by Randy A. Sansone, MD, and Lori A. Sansone, MD
R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, OH, and Director of Psychiatry Education at Kettering Medical Center in Kettering, OH. L. Sansone is a civilian family medicine physician and Medical Director of the Family Health Clinic at Wright-Patterson Air Force Base Medical Center in WPAFB, OH. The views and opinions expressed in this article are those of the authors and do not reflect the official policy or position of the United States Air Force, Department of Defense, or United States Government.
Innov Clin Neurosci. 2013;10(5–6):39–43
This ongoing column is dedicated to the challenging clinical interface between psychiatry and primary care—two fields that are inexorably linked.
Funding: There was no funding for the development and writing of this article.
Financial disclosures: The authors have no conflicts of interest relevant to the content of this article.
Key words: Attitudes, borderline personality, borderline personality disorder, clinicians, mental health clinicians, nurses, reactions, responses, stigma
Abstract: Borderline personality disorder is a complex psychiatric syndrome that is characterized by a number of pathological interpersonal and behavioral symptoms. Because of these symptoms, individuals with borderline personality disorder tend to have difficulties in their relationships with others, including mental health clinicians. Through a literature review, we examined the perceptions and reactions of mental health clinicians toward patients with borderline personality disorder. Our findings indicate that psychiatric nurses are the most studied group of mental health clinicians in this regard, followed by samples of mixed mental health clinicians, and then psychologists. Interestingly, there is no study of psychiatrists only. While sample sizes have been generally small and methodologies have varied, the overwhelming majority of these studies indicate negative perceptions of and emotional responses toward patients with borderline personality disorder. Some researchers have interpreted such findings to suggest that mental health clinicians are more judgmental or prejudicial toward patients with borderline personality disorder, in contrast to other types of mental health patients. However, patients with borderline personality disorder have very complex interpersonal behaviors that tend to illicit negative responses from those around them. Perhaps these data simply reflect a very human reaction to the complex and pathological behaviors of these patients—a conclusion that is relevant to clinicians practicing in either mental health or primary care settings.
Borderline personality disorder (BPD) is a complex psychiatric syndrome that encompasses a number of behavioral and interpersonal symptoms. The symptoms associated with BPD are oftentimes dramatic and emotionally disconcerting (e.g., splitting, stalking behavior, rage reactions, self-mutilation, suicide attempts). In keeping with the nature of these complex symptoms, Aviram et al point out that some mental health clinicians may emotionally distance themselves from patients with BPD in an effort to protect themselves from these distressing types of behaviors. However, the resulting distancing behavior by mental health clinicians may be particularly problematic for patients with BPD because it may reinforce their sensitivity to rejection and abandonment. Distancing behaviors by mental health clinicians may also unintentionally stimulate these patients to engage in unhealthy behaviors to cope with such threats (e.g., self-harm behaviors, withdrawal from treatment). While these types of clinician responses toward patients with BPD are fully understandable, is there any identifiable empirical data to confirm them? In this edition of The Interface, we examine the available data regarding the responses of mental health clinicians toward patients with BPD.
The Parameters of the Review
In examining the responses of mental health clinicians to patients with BPD, we performed a literature search on the PubMed, PsycINFO, and Scopus databases. We entered search terms such as “borderline personality, attitudes, reactions” and “stigma.” Articles were included only if they had an empirical focus. We did not impose any limitations with regard to the publication date of a study. If the abstract was insufficient, we excluded those articles that were not written in English.
Responses of Psychiatric Nurses to Patients with BPD
Without question, the largest number of empirical studies on the responses of mental health clinicians to patients with BPD has been undertaken among psychiatric nurses (N=10). In addition, half of these studies have been undertaken in the United Kingdom.
Studies from the UK. Using a self-report survey format, Markham and Markham and Trower examined the attitudes of 45 and 48 psychiatric nurses, respectively, toward treating patients with BPD. In this survey, inpatient and outpatient nurses were presented with three patient types (i.e., patients with schizophrenia, BPD, and depression) and then asked about their perceptions of these patients. Researchers then compared participants’ responses according to patient type. They found that, in contrast to schizophrenia and depression, participants viewed patients with BPD more negatively (i.e., more dangerous, more likely to be socially distanced by the professional). In addition, patients with BPD generated less sympathy in respondents.
In a 2007 study, Forsyth examined the attitudes of 26 psychiatric nurses who were working in an acute adult psychiatric setting with regard to patients with BPD and patients with major depressive disorder. Using a series of patient vignettes to examine nurse/patient alliance factors, Forsyth concluded that participants were more helpful to patients with a diagnosis of major depressive disorder than to patients with BPD.
In a 2008 study, Woollaston and Hixenbaugh examined the perceptions of six psychiatric nurses, both inpatient and outpatient, with regard to working with patients with BPD. Using semi-structured interviews, the researchers found that participants generally perceived patients with BPD as powerful, dangerous, and unrelenting. Overall perceptions indicated that participants experienced patients with BPD in a negative manner that was summed up in the phrase, “destructive whirlwind.”
In a 2010 study, Westwood and Baker undertook a review of eight studies examining the perceptions of inpatient psychiatric nurses with regard to patients with BPD. As for the individual studies, sample sizes varied from 6 to 229 participants. Overall, compared to non-BPD patients, researchers found that psychiatric nurses displayed significantly higher levels of social distancing toward patients with BPD. However, Westwood and Baker found two studies that indicated positive attitudes of psychiatric nurses toward patients with BPD; interestingly, however, the researchers expressed their concerns about several methodological issues with these two studies (e.g., response rate; the assessment measure, which was the same in both studies).
Studies from other countries. In the extant literature, there are two studies from Canada on nursing perceptions of patients with BPD.[7,8] In the earlier study (1989), Gallop, Lancee, and Garfinkel examined the attitudes of 113 inpatient psychiatric nurses with regard to BPD and schizophrenia. Using hypothetical patient statements, researchers examined participants’ responses and found that, in contrast to patients with schizophrenia, responses to patients with BPD were more likely to be belittling or contradictory. In the second study (1993), Fraser and Gallop examined 17 psychiatric nurses who led treatment groups. Researchers reported that participants responded to patients with BPD in a less empathetic manner.
In a 2006 Australian study of 65 psychiatric nurses working in both inpatient and outpatient settings, Deans and Meocevic found that participants reported negative emotional reactions and attitudes toward patients with BPD. The majority of participants perceived patients with BPD as manipulative, with nearly one-third of participants reporting that such patients anger them.
In a 2007 study from Ireland, James and Cowman examined the perceptions of 65 inpatient psychiatric nurses toward patients with BPD. Using a self-report survey methodology, the researchers found that 80 percent of participants believed that patients with BPD were more difficult to take care of than other types of psychiatric patients.
Lastly, in a 2009 study from Greece, Giannouli and colleagues examined 69 inpatient and outpatient psychiatric nurses using a 23-item questionnaire. This particular study was one of the two positive studies reviewed by Westwood and Baker. Giannouli and colleagues concluded that there were no negative attitudes by respondents toward patients with BPD.
With the exception of the study by Giannouli and colleagues, the remaining studies of psychiatric nurses indicate that these clinicians generally perceive patients with BPD as dangerous, powerful, unrelenting, and more difficult to take care of. Likewise, according to findings, nurses respond to such patients with social distance, less helpfulness, less empathy, more negative emotions and attitudes, and anger.
Responses of Mixed Samples of Mental Health Clinicians to Patients with BPD
A number of studies have examined clinician responses to patients with BPD using study samples that consist of several different professional disciplines. For example, in a 2002 Australian study, Cleary, Siegfried, and Walter examined the impressions of 229 staff members of a mental health service toward patients with BPD. Using a 23-item survey, researchers found that 80 percent of respondents reported that patients with BPD were moderately to very difficult to deal with, and 84 percent believed that such patients were more difficult than other mental health patients.
In a 2006 study from New Zealand, Krawitz and Batcheler surveyed 29 mental health clinicians from inpatient, crisis, and outpatient services regarding their attitudes toward patients with BPD. Using a self-report survey methodology, researchers found that defensive attitudes were common among the participants. Indeed, 85 percent reported having practiced in a manner that was not in the best interest of the patient.
In a 2008 study from the UK, Newton-Howes, Weaver, and Tyrer examined the attitudes of a mixed group of mental health clinicians (N=not clarified) toward patients with personality disorders, not necessarily BPD. Using a survey and interview methodology, researchers found that participants believed that patients with personality disorders were more difficult to manage.
In a 2009 study from Australia and New Zealand, Common Treloar examined a mixed sample of 140 mental health clinicians using an open-query method: “Please provide some comments about your experience or interest in working with patients diagnosed with BPD.” Respondents indicated that patients with BPD generated uncomfortable feelings within them. In addition, the respondents acknowledged specific negative feelings, including feelings of frustration, inadequacy, and being challenged. Respondents also perceived patients with BPD as manipulative and time-consuming, and believed that such patients have poor coping skills, engage in habitual crisis behaviors, and have difficulty interacting with others appropriately.
In a 2011 study from Israel, Bodner, Cohen-Fridel, and Iancu examined a mixed group of mental health clinicians practicing in public institutions (n=57) regarding their attitudes toward BPD. Using a self-report survey of cognitive and emotional attitudes, researchers found that psychologists scored lower than psychiatrists and nurses on antagonistic judgments, whereas nurses scored lower than psychiatrists and psychologists on apathy.
Finally, in a 2011 study, Black and colleagues examined 706 mental health clinicians regarding their attitudes toward BPD. Using a self-report survey methodology, nearly half of the sample indicated their preference to avoid these patients. Psychiatric nurses had the lowest ratings on overall caring attitudes toward patients with BPD, whereas social workers had the highest ratings. Psychiatric nurses also had the lowest ratings on empathy toward patients with BPD.
Responses of Psychotherapists to Patients with BPD
We were only able to locate three studies on the responses of psychotherapists to patients with BPD (the smallest group of studies). In the first study (2007), Servais and Saunders surveyed 306 clinical psychologists, who were asked to rate their responses to patients with depression, borderline personality features, and schizophrenia. In this study, psychologists reported distancing themselves from patients with borderline personality features, who were perceived as dangerous; nearly half of the respondents believed such patients to be undesirable.
In a 2010 study of 80 psychotherapists in Australia, Bourke and Grenyer interviewed and elicited narratives from participants regarding their views of patients with BPD and patients with major depression. Researchers found significantly more negative attitudes toward patients with BPD. In addition, respondents felt less satisfied in their therapeutic role with such patients.
Finally, in a third study from Germany (2010), Jobst and colleagues examined 174 psychotherapists working in Munich. Participants were presented with a short case report followed by several queries. Findings indicated that these psychotherapists oftentimes experienced anxiety and demonstrated some prejudice in working with patients with BPD.
The findings of this review invite a number of general conclusions. First, the bulk of studies in this area have been undertaken with various samples of psychiatric nurses, whereas no study has exclusively examined a sample of psychiatrists. Second, samples have generally been small. Third, with few exceptions, most researchers have found that the majority of participants in various studies harbor negative feelings about and attitudes toward patients with BPD. Indeed, participants in these studies disclose a number of negative feelings, impressions, and behaviors. Feelings include higher levels of negative emotions toward patients with BPD as well as feeling uncomfortable, anxious, challenged, frustrated, manipulated, apathetic, and less caring. Impressions include perceiving patients with BPD as dangerous, powerful, unrelenting, more difficult to take care of, time-consuming, having poor coping skills, engaging in crisis behaviors, and demonstrating poor social interactions. Behavioral responses include social distancing of patients with BPD, defensiveness, being less helpful, expressing less empathy, and expressing anger. Some have interpreted the preceding findings to indicate that mental health clinicians are more judgmental and demonstrate prejudice toward patients with BPD. However, patients with BPD have very complex interpersonal behaviors that tend to illicit negative responses from those around them, professionals or not. Perhaps the data from these mental health clinicians simply reflect a very human reaction to the complex and pathological behaviors of patients with BPD—a conclusion that is relevant to clinicians practicing in either mental health or primary care settings.
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