Implementing a whole-of-service stepped care approach to personality disorder treatment: Impact of training and service redesign on clinician attitudes and skills.

Personality disorders are a highly prevalent mental health condition. Historically, clinician attitudes have been negative, and only a small number have specialised training. This study evaluated clinician attitudes and confidence in working with people with personality disorder following the combination of training and implementation of a stepped care whole-of-service approach. A total of 102 multidisciplinary mental health clinicians were trained to implement the stepped care approach, and completed surveys prior to implementation and at 12 months follow up. Clinicians delivered manualised structured psychological therapy as part of the model. Measures assessed changes in attitudes and confidence, and impact of the service changes and therapy approach. Qualitative responses elucidated core themes. Evaluation at 12 months post training and service redesign showed improvements in clinician skills, confidence, theoretical knowledge and attitudes. Qualitative thematic analysis found core themes of improved understanding, clinical skills and improvements in the accessibility and timeliness of treatment. Implementing a whole-of-service model featuring stepped care therapies enhanced clinician attitudes, confidence, skills and knowledge in working with people with personality disorders. Clinicians identified that the whole-of-service model also improved accessibility to treatment, and quality of clinical care to the consumer and their carers.

Efficacy and recommendations for the delivery of telehealth psychotherapy for people with personality disorder.

OBJECTIVE: There are few studies on the efficacy and acceptability of psychotherapy conducted via telehealth technology for people with personality disorder. This study aims to examine clinician perspectives on virtual psychotherapy. METHOD: Twenty multidisciplinary mental health clinicians (85% female, average age 42 years) with at least 2 years of experience in telehealth psychotherapy contributed quantitative and qualitative ratings of acceptability and efficacy of this modality. RESULTS: Likert scale ratings (1 = not, 5 = very) demonstrated high client acceptability (mean = 4.0), effectiveness (4.0) and high clinician acceptability (4.2) and sustainability (4.2). Three recommendations emerged from qualitative analysis: prioritising frame establishment, ensuring client safety online and maximising alliance-enhancing strategies. CONCLUSIONS: This study, which collected quantitative and qualitative ratings of virtual psychotherapy, found that telehealth psychotherapy can be effective and acceptable for people with personality disorder. Strategies associated with success included strong governance, secure technology and careful attending to relationship management.

Evaluation of a skills-based peer-led art therapy online-group for people with emotion dysregulation.

OBJECTIVE: We developed and piloted a novel art-based online skills program led by a peer mental health professional with lived experience of complex mental health, including Borderline Personality Disorder (BPD). Key challenges of living with BPD and emotion dysregulation were addressed through artmaking informed by a dialectical framework and skills, to evaluate acceptability and efficacy. METHOD: A structured, manualised 2-hour weekly arts-based skills program was piloted for people with BPD over 18 weeks. Evaluation included both quantitative and qualitative measures at commencement and completion. RESULTS: Thirty-eight participants enrolled in the program (89.5% identified she/her pronouns, average age 33.6 years), and 31 completed (82% retention). Multilevel modelling analysis of the primary outcome variable Difficulties in Emotion Regulation Scale (DERS) demonstrated a large improvement over time (effect size Cohen's d = 1.77). Qualitative thematic analysis found participants had improved capacity to regulate emotions and tolerate distress, improved connection with others, enhanced understanding of the self, and higher hope for living well. We found that artmaking facilitated processes and helped the expression of difficult emotions, symbolise challenging relationships, and facilitate greater self-understanding. Participants reported high levels of satisfaction, and 77.4% reported that the program had increased wellbeing. CONCLUSION: This novel artmaking program for emotion dysregulation and BPD was acceptable and potentially effective. Peer facilitation using arts-based skills is a modality of therapy for further investigation.

A Randomized Controlled Trial of Group Psychoeducation for Carers of Persons With Borderline Personality Disorder.

Carers of persons with borderline personality disorder (BPD) experience high burden. Treatment guidelines advocate involving carers in comprehensive therapy approaches. This study is a randomized controlled trial of group psychoeducation, compared to waitlist. Group psychoeducation involved 6-8 carers per group and focused on improving relationship patterns between carers and relatives with BPD, psychoeducation about the disorder, peer support and self-care, and skills to reduce burden. Carers were randomized into intervention (N = 33) or waitlist (N = 35). After 10 weeks, those in the intervention reported improvements in dyadic adjustment with their relative, greater family empowerment, and reduced expressed emotion, sustained after 12 months. There were also improvements in carers' perceptions of being able to play a more active role, such as interacting with service providers. This study demonstrates that providing structured group programs for carers can be an effective way of extending interventions to a group experiencing high burden.

The relationship between expressed emotion and wellbeing for families and carers of a relative with Borderline Personality Disorder.

BACKGROUND: Previous research has found that family environments high in expressed emotion, in particular emotional overinvolvement, are beneficial to the clinical outcome of patients with Borderline Personality Disorder (BPD). AIM: This study aims to investigate the relationship between expressed emotion, carer burden and carer wellbeing. METHOD: A total of 280 carers of a relative with BPD were administered the McLean Screening Instrument for BPD - Carer Version, The Family Questionnaire, Burden Assessment Scale and Mental Health Inventory. RESULTS: Carers reported family environments high in expressed emotion, particularly criticism (82.9% of carers) and emotional overinvolvement (69.6%). Elevated emotional overinvolvement was correlated with higher burden and mental health problems. CONCLUSIONS: Elevated criticism and emotional overinvolvement in family environments represent a dynamic involving high conflict, anxious concern, overprotection and emotional closeness. The findings suggest that carers may benefit from intervention and support options considering the challenged interpersonal dynamic, burden and impaired carer wellbeing reported in this study.

Supporting a person with personality disorder: a study of carer burden and well-being.

Personality disorders are characterized by impaired interpersonal functioning. There are few studies and little data available using validated questionnaires on the impact of caring for a person with personality disorder. The 287 carers included in this study were administered the McLean Screening Instrument for Borderline Personality Disorder-Carer Version, Burden Assessment Scale, Grief Scale, Difficulties in Emotion Regulation Scale, Mental Health Inventory-5, and a qualitative question. Scores were compared to those of published comparison groups. Burden and grief were significantly higher than that reported by carers of persons with other serious mental illnesses. Carers endorsed symptoms consistent with mood, anxiety, and posttraumatic stress disorders. A qualitative concept map highlighted the impact of caregiving on the interpersonal environment. Carers of persons with personality disorder report grieving their change in life and impairment in well-being. Carers are burdened, and appear more so than carers of persons with other serious mental illnesses. The results highlight the need for interventions to support carers.

The relationship between placebo alcohol and affect: motives for drinking.

INTRODUCTION AND AIMS: Although alcohol is often used in an attempt to alleviate negative affect, alcohol oftentimes exacerbates depressive symptoms. Therefore the relationship between alcohol and affect, and the role of motives for drinking remain unclear. The present study hypothesised that placebo alcohol would blunt affective responding and that desire to drink would increase in individuals who expected alcohol to help them cope after a negative experience. The present study also explored whether motives and reasons for drinking altered after a negative experience. DESIGN AND METHODS: Participants (36 first-year psychology students and 41 community members) were randomly assigned to one of four experimental groups, being soft drink or placebo alcohol, neutral or negative mood induction. RESULTS: Two repeated measures analyses indicated that placebo alcohol did not significantly blunt affective responding after the negative mood induction. T-tests showed that desire to drink did not significantly increase post negative mood induction for participants who endorsed coping motives for drinking. However, interestingly coping-depression and enhancement motives decreased after negative mood induction, and participants misattributed the majority of their mood to other life events. DISCUSSION AND CONCLUSIONS: The findings indicate that motives for drinking are amendable with prior learning, providing support for expectancy challenge procedures. The study also provides some evidence for alcohol's effect on emotional lability.

Burden and support needs of carers of persons with borderline personality disorder: a systematic review.

BACKGROUND: A major feature of personality disorders is significant impairment in interpersonal functioning, which may create challenges in close relationships. This article aims to systematically review the experience of carers of persons with personality disorders. METHOD: The PRISMA systematic review method was followed, and empirical studies written in English, published between 1996 and 2011, and cited in major electronic databases were searched. Studies meeting the following selection criteria were included: (1) carers or families of persons with personality disorders; (2) intervention involving the carers or families; (3) burden or related construct used. Studies were required to meet either criteria 1 and 3 or criteria 2 and 3. Reference lists were scanned, and experts were consulted for further studies. RESULTS: Six studies met inclusion criteria, representing data on 465 carers. Five of the six studies focused on carers of persons with borderline personality disorder. The findings indicated that carers experience elevated objective and subjective burden, grief, impaired empowerment, and mental health problems, including depression and anxiety. Scores on objective and subjective burden were half a standard deviation above the mean compared to carers of inpatients with other serious mental illnesses. CONCLUSIONS: This study is the first to report data on a large, aggregated sample of carers of persons with personality disorders. Significant gaps in the literature remain, and it is recommended that future research focus on the burden and support needs of carers of persons across different personality disorders, that attention be paid to the gender balance of patients, and that data be reported in a way to allow meta-analysis.