Processes of recovery through routine or specialist treatment for borderline personality disorder (BPD): a qualitative study.

Background: Recovery processes in borderline personality disorder (BPD) are poorly understood.Aims: This study explored how recovery in BPD occurs through routine or specialist treatment, as perceived by service users (SUs) and therapists.Methods: SUs were recruited from two specialist BPD services, three community mental health teams, and one psychological therapies service. Semi-structured interviews were conducted with 48 SUs and 15 therapists. The "framework" approach was used to analyse the data.Results: The findings were organized into two domains of themes. The first domain described three parallel processes that constituted SUs' recovery journey: fighting ambivalence and committing to taking action; moving from shame to self-acceptance and compassion; and moving from distrust and defensiveness to opening up to others. The second domain described four therapeutic challenges that needed to be addressed to support this journey: balancing self-exploration and finding solutions; balancing structure and flexibility; confronting interpersonal difficulties and practicing new ways of relating; and balancing support and independence.Conclusions: Therapies facilitating the identified processes may promote recovery. The recovery processes and therapeutic challenges identified in this study could provide a framework to guide future research.

Clients' experiences of treatment and recovery in borderline personality disorder: A meta-synthesis of qualitative studies.

OBJECTIVE: This review synthesized findings from qualitative studies exploring clients' experiences of their treatment for borderline personality disorder (BPD) and their perceptions of recovery. METHOD: Fourteen studies were identified through searches in three electronic databases. The Critical Appraisal Skills Programme was used to appraise the methodological quality of the studies. Thematic analysis was used to synthesize the findings. RESULTS: The meta-synthesis identified 10 themes, grouped into 3 domains. The first domain, "Areas of change," suggests that clients make changes in four main areas: developing self-acceptance and self-confidence; controlling difficult thoughts and emotions; practising new ways of relating to others; and implementing practical changes and developing hope. The second domain, "Helpful and unhelpful treatment characteristics," highlights treatment elements that either supported or hindered recovery: safety and containment; being cared for and respected; not being an equal partner in treatment; and focusing on change. The third domain, "The nature of change," refers to clients' experience of change as an open-ended journey and a series of achievements and setbacks. CONCLUSIONS: The meta-synthesis highlights areas of change experienced by individuals receiving treatment for BPD, and treatment characteristics that they value. However, further research is needed to better understand how these changes are achieved.

Symptoms associated with victimization in patients with schizophrenia and related disorders.

BACKGROUND: Patients with psychoses have an increased risk of becoming victims of violence. Previous studies have suggested that higher symptom levels are associated with a raised risk of becoming a victim of physical violence. There has been, however, no evidence on the type of symptoms that are linked with an increased risk of recent victimization. METHODS: Data was taken from two studies on involuntarily admitted patients, one national study in England and an international one in six other European countries. In the week following admission, trained interviewers asked patients whether they had been victims of physical violence in the year prior to admission, and assessed symptoms on the Brief Psychiatric Rating Scale (BPRS). Only patients with a diagnosis of schizophrenia or related disorders (ICD-10 F20-29) were included in the analysis which was conducted separately for the two samples. Symptom levels assessed on the BPRS subscales were tested as predictors of victimization. Univariable and multivariable logistic regression models were fitted to estimate adjusted odds ratios. RESULTS: Data from 383 patients in the English sample and 543 patients in the European sample was analysed. Rates of victimization were 37.8% and 28.0% respectively. In multivariable models, the BPRS manic subscale was significantly associated with victimization in both samples. CONCLUSIONS: Higher levels of manic symptoms indicate a raised risk of being a victim of violence in involuntary patients with schizophrenia and related disorders. This might be explained by higher activity levels, impaired judgement or poorer self-control in patients with manic symptoms. Such symptoms should be specifically considered in risk assessments.

Effectiveness and cost-effectiveness of dialectical behaviour therapy for self-harming patients with personality disorder: a pragmatic randomised controlled trial.

BACKGROUND: A primary goal of dialectical behaviour therapy (DBT) is to reduce self-harm, but findings from empirical studies are inconclusive. The aim of this study was to assess the effectiveness and cost-effectiveness of DBT in reducing self-harm in patients with personality disorder. METHODS: Participants with a personality disorder and at least 5 days of self-harm in the previous year were randomised to receive 12 months of either DBT or treatment as usual (TAU). The primary outcome was the frequency of days with self-harm; secondary outcomes included borderline personality disorder symptoms, general psychiatric symptoms, subjective quality of life, and costs of care. RESULTS: Forty patients each were randomised to DBT and TAU. In an intention-to-treat analysis, there was a statistically significant treatment by time interaction for self-harm (incidence rate ratio 0.91, 95% CI 0.89-0.92, p < 0.001). For every 2 months spent in DBT, the risk of self-harm decreased by 9% relative to TAU. There was no evidence of differences on any secondary outcomes. The economic analysis revealed a total cost of a mean of 5,685 GBP (6,786 EUR) in DBT compared to a mean of 3,754 GBP (4,481 EUR) in TAU, but the difference was not significant (95% CI -603 to 4,599 GBP). Forty-eight per cent of patients completed DBT. They had a greater reduction in self-harm compared to dropouts (incidence rate ratio 0.78, 95% CI 0.76-0.80, p < 0.001). CONCLUSIONS: DBT can be effective in reducing self-harm in patients with personality disorder, possibly incurring higher total treatment costs. The effect is stronger in those who complete treatment. Future research should explore how to improve treatment adherence.

Factors predicting the outcome of psychotherapy for borderline personality disorder: a systematic review.

BACKGROUND: There is substantial variation between individuals with borderline personality disorder (BPD) in the degree of benefit gained from psychotherapy. Information on factors predicting the outcome of therapy for this group could facilitate identification of those at risk for poor outcome, and could enable helpful therapy processes to be identified. METHOD: A systematic search of PsycInfo, EMBASE, CINHAL and Medline identified research on factors predicting symptom change during therapy for patients with a BPD diagnosis. Non-English language papers and dissertations were included. RESULTS: Two consistent positive predictors of symptom change were identified: pre-treatment symptom severity and patient-rated therapeutic alliance. Contrary to theories predicting increasing immutability with age, there was no evidence that age predicted poorer outcome. CONCLUSION: More severely ill patients may have greater potential to achieve change during therapy, and should remain a focus for psychotherapy services. The therapeutic alliance is an important common factor predicting outcome in patients with BPD, even in highly disorder-specific treatments. Outcomes may be improved by further clinical and research focus on forming strong therapeutic alliances. The advancement of the field requires identification and testing of new predictors of outcome, especially those related to specific theories of therapeutic change in BPD.

Recovery in Borderline Personality Disorder (BPD): a qualitative study of service users' perspectives.

BACKGROUND: Symptom improvement in Borderline Personality Disorder (BPD) is more common than previously hypothesised. However, it remains unclear whether it reflects service users' personal goals of recovery. The present study aimed to explore what service users with BPD view as recovery. METHODS: 48 service users were recruited from secondary mental health services and their views on their personal goals and the meaning of recovery were explored in in-depth semi-structured interviews. The study drew on grounded theory and thematic analysis. RESULTS: Service users believed that recovery involved developing self-acceptance and self-confidence, gaining control over emotions, improving relationships, employment, and making progress in symptoms like suicidality and self-harming. They felt that psychotherapies for BPD often had an extreme focus on specific areas, like self-harming or relationships, and that some of their goals were neglected. Although full recovery was seen as a distant goal, interviewees felt that they could learn how to deal with their problems in more effective ways and make meaningful progress in their lives. CONCLUSIONS: Specialist therapies for BPD explicitly address some of the recovery goals that are important to service users, whereas other goals are only indirectly or poorly addressed. Professionals might need to work with service users towards devising comprehensive individualised case formulations, including all treatment targets that are important to service users, their priorities, and long-term plans on how their targets might be met and which services might be involved.

Symptom levels and initial appraisal of hospital treatment in patients with schizophrenia.

The initial appraisal of treatment by inpatients with schizophrenia has been found to be a significant predictor of clinical outcomes. The study aim was to examine whether specific types of symptoms are associated with the initial appraisal of treatment after controlling other patient characteristics. Data of 2105 inpatients with schizophrenia (ICD-10 F20-9) were pooled from three national and international multi-centre studies. Patients were interviewed within the first week of their inpatient admission. Higher levels of manic and positive symptoms were significantly associated with a less favourable initial appraisal of treatment, whilst no association was found with depression/anxiety and negative symptoms. Detained patients had more negative initial treatment appraisals, and the association with manic symptoms was significantly stronger in detained patients compared to those admitted voluntarily. Whilst patient-reported outcomes in psychiatry are usually associated with mood symptoms, this appears not to be the case for the initial appraisal by inpatients with schizophrenia. The association with manic and positive symptoms may be explained by the influence of such symptoms on the hospital experience. Focusing on the initial management of mania and positive symptoms might improve patients' appraisal of treatment in the inpatient environment.

Psychiatric patients' views on why their involuntary hospitalisation was right or wrong: a qualitative study.

PURPOSE: To explore involuntary patients' retrospective views on why their hospitalisation was right or wrong. METHODS: Involuntary patients were recruited from 22 hospitals in England and interviewed in-depth. The study drew on grounded theory and thematic analysis. RESULTS: Most of the patients felt mentally unwell before admission and out of control during their treatment. Despite these common experiences, three groups of patients with distinct views on their involuntary hospitalisation were identified: those who believed that it was right, those who thought it was wrong and those with ambivalent views. Those with retrospectively positive views believed that hospitalisation ensured that they received treatment, averted further harm and offered them the opportunity to recover in a safe place. They felt that coercion was necessary, as they could not recognise that they needed help when acutely unwell. Those who believed that involuntary admission was wrong thought that their problems could have been managed through less coercive interventions, and experienced hospitalisation as an unjust infringement of their autonomy, posing a permanent threat to their independence. Patients with ambivalent views believed that they needed acute treatment and that hospitalisation averted further harm. Nonetheless, they thought that their problems might have been managed through less coercive community interventions or a shorter voluntary hospitalisation. CONCLUSIONS: The study illustrates why some patients view their involuntary hospitalisation positively, whereas others believe it was wrong. This knowledge could inform the development of interventions to improve patients' views and treatment experiences.

Coerced hospital admission and symptom change--a prospective observational multi-centre study.

INTRODUCTION: Coerced admission to psychiatric hospitals, defined by legal status or patient's subjective experience, is common. Evidence on clinical outcomes however is limited. This study aimed to assess symptom change over a three month period following coerced admission and identify patient characteristics associated with outcomes. METHOD: At study sites in 11 European countries consecutive legally involuntary patients and patients with a legally voluntary admission who however felt coerced, were recruited and assessed by independent researchers within the first week after admission. Symptoms were assessed on the Brief Psychiatric Rating Scale. Patients were re-assessed after one and three months. RESULTS: The total sample consisted of 2326 legally coerced patients and 764 patients with a legally voluntary admission who felt coerced. Symptom levels significantly improved over time. In a multivariable analysis, higher baseline symptoms, being unemployed, living alone, repeated hospitalisation, being legally a voluntary patient but feeling coerced, and being initially less satisfied with treatment were all associated with less symptom improvement after one month and, other than initial treatment satisfaction, also after three months. The diagnostic group was not linked with outcomes. DISCUSSION: On average patients show significant but limited symptom improvements after coerced hospital admission, possibly reflecting the severity of the underlying illnesses. Social factors, but not the psychiatric diagnosis, appear important predictors of outcomes. Legally voluntary patients who feel coerced may have a poorer prognosis than legally involuntary patients and deserve attention in research and clinical practice.

Family caregivers' experiences of involuntary psychiatric hospital admissions of their relatives--a qualitative study.

BACKGROUND: Family caregivers of people with mental disorders are frequently involved in involuntary hospital admissions of their relatives. OBJECTIVE: To explore family caregivers' experience of involuntary admission of their relative. METHOD: 30 in-depth interviews were conducted with family caregivers of 29 patients who had been involuntarily admitted to 12 hospitals across England. Interviews were analysed using thematic analysis. RESULTS: Four major themes of experiences were identified: relief and conflicting emotions in response to the relative's admission; frustration with a delay in getting help; being given the burden of care by services; and difficulties with confidentiality. Relief was a predominant emotion as a response to the relative's admission and it was accompanied by feelings of guilt and worry. Family caregivers frequently experienced difficulties in obtaining help from services prior to involuntary admission and some thought that services responded to crises rather than prevented them. Family caregivers experienced increased burden when services shifted the responsibility of caring for their mentally unwell relatives to them. Confidentiality was a delicate issue with family caregivers wanting more information and a say in decisions when they were responsible for aftercare, and being concerned about confidentiality of information they provided to services. CONCLUSION: Compulsory admission of a close relative can be a complex and stressful experience for family caregivers. In order for caregivers to be effective partners in care, a balance needs to be struck between valuing their involvement in providing care for a patient and not overburdening them.

Factorial validity and measurement equivalence of the Client Assessment of Treatment Scale for psychiatric inpatient care - a study in three European countries.

Patients' views of inpatient care need to be assessed for research and routine evaluation. For this a valid instrument is required. The Client Assessment of Treatment Scale (CAT) has been used in large scale international studies, but its psychometric properties have not been well established. The structural validity of the CAT was tested among involuntary inpatients with psychosis. Data from locations in three separate European countries (England, Spain and Bulgaria) were collected. The factorial validity was initially tested using single sample confirmatory factor analyses in each country. Subsequent multi-sample analyses were used to test for invariance of the factor loadings, and factor variances across the countries. Results provide good initial support for the factorial validity and invariance of the CAT scores. Future research is needed to cross-validate these findings and to generalise them to other countries, treatment settings, and patient populations.

Why do some voluntary patients feel coerced into hospitalisation? A mixed-methods study.

This study aimed to investigate factors linked to perceived coercion at admission and during treatment among voluntary inpatients. Quantitative and qualitative methods were used. Two hundred seventy patients were screened for perceived coercion at admission. Those who felt coerced into admission rated their perceived coercion during treatment a month after admission. Patient characteristics and experiences were tested as predictors of coercion. In-depth interviews on experiences leading to perceived coercion were conducted with 36 participants and analysed thematically. Thirty-four percent of patients felt coerced into admission and half of those still felt coerced a month later. No patient characteristics were associated with perceived coercion. Those whose satisfaction with treatment increased more markedly between baseline and a month later were less likely to feel coerced a month after admission. In the qualitative interviews three themes leading to perceived coercion were identified: viewing the hospital as ineffective and other treatments as more appropriate, not participating in the admission and treatment and not feeling respected. Involving patients in the decision-making and treating them with respect may reduce perceived coercion.

Association of treatment satisfaction and psychopathological sub-syndromes among involuntary patients with psychotic disorders.

PURPOSE: Previous research has shown a link between treatment satisfaction and global psychopathology in different groups of psychiatric patients. However, neither the relationship between treatment satisfaction and the sub-syndromes of global psychopathology nor their temporal ordering have been explored. METHODS: Participants admitted involuntarily to psychiatric wards in the UK and diagnosed with psychotic disorders (N = 232) were included. Treatment satisfaction and psychopathological sub-syndromes (i.e., manic excitement, anxiety-depression, negative symptoms, positive symptoms) were measured within 1 week and at 1 month after admission. RESULTS: Repeated measures ANOVAs showed that higher treatment satisfaction is associated with lower scores on the manic excitement, anxiety-depression and positive symptom sub-syndromes, while no significant association was found for negative symptoms. However, cross-lagged panel analyses showed that treatment satisfaction predicted change only in positive symptoms while none of the paths from the relevant sub-syndromes to treatment satisfaction was significant. CONCLUSION: Treatment satisfaction can be regarded as an antecedent of changes in positive symptoms only. These results underline the importance of examining psychopathological sub-syndromes separately as they may relate differentially to other important correlates of psychoses.

Predictors of clinical and social outcomes following involuntary hospital admission: a prospective observational study.

The Study aimed to assess clinical and social outcomes following involuntary admissions over 1 year and identify socio-demographic and clinical patient characteristics associated with more or less favourable outcomes. Seven hundred and seventy-eight involuntary patients admitted to one of 22 hospitals in England were assessed within the first week after admission and at 1 month, 3 month and 12 month follow-ups. Outcome criteria were symptom levels, global functioning, objective social outcomes, and subjective quality of life (SQOL). Baseline characteristics and patients' initial experience were tested as predictors. Symptom levels and global functioning improved moderately. Objective social outcomes showed a small, but statistically significant deterioration, and SQOL a small, but significant improvement at 1 year. In multivariable analyses, admission due to risk to oneself and receiving benefits predicted poorer symptom outcomes. Female gender and higher perceived coercion were associated with better objective social outcomes, whilst higher initial satisfaction with treatment predicted more positive SQOL at follow-ups. Over a 1-year period following involuntary hospital admission, patients on average showed only limited health and social gains. Different types of outcomes are associated with different predictor variables. Patients' initial experience of treatment, in the form of perceived coercion or satisfaction with treatment, has predictive value for up to a year following the admission.

Coercion and treatment satisfaction among involuntary patients.

OBJECTIVE: This study aimed to assess involuntary inpatients' satisfaction with treatment and explore how coercion and other factors are associated with satisfaction. METHODS: An observational prospective study was conducted in 67 acute wards in 22 hospitals in England. A total of 778 involuntary inpatients were recruited, and their satisfaction with treatment was assessed a week after admission and at the one-month, three-month, and one-year follow-ups. Perceived and documented coercion at admission and during hospital treatment, sociodemographic and clinical characteristics, and clinical improvement were tested as potential predictors of satisfaction. RESULTS: Mean scores on the Client's Assessment of Treatment Scale measuring satisfaction with treatment ranged from 5.5 to 6.0 (on a scale with possible scores ranging from 0 to 10) at different time points and improved significantly from admission to the follow-ups. Patients who perceived less coercion at admission and during hospital treatment were more satisfied overall, whereas coercive measures documented in the medical records were not linked to satisfaction. Patients with more symptom improvement expressed higher levels of treatment satisfaction. CONCLUSIONS: Satisfaction with treatment among involuntary patients was associated with perceptions of coercion during admission and treatment, rather than with the documented extent of coercive measures. Interventions to reduce patients' perceived coercion might increase overall treatment satisfaction.

Patients' views of involuntary hospital admission after 1 and 3 months: prospective study in 11 European countries.

BACKGROUND: Legislation and practice of involuntary hospital admission vary substantially among European countries, but differences in outcomes have not been studied. AIMS: To explore patients' views following involuntary hospitalisation in different European countries. METHOD: In a prospective study in 11 countries, 2326 consecutive involuntary patients admitted to psychiatric hospital departments were interviewed within 1 week of admission; 1809 were followed up 1 month and 1613 3 months later. Patients' views as to whether the admission was right were the outcome criterion. RESULTS: In the different countries, between 39 and 71% felt the admission was right after 1 month, and between 46 and 86% after 3 months. Females, those living alone and those with a diagnosis of schizophrenia had more negative views. Adjusting for confounding factors, differences between countries were significant. CONCLUSIONS: International differences in legislation and practice may be relevant to outcomes and inform improvements in policies, particularly in countries with poorer outcomes.

Ethnicity and coercion among involuntarily detained psychiatric in-patients.

We assessed whether adult Black and minority ethnic (BME) patients detained for involuntary psychiatric treatment experienced more coercion than similar White patients. We found no evidence of this from patient interviews or from hospital records. The area (mental health trust) where people were treated was strongly associated with both the experience of coercion and the recording of a coercive measure in their records. Regarding charges of institutional racism in psychiatry, this study highlights the importance of investigating the role of area characteristics when assessing the relationship between ethnicity and patient management.

Patients' views and readmissions 1 year after involuntary hospitalisation.

BACKGROUND: Little is known about the long-term outcome of involuntary admissions to psychiatric hospitals. AIMS: To assess involuntary readmissions and patients' retrospective views of the justification of the admission as 1-year outcomes and to identify factors associated with these outcomes. METHOD: Socio-demographic data and readmissions were collected for 1570 involuntarily admitted patients. Within the first week after admission 50% were interviewed, and of these 51% were re-interviewed after 1 year. RESULTS: At 1 year, 15% of patients had been readmitted involuntarily, and 40% considered their original admission justified. Lower initial treatment satisfaction, being on benefits, living with others and being of African and/or Caribbean origin were associated with higher involuntary readmission rates. Higher initial treatment satisfaction, poorer initial global functioning and living alone were linked with more positive retrospective views of the admission. CONCLUSIONS: Patients' views of treatment within the first week are a relevant indicator for the long-term prognosis of involuntarily admitted patients.

Patient's experiences of involuntary hospital admission and treatment: a review of qualitative studies.

AIMS: This study aimed to explore psychiatric patients' experiences of involuntary admission and treatment by reviewing qualitative studies. METHOD: Qualitative studies investigating patients' experiences of involuntary treatment were identified. Relevant databases were searched and authors were contacted. Thematic analysis was applied for the synthesis of emerging issues. RESULTS: Five studies fulfilled the inclusion criteria. The main areas that appear to be of importance are: patients' perceived autonomy and participation in decisions for themselves, their feeling of whether or not they are being cared for and their sense of identity. In these areas both negative and positive consequences from involuntary admission were mentioned. However, methodological weaknesses were also found, such as small sample sizes. Furthermore, it is not described whether these themes are mentioned by all participants as negative and positive aspects of their experience or whether they reflect views supported by distinct groups. CONCLUSIONS: Although the perceived impact of involuntary treatment is fairly clearly described, differences between distinct patient groups are not examined. Future research should investigate such differences in order to inform relevant policy decisions for particular groups.