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Abstract

Objective: To assess the effect of a two-day training workshop on clinician attitudes to working with people with borderline personality disorder (BPD). The main goal of the workshop was to achieve positive change in the attitude of clinicians treating people with BPD in a public setting. The hypothesis underlying the intervention was that informing clinicians about current concepts of the diagnosis, aetiology, prognosis and treatment of BPD, combined with detailed discussion of the principles of treatment in the public setting, would result in positive attitude change.

Method: Changes in attitudes (optimism, enthusiasm, confidence and willingness to work with people with BPD) and self-perceptions of knowledge and skills among staff working with BPD patients were assessed for 418 participants from public mental health and substance abuse services who attended the workshops over an 18-month period. A survey questionnaire was administered pre- and post-workshop and at 6 month follow-up (time 1, time 2, time 3, respectively). One-way repeated measures analysis of variance (ANOVA) were carried out to compare scores on attitudes and perceptions of knowledge and skills at time 1, time 2 and time 3.

Results: The results from repeated measures ANOVA show that there was a statistically significant effect for time for all six items. Analyses of within-subject contrasts indicated that, for all six variables, the time 2 and the time 3 scores were statistically significantly different from time 1 scores (p < 0.01). These findings confirm that there were statistically significant changes at the post-workshop assessment, which were either maintained or showed a nonsignificant decrease at 6-month follow-up.

Conclusions: The brief training workshop described was effective in achieving positive attitude change in clinicians working with patients with BPD. This research shows that it is possible through brief training to assist clinician positivity and to effect clinician attitude change. Implications of this research could include the influencing of future training of clinicians in public mental health and substance abuse fields.

Keywords

attitudes borderline education personality training

The treatment of people meeting diagnostic criteria for borderline personality disorder (BPD) is a large part of mental health services with estimates of 11% at community clinics and 20% in inpatient units [1]. It is one of the most challenging and difficult areas of mental health, with complex suicide issues being common and intense emotions being experienced not only by patients but also by patients' families, friends and treating clinicians. In a survey of attitudes, Pfohl et al. [2] demonstrated many clinicians struggling with finding empathy for and optimism toward people meeting diagnostic criteria for BPD. Not being reinforced by rapid treatment responses with patients who do not adhere to the sick role of being appreciative, compliant and grateful, may lead to clinician negativity [3–7] and feelings of hopelessness. Many clinicians also experience themselves as having limited skills and confidence in the area [2]. These factors may lead to poor outcomes, which in turn reinforces negativity, thereby perpetuating the cycle. As such, education providers need to consider how to assist clinicians to realistically feel more hopeful and competent in their work. A Medline literature search was performed for the years 1966–2004 which found only one study (4-week follow-up) of attitude change following training in working with people meeting diagnostic criteria for BPD [6]. This reflects the limited attention given to attitude change as part of providing effective treatment in this area. The author developed a two-day workshop to address this gap and evaluated the workshop to investigate whether attitude change was possible following brief training.

Workshop description

The training was a two-day workshop aimed at clinicians working in public mental health and substance and alcohol abuse services and working in inpatient, outpatient, crisis and rehabilitation settings. The workshop was designed to provide a common foundation of knowledge, skills and language suitable for all clinicians whether they had an interest in the area or not. It was intended that this would then serve as a foundation for clinicians and clinical teams planning future patient treatment and would promote clinician communication across different work settings. It was expected that clinicians interested in developing greater expertise could then choose to build on this foundation via further education and training.

The main goal of the workshop was to achieve positive change in the attitude of clinicians treating people with BPD in a public setting. The hypothesis underlying the intervention (the 2-day workshop) was that informing clinicians about current concepts of the diagnosis, aetiology, prognosis and treatment of BPD, combined with detailed discussion of the principles of treatment in the public setting, would result in positive attitude change. A second goal of the training was for participants to be familiar with commonly accepted principles of effective treatment around crisis and longitudinal treatment plans. The purpose of this goal was for participants to acquire a framework for provision of effective treatment, or to address the hurdles preventing effective treatment. The final goal was the acquisition of practical skills to develop and carry out a treatment plan, integrated within existing services, using psychodynamic, cognitive-behavioural, rehabilitation and crisis treatments against a background of systemic and medicolegal issues.

Workshop content included diagnosis, aetiology, prognosis, identifying an effective treatment system structure (key clinician role, focus on community-based treatment with brief hospitalization support), and a treating system culture that promotes cohesion and integration of services. Individualized treatment plans developed in the context of a committed patient–clinician relationship, were explored. The workshop included conceptual frameworks guiding treatment such as the finely tuned balancing of client and clinician responsibility, power and power struggles, acute versus chronic suicidality, and balancing short versus long-term risks and gains. Specific treatment topics explored were: how to keep acute hospitalizations brief; containment; skills training; behavioural chain analysis; pharmacology; and selfharm. Ethical and medicolegal issues included boundaries, professionally indicated risk-taking, risk/benefit analysis and the minimal use of mental health legislation. A comprehensive exploration of the concept of professionally indicated short-term risk-taking has been published and is available elsewhere [8]. The workshop concluded with clinician self-care issues, including supervision. The topics of staff differences, boundaries and the importance of monitoring and processing clinician emotions were woven into the workshop.

The educational style of the workshop was studentcentred participatory learning, in keeping with current education research. Consistent with teaching knowledge that people learn best when interested and energised, multiple educational media were used. Media included overheads, posters, audiotapes, videotapes and interactional methods. Similarly, didactic teaching was kept to a minimum with considerable use of interactional learning in small and large groups using both open and structured discussion (including clinical vignettes and questions generated by the presenter or participants) and planned and spontaneous role–play. Interactional learning activities accounted for an estimated 85% of an average workshop with approximately equal time in the different interactional areas described. Didactic teaching from the presenter occupied approximately 10% of workshop time and video viewing, 5%. A more comprehensive description of the workshop has been published and is available elsewhere [9]. Each workshop participant was given a 150-page book [10] (revised in 2003 [11]) coauthored by the author of this paper. The book followed the format of the workshop, making notetaking largely irrelevant, thereby assisting participants' attention.

Method

Sample

Nine hundred and ten participants attended 44 training workshops provided to all 22 public mental health and substance abuse services in the state of Victoria, Australia over an 18-month period. Workshop numbers ranged from eight to 35. The mean number per workshop was 20.7 participants. Two hundred and forty-one participants were excluded from the research sample as they had attended other training on BPD in the 6-month follow-up period, leaving 669 participants. Of these, 62% (n = 418) completed the survey at all three time intervals (preworkshop, postworkshop, 6-month follow-up) and are the sample reported on. Demographic data was collected for age, work setting and professional group. The age of participants ranged from 21 to 60 years with a mean of 37.5 years (SD = 9.2). The largest numbers worked in community mental health services (36%) followed by acute inpatient units (17%) and crisis services (14%). Nurses (46%) were the largest professional group attending, followed by psychologists (14%), social workers (14%), occupational therapists (8%) and doctors (5%). Data was not available on the numbers of each professional group employed in public services in Victoria to assess whether the numbers attending the workshops were representative of the overall proportion of those employed in Victoria. Data on non-responders was not collected, so assessment could not be made as to whether there were any significant demographic differences between those who responded and those who did not.

Survey questionnaire and data collection

Participants were asked to rate from 1 to 5 their ‘willingness’, ‘optimism’, ‘enthusiasm’, ‘confidence’, ‘theoretical knowledge’ and ‘clinical skills’ in working with people with BPD. This questionnaire was administered pre-and post-workshop and at 6-month follow-up. In addition at 6-month follow-up, participants rated the impact the workshop had on their clinical practice. Post-workshop, participants also rated the workshop overall, its relevance to their work and whether they would recommend the workshop to colleagues. Participants were requested to record their date of birth as the way of matching evaluations at the three time intervals, while still retaining anonymity. The purpose of the survey (to evaluate the training) was explained to workshop participants immediately prior to the workshop, after which the pre-workshop survey was collected. Immediately on completion of the workshop, the post-workshop survey was completed. The followup survey was posted to all participants 6 months post-workshop. Participants returned the follow-up survey in a stamped self-addressed envelope and in a separate stamped self-addressed envelope they recorded their name. This enabled a second mail-out to be sent to those who did not respond. Data is not available on the numbers who responded only to the second mail-out.

Results

The results from post-workshop evaluation showed the workshop overall was positively received (mean = 8.7, SD = 1.1; scale: 1 = poor to 10 = excellent) and as relevant to participants work (mean = 8.6, SD = 1.5; scale: 1 = poor to 10 = excellent). The vast majority of the participants (99%) stated they would recommend the workshop to colleagues. At 6-month follow-up participants reported the workshop having had considerable impact on their clinical practice (mean = 7.3, SD = 1.7; scale: 1 = poor to 10 = excellent).

One-way repeated measures analysis of variance (ANOVA) were carried out to compare scores on attitudes and perceptions of knowledge and skills at time 1, time 2 and time 3. The means and standard deviations for each of the six items rated by clinicians at the three assessment times are shown in Table 1. The results from repeated measures ANOVA, presented in Table 2, show that there was a statistically significant effect for time for all six items. A within-subjects analysis of variance using the Greenhouse-Geisser ∑ adjustment (Table 2) revealed a significant difference in attitudes, theoretical knowledge and clinical skills over time. Additional analyses of withinsubject contrasts indicated that, for all six variables, the time 2 and the time 3 scores were statistically significantly different from time 1 scores (p < 0.01). These findings confirmed that the statistically significant improvements in clinicians' attitudes and perceptions of skill and knowledge at time 2 were maintained at time 3 (there were statistically significant changes at the post-workshop assessment which were either maintained or showed a non-significant decrease at 6-month follow-up). There was no relationship between attitude change and demographic variables of age, work setting and professional group of participants.

Table 1.

Mean and SDs for clinician attitudes and perceptions of knowledge and skills at pre-, post-workshop and 6-month follow-up

Table 2.

One-way repeated measures ANOVA comparing scores on clinician attitudes and perception of theoretical knowledge and clinical skills over time

Study strengths and weaknesses

The survey questions on attitudes have not been tested for reliability and validity. The study sample is biased toward clinicians who wanted to attend the training workshop and also those who filled out ratings at all three time intervals. The large sample size is a strength of the study. Having only those who completed the follow-up survey included in the sample was essential in determining whether any of the initial changes made had any lasting impact. Exclusion of those who chose to attend other training on BPD was necessary to eliminate this as a confounding variable of attitude change. It is possible that those who chose to attend further training did so because of interest and enthusiasm generated by attending the workshop reported on; however, there is no way of determining this. Of the remaining workshop participants, the 62% (n = 418) response rate is high considering surveys were carried out at three different times including a 6-month follow-up which was a mail-out.

While participants believed the workshop improved their knowledge and clinical skills, it is not possible within the framework of this study to determine whether this was actually the case. However, a contemporary study found clinicians' perceptions of their drug and alcohol knowledge and competence correlated with actual knowledge as tested by formal brief examination [12]. Likewise it was beyond the scope of the research to assess whether the attitude changes reported resulted in improved treatment outcomes.

Discussion

The clinical importance of attitudes is highlighted by the finding that clinicians who hold non-pejorative conceptualizations of their patients achieve better results as measured by a decrease in patient self-harm episodes and suicidal thoughts [13]. Improved outcome has also been linked with levels of clinician empathy [13], [14]. In light of the positive changes reported in this survey, it is useful to consider what factors might have led to participants' attitude changes.

The goal of setting a culture of realistic hope and respect for patients was begun in the preparatory workshop reading and continued throughout the workshop. Negative terminology and derogatory attitudes were addressed by setting expectations, naming the presenter's and other professionals' struggles to change offensive terminology and modelling an alternative. Patient and ex-patient (video and literature) comments provided clinicians with a positive patient perspective.

Breeze and Repper found clinicians more likely to define patients as ‘difficult’ if the patient challenged the clinician's sense of competence and control [15]. The workshop aimed to provide participants with a robust, practical framework to assist clinician feelings of competence by increasing their effectiveness in working with people with BPD. Existing general mental health skills and knowledge (case management, crisis, rehabilitation, supportive psychotherapy and skills training) were built on and integrated with psychodynamic, cognitivebehavioural and relationship management psychotherapy skills. Clinicians' current competencies were affirmed and validated, preventing clinicians ‘coming away feeling guilty and even hopeless – “put on a guilt trip”’ [16]. Ex-patients' expressions of principles of effective treatment similar to those of clinicians was likely to have been a contributory factor in clinicians' attitude change.

The myth of poor outcome was named and refuted on the basis of prognosis and treatment outcome studies [17–31]. A longitudinal view can assist clinicians when doubting themselves and the work. Successful outcome stories were shared by the trainer, quoted from patients, heard from patients on video and invited from participants. Ex-patients, talking about their past and present, provided visible beacons of hope and inspiration [16].

I started self-harming at the age of 11, came into contact with mental health services at 18 and had over 50 psychiatric admissions, many under mental health legislation and many for several months. The first step in my recovery was being accurately diagnosed followed by a clinical plan. Relationships of trust with clinicians slowly developed and I began to use available support. Instead of, ‘I am going to kill myself’, it is now, ‘I am finding things a bit difficult, could you help me to find ways to help myself.’ After many years on a benefit I am working, leading an active social life and it is some time since I self-harmed. For the first time in my life I am living a life with long-term goals and a vision for the future, something I didn't have before and didn't think was possible. (Transcript of video interview, p. 132 in [10], printed with the permission of W. Jackson.)

In their evaluation of an ex-patient-led training workshop on self-abuse, Thomas and Thomas [16] found clinicians highlighting the positive impact of seeing and hearing from patients who had successful outcomes: ‘… offers great hope for a seemingly “futile” problem’.

All clinicians working with people with BPD are vulnerable to intense emotions. At the beginning of the workshop, clinicians' episodic anger, frustration and powerlessness was acknowledged as inevitable and understandable. The aim was to provide a ‘safe space for clinicians to think and reflect on, rather than deny and flee from, problems and feelings’ (M. Owens, p. 130 in [10]). Aetiological pathways of altered neurophysiology, high incidence of trauma and patient descriptions of their overwhelming distress were likely to have aided empathy. Prioritizing treatment strategies on achieving stability [32–35] when faced with recurrent crises, was presented as a way for clinicians to contain their overwhelming feelings. Appropriate limit-setting can assist clinicians from being overburdened but is sometimes not legitimized in health professionals' training where insufficient attention may be given to clinician needs. Appropriate limit-setting can be beneficial for patients as well by decreasing the likelihood of clinician hostility to, or untherapeutic disengagement from, their patients and increasing the probability of clinicians maintaining a warm welcoming stance toward their patients. Having experts, such as Linehan [34] and Young [35], legitimizing clinician limit-setting was likely to have assisted some clinicians protecting themselves from burning out.

Increased knowledge of the medicolegal environment can decrease clinician anxiety about possible medicolegal consequences and thereby increase clinicians' willingness to work in the area. An overview was provided of legal concepts such as ‘duty of care, negligence, foreseeable risk’ and the ‘reasonable practitioner standard’. The workshop explored current clinician, consumer and legal opinion about balancing short-term and longterm risks and gains [8], [34],[36–41]. Clinicians were encouraged to share risk both horizontally and vertically within their organizations, to ensure that practice was in the ‘reasonable practitioner standard’ and that they felt practically and emotionally supported.

The workshop deliberately built on existing clinician knowledge and skills, interfacing this with the presenter's clinical experience and literature knowledge. While the composition of all workshops was similar, each group of participants brought their own particular history, context and content to the workshop, resulting in a unique set of participant and presenter interactions within each workshop. This manifested in the estimated 85% of workshop time assigned to interactional learning. It is hypothesized that this interactional style assisted participants to remain personally engaged and was a reason why participants rated the workshop as highly relevant to their clinical work (mean = 8.6, SD = 1.5; scale: 1 = poor to 10 = excellent). It is hypothesized also that the interactional nature of the workshop was an ingredient of the workshop's success in effecting attitudinal change.

Clarke has recently written of the importance of moving from a position of demoralization and being overwhelmed to a place of mastery and a sense of competence through a process of restoration of hope and morale [42]. The workshop appears to have assisted clinicians achieving realistic hopefulness defined by Clarke as looking ‘for a favourable outcome within the realm of possibilities’ [42]. Aside from subjective benefits, working toward achieving an optimistic stance is appropriate because it is effective [13], [14], [42].

This study demonstrates that the workshop facilitates positive attitude change that could influence future training of clinicians in mental health and substance abuse fields. However, it was beyond the scope of the research to assess which factors enhanced or decreased efficacy. It would be worthwhile to do a replication study and to evaluate different components. Areas would include participants' experience of the interactional nature of the workshop, information on treatment outcomes/prognosis, discussion on the medicolegal environment and of patient and ex-patient contributions. Feedback has resulted in an ongoing process of workshop modification. In response to overwhelmingly positive feedback of the value of patient contributions, the workshop has evolved since the study reported and is now presented, where possible, conjointly with a consumer consultant. It would be worthwhile to assess the efficacy of this presentation.

Footnotes

Acknowledgements

Thanks to Carol Hulbert and Rosemary Thomas for their data analysis and to Nick Argyle for his review of an earlier draft. This work was undertaken at Spectrum, Personality Disorder Service for Victoria, Melbourne, Australia.

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Borderline Personality Disorder: Attitudinal Change Following Training

Abstract

Keywords

Workshop description

Method

Sample

Survey questionnaire and data collection

Results

Study strengths and weaknesses

Discussion

Footnotes

Acknowledgements

References