Structural stigma and its impact on healthcare for borderline personality disorder: a scoping review

BACKGROUND

People with Borderline Personality Disorder (BPD) and their carers/families continue to experience structural stigma when accessing health services. Structural stigma involves societal-level conditions, cultural norms, and organizational policies that inhibit the opportunities, resources, and wellbeing of people living with attributes that are the object of stigma. BPD is a serious mental illness characterized by pervasive psychosocial dysfunction including, problems regulating emotions and suicidality. This scoping review aimed to identify, map, and explore the international literature on structural stigma associated with BPD and its impact on healthcare for consumers with BPD, their carers/families, and health practitioners.

METHODS

A comprehensive search of the literature encompassed MEDLINE, CINAHL, PsycINFO, Scopus, Cochrane Library, and JBI Evidence-Based databases (from inception to February 28th 2022). The search strategy also included grey literature searches and handsearching the references of included studies. Eligibility criteria included citations relevant to structural stigma associated with BPD and health and crisis care services. Quality appraisal of included citations were completed using the Mixed Methods Appraisal Tool 2018 version (MMAT v.18), the Joanna Briggs Institute (JBI) Checklist for Systematic Reviews and Research Syntheses Tool, and the AGREE II: advancing guideline development, reporting, and evaluation in health care tool. Thematic Analysis was used to inform data extraction, analysis, interpretation, and synthesis of the data.

RESULTS

A total of 57 citations were included in the review comprising empirical peer-reviewed articles (n = 55), and reports (n = 2). Studies included quantitative, qualitative, mixed methods, and systematic review designs. Review findings identified several extant macro- and micro-level structural mechanisms, challenges, and barriers contributing to BPD-related stigma in health systems. These structural factors have a substantial impact on health service access and care for BPD. Key themes that emerged from the data comprised: structural stigma and the BPD diagnosis and BPD-related stigma surrounding health and crisis care services.

CONCLUSION

Narrative synthesis of the findings provide evidence about the impact of structural stigma on healthcare for BPD. It is anticipated that results of this review will inform future research, policy, and practice to address BPD-related stigma in health systems, as well as approaches for improving the delivery of responsive health services and care for consumers with BPD and their carers/families.

REVIEW REGISTRATION

Open Science Framework ( https://osf.io/bhpg4 ).

The Influence of Interpersonal Patterns on the Therapy Process in a Case of Childhood Trauma

Research concerning the influence of core interpersonal patterns related to childhood trauma on the therapeutic process is scarce. We investigated interpersonal patterns at the start of treatment, changes in interpersonal patterns as treatment progressed, and the change process in a mixed-methods single case study of a supportive-expressive psychodynamic psychotherapy with a 33-year-old female with a history of childhood trauma. The patient showed a pervasive inability to open up towards others throughout the entire treatment, which is closely associated with others' actual or anticipated rejection, disrespect and disinterest. Excessive use of expressive interventions, which target interpersonal change, initially led to a worsening of the patient's condition. Via supportive and general interventions, symptom stabilization was achieved. The findings of this study suggest a thorough understanding of dominant interpersonal patterns is necessary to recognize their influence on the therapy process.

Core Interpersonal Patterns in Complex Trauma and the Process of Change in Psychodynamic Therapy: A Case Comparison Study

We performed a case comparison study to investigate the nature of interpersonal patterns in childhood trauma and the process of change therein. We analyzed three matching cases of childhood trauma that followed a psychodynamic treatment via a mixed-methods design. We found that (1) the core tendency to avoid negative reactions from others through passive behaviors emerged in all three cases, both in childhood and adulthood, (2) core interpersonal patterns transpired in the interaction between patient and therapist and thereby affected the therapeutic relationship, and (3) change ensued when a repetition of core interpersonal patterns was avoided and a new relational experience occurred. The accumulated findings across cases further resulted in several clinical implications and recommendations, such as the importance of the assessment of patients' (covert) conditions, responsiveness, supervision and facilitating patients' agency, and provided several avenues for further research.

Sheltered women's perceptions of their abusive marital relationship: Conflictual themes of dominance and submissiveness

The Core Conflictual Relationship Themes (CCRT) approach was applied in order to examine the conflictual nature of sheltered women's perceptions of their marital relationship following domestic violence in Israel. Thirty-six sheltered women and 89 community-based women were compared. The CCRT method was useful in revealing that battered women, when thinking retrospectively about their relationships with their abusive partners, are concerned with conflictual themes of dominance and submissiveness. The sheltered women reported a desire to be more dominant and less submissive in their relationships with their abusive spouse, despite being less dominant than they wished in practice. These findings help clarify the emotional conflicts that battered women may be dealing with after leaving an abusive relationship and imply that interventions should promote their empowerment.

Change in the core conflictual relationship theme after long-term dynamic psychotherapy

This naturalistic study focuses on changes in central relationship patterns after long-term dynamic psychotherapy (mean duration = 3 years) with experienced psychotherapists. Relationship patterns before and after treatment were assessed according to the core conflictual relationship theme (CCRT) method, which includes 3 components: most frequent wish, response from others, and response of the self. Overall, the main CCRT did not change substantially after therapy. There were, however, a few significant changes for some of the standard cluster categories after therapy. Patients' flexibility regarding their use of different wishes and negative responses from others and the self increased, as did the frequency of positive responses from others and the self. The positive changes in relationship patterns were only rarely related to changes in symptoms and character pathology.

The meaning of self-injury and overdosing amongst women fulfilling the diagnostic criteria for 'borderline personality disorder'

OBJECTIVES

To explore the meanings of self-injury and overdosing, and the relationship of each to the other, for women who have fulfilled the diagnostic criteria for borderline personality disorder.

DESIGN

Four women with a history of both self-injury and overdosing were recruited through a local psychotherapy service and interviewed following a semi-structured framework.

METHODS

The interview transcripts were systematically analysed utilizing interpretative phenomenological analysis.

RESULTS

The analysis lead to the construction of three interrelated themes: (a) The context of distress. Examples were inclusive of temporally distal factors such as childhood abuse and loss, and proximal factors ranging from the interpersonal (e.g., conflict) through to the intra-personal (e.g., negative thoughts relating to self). (b) The progressive management of distress. An overdose was depicted as a last resort once self-injury had become insufficient a means of self-help to manage feelings of desperation and isolation. (c) Ambivalence in relation to death. The clearly stated intention of an overdose was 'to die'. However, both words and (descriptions of) deeds suggested considerable ambivalence in relation to this--overdoses appearing to depict an attempt to resolve unbearable feelings through an unarticulated 'cry for help' rather than suicide completion.

CONCLUSIONS

The overall impression gained was of a group of women in a world of problematic relations (to both self and others) struggling to know how best to attract support and understanding. In discussion, links are made to the literature on reflectivity/reflexivity through Fonagy's notion of 'mentalization'.

Assessing the wish to die: a 30-year review of the suicide intent scale

This analysis drew from decades of published research to evaluate the Suicide Intent Scale (SIS), the dominant research tool for assessing intent to die in apparent suicide attempts. The review sought to 1) synthesize findings related to the scale's normative scores, reliability, and validity (factorial, convergent, and predictive), and 2) examine the objective and subjective subscales' performance. A literature search yielded 158 studies reporting findings for the SIS. Psychometric properties were summarized. Studies supported the scale's reliability, especially that of the subscale assessing self-reported (versus circumstantial indicators) of intent. Mixed findings emerged regarding convergent and predictive validity. The review identified shortcomings in factorial validity and the subscales' performance, especially for adolescents. The Suicide Intent Scale has some strengths, but the weaknesses require further investigation into how to better measure intent to die in attempted suicide.

[How do conflict and structure present themselves in relationships?]

It is argued that the approaches used up to now for analyzing dysfunctional relationship patterns are more or less explicitly based on a conflict model and therefore not adequate for describing relationships characterized by structural impairments of a patient's personality. Using the concepts of conflict and structure as derived from the Operationalized Psychodynamic Diagnostic system (OPD-2), four principles of a dysfunctional relationship formation are discussed. It is shown that the differentiation of conflict- and structure-related pathology is highly significant with regard to the selection of an appropriate psychotherapeutic strategy. Furthermore, the connections between the OPD axes relationship, conflict, and structure are conceptualized.

Welche Kategorien des zentralen Beziehungs- Konflikt-Themas stehen in Zusammenhang mit Depressions-Symptomen? Eine explorative Studie/ Which core conflictual relationship themes are consistent with depressive symptoms? An exploratory study

OBJECTIVES

We study the pattern of interpersonal alliances typical of depressive symptoms by means of the Core Conflictual Relationship Theme (CCRT) method. In an exploratory manner we examine which CCRT-coded wishes, perceived responses from the other and associated responses of the self predict the magnitude of a score on the Beck Depression Inventory-II.

METHODS

Interview data from 31 mental health patients were coded (CCRT expanded standard categories system). Relations between the CCRT categories and the dependent variable were examined by combining 1000-fold forward stepwise regression analyses, and multiple regression analyses in which confidence intervals were estimated with the bootstrap technique.

RESULTS

Three CCRT categories that jointly explain more than half of the variance were selected: diminished levels of the wish to be understood, and elevated levels of disliking others and of feeling helpless.

CONCLUSIONS

The results and implications for psychotherapy are discussed within a psychoanalytic context. Suggestions for further research are indicated.

The Same Old Song?-Stability and Change in Relationship Schemas From Adolescence to Young Adulthood

Relationship schemas are core elements of personality that guide interpersonal functioning. The aim of this study is to examine stability and change in relationship schemas across two developmental epochs-adolescence and young adulthood-in the stories that people tell about their interactions with others. Using the Core Conflictual Relationship Theme Method, relationship themes were coded from semistructured interviews conducted in adolescence and again at age 25. The sample consisted of 40 participants in a longitudinal study of adolescent and young adult psychological development. There was considerable stability in the frequency with which particular themes were expressed in the narratives of adolescents and young adults. Significant changes from adolescence to young adulthood included a decrease in the perception of others as rejecting and of the self as opposing others. Young adults saw themselves and others more positively, and used a broader repertoire of themes in their relationship narratives than they had as adolescents. The basic continuity and particular changes in relationship schemas found in this study are consistent with knowledge about the adolescent-to-young-adult transition derived from other empirical and clinical findings. Relationship schemas may be rich units of study for learning about the development of interpersonal functioning.

Relationships between God and people in the Bible: a core conflictual relationship theme study of the Pentateuch/Torah

The most widely known images of God are from the Bible. An important characteristic of these images is their portrayal of God's interactions with people. Although there have been many religious and literary discussions of God's relationships with people in the Bible, no systematic psychological assessment has been reported. Therefore, the aim of this study was an innovation: to identify patterns of relationship between God and people portrayed in the first five books of the Bible, the Pentateuch or Torah, by using the core conflictual relationship theme (CCRT) method, a widely used scoring system for the assessment of interpersonal relationships. Reliability for the application of the CCRT method to relationship episode narratives in the Pentateuch/Torah was assessed and found to be very good. Results show that the most frequent theme in relationship episode narratives about God and people is that God is helpful. Two less frequent but also highly repetitive themes are that God controls or hurts the other person. Many differences were found between relationship themes defined by the type of person with whom God interacted: patriarch, Moses, woman, non-Israelite, or not a non-Israelite. Thus, the CCRT results identify several different patterns of relationship between God and people.