Q44 I would discuss my feelings towards people with BPD in supervision if this was encouraged Q3 I thinking about clients with BPD on my caseload .486 .191 -.006 .532 .310 .186 .464 .317 Q28 People with BPD are never satisfied with the services they receive .478 .036 .307 .562 .271 .438 .528 .413 Q21 If I had the choice I would accept the referral of a client with depression over a client with BPD .474 .066 .305 .565 .300 .447 .507 .424 Q33 Working with people with BPD is rewarding .460 .270 .154 .564 .443 .369 .634 .436 Q46 If I had the choice I would prefer not to work with people with BPD .425 .435 .052 .546 .560 .322 .626 .492 Q23 People with BPD make me feel -.121 .715 0.18 .061 .692 .260 .554 .492 Q40 Working with people with BPD makes me feel helpless -.173 .667 .117 .022 .669 .328 .627 .481 Q30 People with BPD frighten me -.016 .586 -.027 .123 .572 .192 .432 .328 Q17 People with BPD make me feel hopeless .013 .585 .109 .185 .630 .335 .539 .407 Q25 I easily lose my temper with people with BPD .223 .557 -.065 .345 .588 .202 .490 .392 Q35 I dislike people with BPD .259 .555 -.157 .359 .560 .118 .573 .386
Q45 Working with people with BPD makes me feel stressed -.168 .548 .361 .057 .643 .529 .621 .533 Q43 I feel isolated in working with people with BPD .122 .455 .052 .252 .512 .273 .612 .283 Q29 I feel optimistic working with people with BPD Q12 I feel drained by people with BPD .367 -.120 .404 .347 .134 .446 .500 .076 .546 .487 .378 .548 .583 .533 .455 .404 Q16 In comparison with other client groups people with BPD are demanding .102 -.059 .670 .252 .221 .673 .575 .464 Q10 People with BPD are difficult to work with -.105 .103 .669 .085 .331 .683 .571 .482 Q9 People with BPD are more manipulative than client groups .366 -.102 .559 .478 .202 .610 .633 .496 Q27 In comparison with other client groups people with BPD are attention seekers .402 .130 .397 .532 .381 .545 .569 .481
References Allison, P. D., & Oaks, T. (2002). Missing data: Quantitative applications in the social sciences. British Journal of Mathematical and Statistical Psychology,55(1), 193-196. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). Arlington: American Psychiatric Association. Bagozzi, R. P., Tybout, A. M., C. S., & Sternthal, B. (1979). The construct validity of the tripartite classification of attitudes. Journal of Marketing Research, 88-95. Bartlett, M. S. (1954). A note on the multiplying factors for various chi square approximations. Journal of Royal Statistical Society, 16(Series B), 296-298. Bateson, C. D., Polycarpou, M. P., E., Imhoff, H. J., Mitchener, E. C., Bednar, L. L., ... & Highberger, L. (1997). Empathy and attitudes: Can feeling of a member of a stigmatized group improve feelings towards the group. J Person Soc Psychol, 72, 105-18. Becker, D. (1997). Through the looking glass: Women and borderline personality disorder. Colorado: Westview Press. Black, D.W., Pfohl, B., Blum, N., McCormick, B., Allen, J., North, C.S.....Zimmerman, M. (2011). Attitudes towards personality disorder: A survey of 706 clinicians. CNS Spectrums, 16, 67-74. doi:10.1017/S109285291200020X.
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The purpose of this survey is to develop a questionnaire looking at mental health staff’s thoughts, feelings and actions when working with people who meet the diagnostic criteria for borderline (emotionally unstable) personality disorder. It is hoped this questionnaire will be useful the recruitment and training of staff who work with this client group. If you have some experience of working with people with borderline personality disorder (BPD) you are invited to participate in this study. We are aware some people prefer not to use diagnostic labels such as BPD. We would still appreciate your input if you do not use this diagnostic category but have experience of working with people who would meet the criteria for this diagnosis. We are using this diagnostic category within the study to identify a particular group of service users. The procedure involves filling in a survey which will take approximately 15 minutes of your time. The survey consists of the new questionnaire and existing measures of attitudes, empathy and social distance. Your responses will be confidential and we will not collect any identifying information such as your name or email address. To protect your confidentiality your responses will be stored in a password protected electronic format in accordance with the Data Protection Act (1998). As you will be asked about your feelings towards working with people with BPD it is possible you might find the survey has an emotional impact. Should this happen you have the options of discussing this with the researcher, or your manager in clinical supervision. This study is being conducted by Emma McQuillan, a trainee clinical psychologist at the University of Surrey as part of her clinical psychology doctorate (PsychD) and is supervised by Dr Fiona Warren (Lecturer). Your participation in this study is entirely voluntary and you may choose not to participate, without justifying this decision. If you choose to participate in the study you will be free to withdraw at any time, again without justifying your decision and without prejudice. This research has been approved by The Faculty of Arts and Human Sciences Ethics Committee at the University of Surrey. If you have any further questions about this study prior to making a decision about please contact: Emma McQuillan (Researcher) Psychology Department University of Surrey Guilford GU27XH (for research purposes only) email:e.mcquillan@surrey.ac.uk Dr Fiona Warren (Supervisor) Lecturer Department of Psychology University of Surrey
17 I feel angry towards PD people 1 2 3 4 5 6 18 I feel provoked by PD people 1 2 3 4 5 6 19 I enjoy spending time with PD people 1 2 3 4 5 6 20 Interacting with PD people makes me shudder 1 2 3 4 5 6 21 PD people make me feel irritated 1 2 3 4 5 6 22 I feel warm and caring towards PD people 1 2 3 4 5 6 23 I feel protective towards PD people 1 2 3 4 5 6 24 I feel oppressed or dominated by PD people 1 2 3 4 5 6 25 I feel that PD people are alien, other, or strange 1 2 3 4 5 6 26 I feel understanding towards PD people 1 2 3 4 5 6 27 I feel powerless in the presence of PD people 1 2 3 4 5 6 28 I feel happy and content in PD people’s company 1 2 3 4 5 6 29 I feel cautious and careful in the presence of PD people 1 2 3 4 5 6 30 I feel outmanoeuvred by PD people 1 2 3 4 5 6 31 Caring for PD people me feel satisfied and fulfilled 1 2 3 4 5 6 32 I feel exploited by PD people 1 2 3 4 5 6 33 I feel patient when caring for PD people 1 2 3 4 5 6 34 I feel able to help PD people 1 2 3 4 5 6 35 I feel interested in PD people 1 2 3 4 5 6 36 I feel unable to gain control of the situation with PD people 1 2 3 4 5 6 37 I feel intolerant. I have difficulty tolerating PD people’s behaviour 1 2 3 4 5 6
Appendix J Basic Empathy Scale (Joliffe & Farrindgon, 2006) The following sentences refer to characteristics that may or may not correspond to you. Please, circle one answer for each statement to indicate to what extent you agree or disagree with the statement. Please, answer as honestly as you can 1. My friends’ emotions don’t affect me much Strongly disagree Disagree Neither agree nor disagree Agree Strongly Agree 2. After being with a friend who is sad about something, I usually feel sad Strongly disagree Disagree Neither nor disagree Agree Strongly Agree 3. I can understand my friend’s happiness when she/he does well at something Strongly disagree Disagree Neither agree nor disagree Strongly Agree
4. I get frightened when I watch characters in a good scary movie Strongly disagree Disagree Neither agree nor disagree Agree Strongly Agree 5. I get caught up in other people’s feelings easily Strongly disagree Disagree Neither agree nor disagree Agree Strongly Agree 6. I find it hard to know when my friends are frightened Strongly disagree Disagree Neither agree nor disagree Agree Strongly 7. I don’t become sad when I see people crying Strongly disagree Disagree Neither agree nor disagree Agree Strongly 8. Other people’s feeling don’t bother me at all Strongly disagree Disagree Neither agree nor disagree Agree Strongly Agree 9. When someone is feeling ‘down’ I can usually understand how they feel Strongly disagree Disagree Neither agree nor disagree Agree Strongly 10. I can usually work out when my friends are scared Strongly disagree Disagree Neither agree nor disagree Agree Strongly Agree 11. I often become sad when watching sad things on TV or in films Strongly disagree Disagree Neither agree nor disagree Agree Strongly Agree 12. I can often understand how people are feeling even before they tell me Strongly disagree Disagree Neither agree nor disagree Agree Strongly Agree 13. Seeing a person who has been angered has no effect on my feelings Strongly disagree Disagree Neither agree nor disagree Agree Strongly Agree 14. I can usually work out when people are cheerful Strongly disagree Disagree Neither agree nor disagree Agree Strongly Agree 15. I tend to feel scared when I am with friends who are afraid Strongly disagree Disagree Neither agree nor disagree Agree Strongly 16. I can usually realize quickly when a friend is anger Strongly disagree Disagree Neither agree nor disagree Agree Strongly 17. I often get swept up in my friends’ feelings Strongly disagree Disagree Neither nor disagree Agree Strongly agree 18. My friend’s unhappiness doesn’t make me feel anything Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 19. I am not usually aware of my friends’ feelings Strongly disagree Disagree Neither agree nor disagree Agree Strongly agree 20. I have trouble figuring out when my friends are happy Strongly disagree Disagree Neither agree nor disagree Strongly agree
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Table 2. Quantitative Studies Measuring and Describing MHPs’ Attitudes to Personality Disorder Study Location/ Setting Design/ Method Sample (response rate) Measurement of attitudes Results Black et al. 2011 USA 9 centres Survey Questionnaire N=706 (48%) 343-P, 98 SW, 114 PN, 89 PSY, 52 other 15 items rated on 7 point scale. Sub-scales: Empathy, caring attitudes, treatment optimism Overall low scores “negative attitudes”. Significant differences: empathy (p=.002), treatment optimism (p<.001), caring attitudes (p<.001). Bodner et al. 2011 Israel Several hospitals Survey Questionnaire N=57 25 PN, 19 P, 13 PSY. Cognitive items (47) Emotional (20) on 5 point scale. Significant differences: antagonistic judgements (p<.001, n²=.38) and empathy (p<.001, n²=0.20). Cleary et al., 2002 Australia (Sydney) One MH service Survey Questionnaire N=229 (44%) 152 PN, 35 P, 15 PSY, 15 SW, 6 OT, 3 other. 23 items; experience, knowledge and “attitudes”. Agree/ disagree response. 80% found working with people with BPD “difficult”. & Australia & NZ 3 health Survey Questionnaire N=140 (50%) 69.3% nurses ADSHQ-validated 33 items rated on 4 point scale. MHPs significantly (p< .001) more positive attitudes to DSH/BPD than Commons- Trealor
Lewis 2008a services 17.1% AH 13.6% medical Higher score=more positive attitude to DSH EC’s (d=0.79). AH significantly (p<.01) more positive attitudes than professionals (d=0.52). Deans & Moecevic 1996 Australia Melbourne 1 MH service Survey Questionnaire N=65 (60%) P 50 items Clinical description (20) concerns (10) emotional reactions(10) management (10) on 5 point scale High proportion of staff reported “negative attitudes” and “negative emotions” Fraser & Gallop, 1993 Canada 4 MH Observational N=17 PN Patients: BPD-20.7% Schiz-12.8% AD-55.4% Confirmation/dis-confirmation rating scale Hospital treatment rating scale BPD significantly more responses (p<.01) & negative feelings (p<001) than other diagnostic groups. Giannouli et al. 2009 Greece, Athens 4 hospitals (2 general, 2 psychiatric) Survey Questionnaire N=69 (53.3%) PN Cleary et al. (2002) No significant differences in attitudes of PN in psychiatric and general hospitals. 85.5% found people with BPD “difficult” to work with.
James & Cowman 2007 Ireland, Dublin 1 MH service Survey Questionnaire N=65 (41.4%) PN Cleary et al. (2002) 75% BPD “difficult” to work with. & Appleby 1988 UK Various Experimental Questionnaire N=173 (72%) P 22 semantic differentials ranked on 6 point scale. Higher score=more “negative” attitude. Significant difference between PD/ no PD groups on 16/22 semantic differentials (p<.05). Markham & Trower 2004 UK One NHS (Inpatient) Quasi experimental Repeated measures N=48 (96%) PN Attribution style Q (Dangan, 1998)-rated cause attribution for challenging behaviours. Sympathy & optimism rated on 7 point scale. Control sig higher (p<.001) BPD than depr (d=0.98) or schiz (d=1.44). Sympathy significantly lower (p<.001) BPD than depr (d=1.44) or schiz (d=1.85). Optimism significantly lower (p<.001) for BPD than depr (d=1.26) or schiz (d=0.91). Markham 2003 UK As above As above N=71 (99%) 50 PN 21 HCA’s Social distance 11 items, 5 point scale Dangerousness scale (Link et al. 1987). Optimism-4 items, 7 point scale. PN’s scores significantly higher (p<.001) on social distance for BPD than schiz (d=0.84) or depr (d=1.69). PN’s scores significantly higher (p<.001) on dangerousness for BPD than schiz (d=0.90) or depr (d=1.83). Optimism significantly lower (p<.001) for BPD than depr (d=1.22) or schiz (d=0.77).
Purves & Sands 2009 Australia 4 MH services Survey Questionnaire N=61 (54%) 62.2% PN 19.6% AH 16.3% D APDQ 5 dimensions Validated measure. Higher positive attitude. Postgraduate education significantly correlated (p<.05) with APDQ dimensions (r=0.3). More negative (54.1%) than positive attitudes (45.9%) Webb & McMurran 2007 1 NHS Trust Survey Questionnaire n=117 (99%) CMHT nurses n=645 forensic nurses APDQ CMHT nurses scored sig higher (p<.002) on enjoyment (d=0.68), sig lower (p<.002) on security (d=2.09), acceptance (d=1.61) and purpose (0.65) than forensic nurses. See Appendix 1 for key
Table 3. Qualitative studies Study Location/ Setting Sample/ Sampling Data analysis/ Collection Findings Treloar Australia & NZ 3 services N=140 69.3% nurses 17.1% AH 13.6% medical Purposive sampling Questionnaire Thematic analysis BPD= uncomfortable personal response, Millar et al. (2012) Scotland 1 NHS Trust N=16 9 TCP’s 7 CP’s Purposive sampling Focus groups x4 IPA Negative & positive perceptions & feelings to BPD. Webb (2005) Wales, 1 CMHT N=14 8 SW, 6 health Convenience sampling Focus group x 2 Thematic analysis Difficulties in working with PD. Woollaston & Hixenbaugh (2008) UK, London N=6 PN Convenience sampling Semi-structured interview Thematic analysis Negative perceptions BPD “destructive whirlwind” See Appendix 1 for key
2008 Victoria Range MH services Experimental 6m FU 48% PN, 14% PSY, 14% SW, 14% OT, 5% D diagnosis, aetiology, prognosis & treatment of BPD. willingness, enthusiasm, confidence, knowledge, clinical skills. improvement on all ratings (p<.01). d=0.39 (post) d=0.20 (FU) Shanks et al. 2011 USA 3 locations Quasi Experimental N=271 38.4 SW, 20.7% CO, 9.2% PSY, 31.7% others. 6 hours STEPPS workshop 31 item Q, 9 related to attitudes Rated 1-7. See Appendix 1 key Sig improvement on 7/9 items (p<.001). d=0.18-0.57.