as static, but rather as a product of how they understand the client’s presentation, ‘in the moment’. This can provide a synthesis to explain previous research that shows a polarized view of staff attitudes. Bodner et al. (2011) found that psychologists held less ‘antagonistic judgements’ compared with psychiatrists and mental health nurses. Although it could be argued that nurses are often on the ‘front line’, so exposed to more challenging behaviour, this finding may support the current research about application of knowledge ‘in the moment’. Bodner et al. (2011) suggested that psychologists may be more likely to ‘accept, empathise and understand patients as opposed to the authoritarian and limit-setting style of the other professionals’. As psychologists often develop a formulation (framework) to conceptualize the development and maintenance of an individual’s difficulties, this formulation may help the psychologist to understand the individual’s presentation ‘in the moment’ and maintain an empathic stance. In contrast, psychiatrists and mental health nurses can often focus upon the individual’s diagnosis (medical model), which may not contextualize the person’s ‘in the moment’ presentation in relation to their early life experiences and history. Previous studies have suggested that positive attitudes towards clients may be mediated by education and experience (Bodner et al, 2011; Purves & Sands, 2009; Westwood & Baker, 2010). This is partly supported by the current research, as staff members who have a clear conceptual framework to explain a client’s behaviour were less pejorative and viewed the client in more nurturing terms. Bodner et al. (2011) proposed that the more experience (‘seniority’) a clinician had working with this client group, the less negative these patients were viewed. Although the current sample is too small to generalize from, what is indicated is that seniority/experience may be less important in understanding attitudes than knowledge base. For example, participants 2 and 3 had worked in mental health settings for up to 30 years, but where they did not have a
Copyright © 2012 John Wiley & Sons, Ltd.
basis to explain a client’s presentation, they could express negative attitudes. As well as the participant’s conceptual framework being crucial to the understanding and subsequent attitudes towards clients, this needed to be considered in relation to service context. Within the current research, supervision was seen as a key factor in facilitating the understanding of a client’s presentation and maintaining adherence to a model/therapeutic approach. The need for good supervision in developing/maintaining knowledge is supported within previous research (Purves & Sands, 2009; Westwood & Baker, 2010). Purves and Sands (2009), citing references by Gilbert (2001) and Bland and Rosen (2005), acknowledged that ‘clinical supervision provides support for professionals to maintain compassion, therapeutic optimism and prevent “burn out”’. Supervision is just one aspect of the service context. What is also highlighted within the current study is the impact on staff attitudes from the ‘prevailing culture’. For example, overt focus on risk and litigation appeared to result in more guarded attitudes towards the client and detract from patient care. The participant within DBT services emphasized that experiencing a service culture that drew upon a conceptual model and took ‘positive risks’ facilitated working with this client group. Service context and culture are crucial in understanding staff attitudes towards this client group and go beyond education, training and supervision. Similarly, it could be proposed that a ‘service culture’ where there is little education, training or supervision around BPD may foster negative attitudes within a staff team. The researchers hypothesized that knowledge, attitudes and service context were all inextricably related to each other and could impact upon the participant’s approach to the clients. The participant’s approach towards clients was conceptualized on a continuum of ‘connectedness’ (‘connected’– ‘disconnected’). This is supported by a number of strands of previous research. Firstly, Westwood and Baker (2010) found that where RMNs expressed negative attitudes towards this client group, they were also more ‘socially distant’
(2012) DOI: 10.1002/pmh
Stroud and Parsons
(akin to ‘disconnected’). The author proposed that this was also related to a lack of knowledge about BPD. Similarly, Bodner et al. (2011) found that ‘the less negative the practitioners’ evaluations, the higher the empathy towards the client’. When also considering therapeutic approaches towards clients with BPD, both DBT and Schema therapy place the therapeutic relationship at the centre of treatment. For example, at the heart of schema therapy is ‘limited reparenting’ (Young et al., 2003). Effective ‘limited reparenting’ is characterized by warmth, genuineness, connection with the client, (appropriate) selfdisclosure, nurturance, setting limits and so forth. All of these characteristics are consistent with the ‘connected’ concept that was apparent within participants’ narratives. In order to develop an effective therapeutic relationship with clients, it is important to have a framework to understand the individual’s presentation and a service culture that supports this. Limitations of the current study The study has identified a number of emerging themes that have been posited to be inter-related (e.g. knowledge, attitudes, service context and approach to clients). It is not possible to attribute causality to these factors from the study. For example, it cannot be determined whether positive attitudes towards clients with BPD lead participants to ‘seek out’ knowledge or whether increased knowledge leads to changes in attitudes. Although participant 4’s narrative provided some initial support for the view that increased knowledge leads to changes in attitudes, it is possible that this individual’s underlying attitudes may have led to him seeking out further training. The current study utilized a semi-structured interview. Although this allowed detailed exploration of the participants’ views and experiences, one criticism is that the analysis can be subject to the researchers’ interpretation, culture, values and beliefs. Attempts were made to control for this by analysing the results separately and utilizing a
Copyright © 2012 John Wiley & Sons, Ltd.
researcher with less experience of BPD, to try and minimize the impact of preconceived ideas on the research. It should also be acknowledged that participants may want to present themselves in the best light when discussing their experiences of working with clients. As a result, it may be that their true attitudes or values are not fully revealed during the interview. This limitation may be applicable to any form of research in this area. The current researchers attempted to address this by ensuring clients were at ease during the research. There are also a number of limitations with regards to sampling. Firstly, despite the sample size being appropriate for a qualitative methodology (Smith et al., 1999), it is too small to draw firm conclusions from. Secondly, the researchers only included participants who had experience working with clients with BPD as it was felt that they would provide a rich source of data. It may be that CPNs who have limited contact with clients with BPD do so because of their attitudes. This should be an area for further investigation. Future research On the basis of the current research, a number of avenues can be considered for future research. Firstly, as outlined earlier, the sample size was relatively small. Therefore, replicating the study with a larger sample may be beneficial. In addition, widening the sample to extend beyond nurses with direct contact with clients with BPD may also be important. Secondly, as it has been hypothesized that staff may take either a ‘connected’ or ‘disconnected’ approach to clients with BPD, it may be valuable to conduct research from the client’s perspective to find out if this is supported by their experiences. Furthermore, investigating how the staff’s approach impacts upon the client may shed light on the reciprocal relationship between staff and clients. As the service context appears to be an influential factor in participants’ acquisition of knowledge, attitudes and approach to clients, further research into how these factors vary in
(2012) DOI: 10.1002/pmh
Professional’s knowledge and attitudes towards borderline personality disorder
different context would be enlightening. Similarly, changing the ‘service context’ (e.g. providing more training, support and supervision) would allow future research to investigate the impact on the professional and the approach they take with the clients.
Funding This research received no specific grant from any funding agency in the public, commercial or non-profit sectors.
Implications of the current research
References
It is paramount to ensure that staff working with this client group have appropriate training in a theoretical framework in order to understand the individual’s often rapidly changing presentation. Staff working with such a complex client group need regular clinical supervision. This would ensure that they are providing the best evidence-based treatment and that they are adhering to a framework that maintains their understanding of BPD and to help to prevent ‘burn out’. In addition, this may help staff to approach clients in a ‘connected’ way, which may help to improve the service the individual receives. The current research raises the implications for the service context in which the clients are seen. It was highlighted within the participants’ narratives that they were under pressure with high caseloads, lack of support and considerable documentation, and there was often a fear of litigation. These factors may overshadow the needs of the clients, reinforcing the sense of invalidation. Therefore, the service context needs to be carefully considered to allow staff to work with this client group effectively.
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Acknowledgements The researchers would like to thank the participants for taking the time to assist us with this study. Thank you to Dr Bethan Lloyd (Consultant Clinical Psychologist) who supported this project. Conflict of interests No conflict of interest has been declared by the authors.
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Address correspondence to: Dr James Stroud, Hafan Hedd Resource Centre, Adpar, Newcastle Emlyn, SA38 9NS, UK. Email: [email protected]
(2012) DOI: 10.1002/pmh
