An evaluation of the difficulties and attitudes mental health professionals experience with people with personality disorders

Antisocial personality disorder and therapeutic pessimism - how can mentalization-based treatment contribute to an increased therapeutic optimism among health professionals?

Antisocial personality disorder (ASPD) is associated with therapeutic pessimism among health professionals. Several variables are associated with obstacles in therapist's willingness to treat ASPD. Variables that are relevant are (i) confusion associated with the term ASPD, (ii) characteristics of the disorder, (iii) attitudes, experiences, and knowledge clinicians possess, and (iv) insufficient management of countertransference. We assume that therapeutic pessimism is related to the lack of evidence-based, effective treatment for individuals with ASPD. This is problematic because ASPD is associated with large socio-economic costs and considerable suffering for the individual and the society. Mentalization-based treatment (MBT) was developed in treating borderline personality disorder (BPD) and is now considered an effective treatment for this group. Mentalization is defined as the process by which individuals make sense of themselves and others in terms of subjective states and mental processes. This ability affects an individual's psychological functioning, mental health, self-organization, and interpersonal relationships. The overall goal of MBT is to strengthen the individual's mentalizing abilities and facilitate more adaptive handling of problematic, internal states. Recently, a version of MBT tailored for individuals with ASPD (MBT-ASPD) has been developed. The purpose of this review is to investigate how MBT-ASPD relates to the major obstacles that contribute to the therapeutic pessimism toward this group. Despite a limited evidence base, preliminary studies indicate promising results for MBT-ASPD. More research is still required, this review suggests MBT-ASPD can contribute to increased therapeutic optimism and demonstrate specific characteristics of MBT-ASPD that contribute to management of therapeutic pessimism.

Judging Personality Disorder: A Systematic Review of Clinician Attitudes and Responses to Borderline Personality Disorder

BACKGROUND

It has been suggested that the diagnosis of borderline personality disorder (BPD) is associated with particularly stigmatizing connotations, particularly among mental health professionals. The goal of this study was to synthesize quantitative studies investigating the attitudes and responses of clinicians to BPD and to appraise the methodological quality of these studies.

METHODS

A systematic search was carried out using MEDLINE Complete, CINAHL Complete, PsychoINFO, PsychARTICLES, Scopus, Social Sciences Citation Index, and Academic Search Complete. Study quality was rated using an adapted tool.

RESULTS

This review included 37 papers involving an estimated 8196 participants: 21 cross-sectional survey studies, 5 studies assessing training workshops, 5 studies assessing countertransference, and 6 experimental studies. The methodological quality of the studies was mixed, with many differing measures with questionable validity used.

CONCLUSIONS

Negative attitudes toward BPD continue to be a problem to differing degrees among clinical staff. Although this issue is most prominent among psychiatric nurses, the results of this review highlight evidence of negative attitudes across all mental health professions as well as potentially in professionals working in physical health settings. Various clinician-level factors may play a role in the development and maintenance of such attitudes. Greater exposure to patients with BPD and attendance at training programs have been found to be associated with improved attitudes. Professionals require regular training concerning BPD that is sufficiently evidence-based.

The attitudes of mental health nurses that support a positive therapeutic relationship: The perspective of people diagnosed with BPD

WHAT IS KNOWN ON THE SUBJECT?: Some nurses develop positive relationships with people diagnosed with borderline personality disorder (BPD), while others have negative emotional reactions to people diagnosed with this disorder. The therapeutic relationship is key in the practice of mental health nursing. Enhanced knowledge of BPD allows mental health nurses to develop improved self-awareness, knowledge and understanding of the individuals and insight into the therapeutic challenges, which can improve attitudes towards people with this diagnosis. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: We are lacking knowledge about the perspective of people diagnosed with BPD on the attitudes of mental health nurses that facilitate a positive therapeutic relationship. The perspective of people with a BPD diagnosis on the therapeutic relationship offers key information about the attitudes that they credit with supporting their recovery. The participants-people diagnosed with BPD-perceived that the following attitudes of mental health nurses reinforced the therapeutic relationship: confidence in the person's recovery, non-judgement, sense of humour, availability and humanity. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The study highlights mental health nurses' attitudes that participants perceived as having a positive effect on the therapeutic relationship. The recognition among people diagnosed with BPD of the constructive attitudes of mental health nurses may improve nurses' motivation to improve care for these patients. This study will allow mental health nurses to increase their awareness of the importance of attitude in the therapeutic relationship with people diagnosed with BPD. ABSTRACT: Introduction The therapeutic relationship between mental health nurses and people diagnosed with borderline personality disorder (BPD) is essential to successful treatment, and nurses' attitudes are a key component of this relationship. Some nurses develop positive therapeutic relationships with people diagnosed with BPD, while others have negative emotional reactions which in turn limit their ability to develop a positive therapeutic relationship. There is a gap in the literature with respect to how people diagnosed with BPD perceive the attitudes of mental health nurses that foster a positive therapeutic relationship. Aim To describe how people diagnosed with BPD who have experienced an improvement perceive the role of the attitudes of mental health nurses in building a positive therapeutic relationship. Method Qualitative descriptive design with 12 interviews; thematic content analysis. Results Participants identified five attitudes of mental health nurses as contributing to a positive therapeutic relationship: confidence in their ability to recover, non-judgement, humour, availability and humanity. Discussion Nurses' attitudes are key to the therapeutic relationship. It may be possible for nurses to improve their attitudes towards patients diagnosed with BPD through self-reflection. Implications for practice Mental health nurses should incorporate methods that explore attitudes and attitudinal development of the workforce.

An integrative review exploring the experiences of service users carrying a diagnosis of personality disorder and student mental health nurses and the time they share together

OBJECTIVES

This integrative review provides a collective understanding of the experiences of student mental health nurses and service users carrying a diagnosis of personality disorder and the time they share together.

DESIGN

Published studies about the time service users and students share together were systematically selected in order to integrate their findings in a thematic analysis.

DATA SOURCES

Various databases were searched from 1984 until 2020. Specific search terms were used.

REVIEW METHODS

37 studies were included in the integrative review. The studies were from peer reviewed nursing, student, psychology and health related journals. A quality appraisal was completed using Walsh and Downe (2006) framework.

FINDINGS

Four themes emerged from a thematic analysis of the integrative review. These were; With 'Impact of time' as an overarching theme.

CONCLUSION

A positive environment which considers time and focuses on seeing the person, as an individual can lead to the development of therapeutic relationships; a core element of the Nursing and Midwifery Council standards for nursing registration in the UK (Nursing and Midwifery Council, 2018). Students attempting to build such relationships need to be mindful of service users' and their own attachment experiences and the impact these can have on experiences of transference and countertransference, particularly for service users carrying a personality disorder diagnosis. It is important for students to be aware of the supportive impact of positive environments and how doing 'everyday stuff' can make a person feel human despite residing in potentially dehumanizing places.

Patient personality and psychotherapist reactions in individual psychotherapy setting: a systematic review

Despite the importance of psychotherapists' subjective experiencse working with patients with mental issues, little is known about the relationship between therapists' emotional reactions and patients' personality problems. The present study is a systematic review of quantitative research on the association between patients' personality pathology and psychotherapists' emotional, cognitive and behavioural reactions in individual psychotherapy setting. A systematic database search (from January 1980 to August 2019) supplemented by manual searches of references and citations identified seven relevant studies. Significant and consistent relationships were found between therapist reactions and specific personality traits or disorders. In general, odd and eccentric patients tend to evoke feelings of distance and disconnection; emotionally dysregulated patients tend to evoke anxiety and incompetence, and anxious and withdrawn patients tend to evoke sympathy and concern. However, the relatively small sample of studies and methodological inconsistencies across studies limit firm conclusions and suggest the need for more systematic research. Findings from this review indicate that patients who share the same personality disorder or symptoms tend to evoke specific and similar cognitive, emotional and behavioural reactions in their therapists. This suggests that therapists overall reactions toward patients may be source of valuable diagnostic information.

Stigmatizing attitudes of tertiary hospital physicians towards people with mental disorders in Saudi Arabia

OBJECTIVES

To measure stigma among doctors in one of the major specialized hospitals in Saudi Arabia.

METHODS

This cross-sectional study was conducted at King Abdullah Medical City, Jeddah, Saudi Arabia between October and November 2018. Eighty physicians were recruited in this study. The participants administered the sociodemographic questionnaire as well as the Mental Illness Clinicians' Attitude 4th version (MICA 4).

RESULTS

The overall MICA score ranged between 31 and 61 with a mean±SD of 45.75±7.54. The highest reported score was among outpatient physicians (51.33±6.66), while the lowest score was among consultants/assistant consultants (43.17±7.82).

CONCLUSION

The results of this study showed a relatively high MICA-4 score that could indicate a high stigmatizing attitude among physicians toward patients with mental illnesses compared with the other MICA-4 studies. Thus, training workshops could improve the attitudes in the short-term.

When personality is the problem: Managing patients with difficult personalities on the acute care unit

Personality disorders are pervasive patterns of maladaptive behaviors, thoughts, and emotions that often go unrecognized and can wreak havoc in the patient's interpersonal life. These inflexible patterns of managing the world can be disruptive when an individual is admitted to the hospital, causing distress for both the patient who lacks the skills to deal with the expectations of the hospital environment and the treatment team who can feel ill equipped to manage such behavior. Having a personality disorder has implications for an individual's healthcare outcomes; those with a personality disorder have a life expectancy nearly 2 decades shorter than the general population for a multitude of reasons, among them trouble interacting with the healthcare system. Although a diagnosis of a specific personality disorder may be difficult to make on an acute care unit, identification of dysfunctional personality structures can provide opportunity for better management of an individual patient's medical and psychological needs. This review focuses on the identification of these individuals in the acute care setting and provides an overview of evidence-based behavioral and pharmacological interventions. Journal of Hospital Medicine 2015;11:873-878. © 2015 Society of Hospital Medicine.