Stress and burnout in psychiatric professionals when starting to use dialectical behavioural therapy in the work with young self-harming women showing borderline personality symptoms

Socio-demographic Predictors of Hospitalization Duration Among Patients with Borderline Personality Disorder

Borderline personality disorder (BPD) is a complex psychopathology associated with high service utilization rates. In turn, the hospitalization of BPD patients is a controversial challenge for mental health professionals. Prior literature has identified certain socio-demographic factors as linked to an increased risk of BPD. In this study, we examined the possible connection between these socio-demographic factors and hospitalization duration. We analyzed 1077 hospitalization records of 200 BPD-diagnosed patients. Patients' gender, age, education level, employment and marital statuses, and living arrangement were statistically significantly linked with hospitalization duration. Specifically, female gender, age twenty or below, no high-school diploma (or, to a lesser extent, a diploma with no academic education), unemployment status and/or patients who live with parents are strongly associated with longer hospitalizations compared to male gender, older patients, more educated, married/divorced status and/or those who do not live with their parents. Additionally, the results point to a weak, albeit statistically significant, temporal pattern with more advanced hospitalizations generally aligning with the duration of their preceding ones, while being slightly shorter. In order to prevent potentially unnecessary prolonged and regressive hospitalizations, an estimation of the expected hospitalization duration should be explicitly considered when setting hospitalization goals and plans.

Making Lemonade out of Lemons: Dialectical Behavior Therapy via Telehealth During a Pandemic

The COVID-19 pandemic has created a burden on healthcare systems and increased demand for mental healthcare at a time when in-person services are limited. Many programs offering dialectical behavior therapy (DBT) for complex clients have pivoted to telehealth in order to increase access to critical mental healthcare. There is, however, limited research on the provision of telehealth treatment for clients with complex psychopathology more broadly, or the telehealth implementation of DBT more specifically. The aim of this study was to examine the use of telehealth services and related clinician attitudes and experiences in the context of DBT. We examined the degree of telehealth platform adoption among DBT clinicians, as well as changes in stress and self-care strategies. A supplemental aim was to gather clinicians' recommendations for providing DBT via telehealth. Participants included N = 99 DBT practitioners (79.8% female; 20.2% male). Qualitative and quantitative methods were used for data analysis. Findings show that telehealth DBT has been widely adopted among DBT clinicians, and that clinicians' attitudes to telehealth DBT are cautiously optimistic. Participants described three main areas of stress associated with DBT via telehealth provision, as well as lost and novel self-care strategies.

Clinician perspectives on what constitutes good practice in community services for people with complex emotional needs: A qualitative thematic meta-synthesis

INTRODUCTION

The need to improve the quality of community mental health services for people with Complex Emotional Needs (CEN) (who may have a diagnosis of 'personality disorder') is recognised internationally and has become a renewed policy priority in England. Such improvement requires positive engagement from clinicians across the service system, and their perspectives on achieving good practice need to be understood.

AIM

To synthesise qualitative evidence on clinician perspectives on what constitutes good practice, and what helps or prevents it being achieved, in community mental health services for people with CEN.

METHODS

Six bibliographic databases were searched for studies published since 2003 and supplementary citation tracking was conducted. Studies that used any recognised qualitative method and reported clinician experiences and perspectives on community-based mental health services for adults with CEN were eligible for this review, including generic and specialist settings. Meta-synthesis was used to generate and synthesise over-arching themes across included studies.

RESULTS

Twenty-nine papers were eligible for inclusion, most with samples given a 'personality disorder' diagnosis. Six over-arching themes were identified: 1. The use and misuse of diagnosis; 2. The patient journey into services: nowhere to go; 3. Therapeutic relationships: connection and distance; 4. The nature of treatment: not doing too much or too little; 5. Managing safety issues and crises: being measured and proactive; 6. Clinician and wider service needs: whose needs are they anyway? The overall quality of the evidence was moderate.

DISCUSSION

Through summarising the literature on clinician perspectives on good practice for people with CEN, over-arching priorities were identified on which there appears to be substantial consensus. In their focus on needs such as for a long-term perspective on treatment journeys, high quality and consistent therapeutic relationships, and a balanced approach to safety, clinician priorities are mainly congruent with those found in studies on service user views. They also identify clinician needs that should be met for good care to be provided, including for supervision, joint working and organisational support.

Playing-Dumb Behavior of Trainers During Online Streaming and Trainee's Burnout Behavior: Mediating Role of Psychological Disengagement

A trainer's behavior is a crucial factor, and it can affect the cognitive engagement of trainees in parts of training and development programs; thus, playing-dumb behavior by a trainer can cause lower attachment and less interested trainees during courses. This study was planned to investigate the impact of trainers' playing-dumb behavior on trainees' burnout behavior under the mediating role of psychological disengagement in online broadcasting. This study followed a convenience sampling technique under a cross-sectional research design, and data are collected from 371 trainees through a questionnaire. This study follows structural equation modeling to model the path relationship among study constructs. Results of this study indicate the presence of a relationship between trainers' dumb behavior and its impact on trainee psychological disengagement, which leads to burnout. Findings of this study contribute to the inclusive body of knowledge pertaining to playing-dumb behavior and trainees' burnout during the course.

Phone consultation and burnout among providers of dialectical behaviour therapy

Adherent dialectical behaviour therapy (DBT) includes between-session phone consultation to help clients generalize skills, solve problems during crises, and repair relationships. Despite benefits of phone consultation, it is frequently not implemented in outpatient settings. The perceived burden phone consultation places on providers is one of the most frequently cited reasons for its omission. The current study examined phone consultation in relation to providers' burnout using a cross-sectional design. We hypothesized that (1) DBT experience and support from peer consultation team members, including perceived team efficacy and shared coaching responsibilities, would be associated with lower rates of burnout and (2) higher numbers of crisis contacts and "other" contacts, but not noncrisis skills generalization contacts, would be associated with increased burnout. Participants were 65 DBT therapists who completed an anonymous survey online. Results suggest that both having more effective consultation teams and sharing phone consultation among team members were associated with decreased burnout. Additionally, more crisis contacts were found to be associated with higher burnout, whereas higher number of skills generalization calls was not. This study represents an important first step towards evaluating the impact of phone consultation on providers and highlights the importance of effective peer consultation in reducing therapist burnout.

A mixed methods exploratory evaluation of burnout in frontline staff implementing dialectical behavior therapy on a pediatric eating disorders unit

BACKGROUND

Eating disorders are life-threatening illnesses that commonly affect adolescents. The treatment of individuals with eating disorders can involve slow treatment progression and addressing comorbidities which can contribute to staff burnout. Dialectical behavior therapy (DBT) has emerged as a viable treatment option and has reduced staff burnout in several other settings. Our aim was to describe frontline staff burnout using mixed methodology on a DBT-trained combined inpatient/day hospital unit for pediatric eating disorders.

METHOD

Frontline staff were trained to provide DBT skills for adolescents with eating disorders. Twelve months following the training and implementation, they completed the Copenhagen Burnout Inventory (CBI) and a qualitative interview. Directed and summative content analyses were used.

RESULTS

Eleven frontline staff including nurses, child life specialists and child and youth workers participated. The CBI revealed that only one staff member experienced high personal burnout, while another experienced high client-related burnout. Qualitative data indicated that all frontline staff felt DBT had the potential to reduce burnout.

CONCLUSION

Qualitative data indicate that staff believe that DBT may hold promise in reducing burnout for pediatric frontline staff who treat children and adolescents with eating disorders. Further study is needed. Understanding burnout is particularly important for nursing staff in inpatient and day hospital settings for eating disorders, as nursing staff generally have the most frequent patient contact; thought to be a risk factor for burnout. The reduction of burnout can prevent detrimental effects on job performance, personal well-being, and patient outcomes. Our exploratory study shows that frontline staff believe that DBT may have the potential to reduce burnout in staff treating children and adolescents with eating disorders in a combined inpatient/day hospital setting. Further study is needed in this area.

Brief admission (BA) for patients with emotional instability and self-harm: nurses' perspectives - person-centred care in clinical practice

Purpose: Emotional instability and self-harm pose major problems for society and health care. There are effective interventions in outpatient care, but when patients need inpatient care, nurses often struggle meeting their patient’s needs. Brief admission (BA) is a newly implemented crisis intervention and novel form of inpatient care. The aim of this study is to describe nurses’ experiences working with BA related to patients with emotional instability and self-harm.

Methods: Eight nurses were interviewed according to a semi-structured interview guide. The data was analysed using qualitative content analysis.

Results: Four main categories emerged regarding nurses’ experiences with BA: provides security and continuity, fosters caring relationships, shifts focus towards patient’s health and empowers the patient. The nurse’s role shifted from “handling problems” to establishing caring relationships with a focus on the person’s health and possibilities for recovering instead of psychiatric symptoms.

Conclusions: Previous studies on patients’ perspective of BA describe positive experiences such as increased autonomy and participation in the healthcare process. This study supports those findings, albeit from the perspective of nurses. Our findings suggest that BA may reduce work-related stress experienced by nurses while caring for persons with emotional instability and self-harm. BA may also support nurses in their ability to provide more meaningful and constructive psychiatric inpatient care.

Treatment of Borderline Personality Disorder: Is Supply Adequate to Meet Public Health Needs?

OBJECTIVES

This study aimed to assess the supply of and demand for treatment of borderline personality disorder (BPD) to inform current standards of care and training in the context of available resources worldwide.

METHODS

The total supply of mental health professionals and mental health professionals certified in specialist evidence-based treatments for BPD was estimated for 22 countries by using data from publicly available sources and training programs. BPD prevalence and treatment-seeking rates were drawn from large-scale national epidemiological studies. Ratios of treatment-seeking patients to available providers were computed to assess whether current systems are able to meet demand. Training and certification requirements were summarized.

RESULTS

The ratio of treatment-seeking patients with BPD to mental health professionals (irrespective of professionals' interest or training in treating BPD) ranged from approximately 4:1 in Australia, the Netherlands, and Norway to 192:1 in Singapore. The ratio of treatment-seeking patients to clinicians certified in providing evidence-based care ranged from 49:1 in Norway to 148,215:1 in Mexico. Certification requirements differed by treatment and by country.

CONCLUSIONS

Shortages of both providers available to treat BPD and providers certified in specialist treatments of BPD exist in most of the 22 countries studied. In well-resourced countries, training clinicians to provide generalist or abbreviated treatments for BPD, in addition to specialist treatments, could help address the current implementation gap. More resource-efficient alternatives must be considered in countries with insufficient staff to implement even generalist treatments. Consideration of realistic allocation of care may shape future guidelines and standards of BPD treatments, beyond intensive evidence-based psychotherapies.

The development and theoretical application of an implementation framework for dialectical behaviour therapy: a critical literature review

BACKGROUND

Dialectical behaviour therapy (DBT) is a third wave behaviour therapy combining behaviour based components with elements of mindfulness. Although DBT effectiveness has been explored, relatively little attention has been given to its implementation. Frameworks are often the basis for gathering information about implementation and can also direct how the implementation of an intervention is conducted. Using existing implementation frameworks, this critical literature review scoped the DBT implementation literature to develop and refine a bespoke DBT implementation framework.

METHOD AND RESULTS

The initial framework was developed by consolidating existing implementation frameworks and published guidance on DBT implementation. The critical literature review retrieved papers from Medline, CINAHL, PsycInfo, PubMed, and the reference lists of included papers. Framework elements were used as codes which were applied to the literature and guided the synthesis. Findings from the synthesis refined the framework.The critical literature review retrieved 60 papers but only 14 of these explicitly focused on implementation. The DBT implementation framework captured all the execution barriers and facilitators described in the literature. However, the evidence synthesis led to a more parsimonious framework as some elements (e.g., research and published guidance) were seldom discussed in DBT implementation.

CONCLUSION

To our knowledge this is the first published review exploring DBT implementation. The literature synthesis suggests some tentative recommendations which warrant further exploration. For instance, if DBT implementation is not pre-planned, having someone in the organisation who champions DBT can be advantageous. However, as the literature is limited and has methodological limitations, further prospective studies of DBT implementation are needed.

Exploring staff perceptions of the utility of clinician connections when working with emotionally dysregulated clients

BACKGROUND

Borderline personality disorder (BPD) is considered to be a challenging condition for clinicians to treat. Clinicians routinely working with individuals who experience severe emotional dysregulation often do not receive appropriate training and support to work with this client group. This article describes an intervention, Clinician Connections (CC), which was developed to support practitioners who work with individuals with BPD. CC aims to increase practitioner's knowledge of BPD, develop a skillset to work with emotionally dysregulated individuals and enhance practitioner's self-efficacy with regard to working effectively with this client group. The aim of this study is to investigate the perceived utility and acceptability of CC, and identify areas for further development of the intervention.

METHOD

A seven-hour CC workshop was provided to Emergency Department and community mental health clinicians. Three focus groups were completed following completion of the intervention with 13 clinicians (12 female; 1 male) and were audio recorded. The study utilised a thematic analysis framework.

RESULTS

Six master themes emerged from the focus group data which included 10 subordinate themes. The master themes identified were: the need for training; a new understanding; validation; barriers to applying new skills; overcoming barriers to skill application; and future direction: practical application of skills. Participants reflected on how their new understanding of transactions and their own experiences affects their practice. They also noted improved client interactions and client relationships resulting from the use of validation. While there was an increase in participants' self-efficacy in working with individuals with BPD, a need for further skills and practice was also highlighted.

CONCLUSION

The evidence presented here suggests that CC is both beneficial and feasible. Qualitative feedback suggests there is a need for further support in the strengthening and generalisation of skills. Suggestions were made by practitioners regarding potential improvements to the delivery of the workshop. Future research could evaluate the changes made to CC and focus on a quantitative approach to quantify the impact of CC.

Predictors of Adoption and Reach Following Dialectical Behavior Therapy Intensive Training™

Dialectical behavior therapy (DBT) is an evidence-based treatment for borderline personality disorder. The DBT Intensive Training™ is widely used to train community clinicians to deliver DBT, but little is known about its effectiveness. This study prospectively evaluated predictors of adoption and reach of DBT among 52 community teams (212 clinicians) after DBT Intensive Training™. Pre-post training questionnaires were completed by trainees and a follow-up survey by team leaders approximately 8 months later. Overall, 75% of teams adopted all DBT modes and delivered DBT to an average of 118 clients. Lower training and program needs, fewer bachelor's-level clinicians, and greater prior DBT experience predicted adoption of more DBT modes. More prior DBT experience, smaller team size, more negative team functioning, and staff with lower job satisfaction, growth, efficacy, and influence predicted greater DBT reach. DBT Intensive Training™ appears effective in promoting DBT adoption and reach in routine clinical practice settings.

Implementation of Dialectical Behavior Therapy in Residential Treatment Programs: A Process Evaluation Model for a Community-Based Agency

Dialectical behavior therapy (DBT) can be challenging to implement in community-based settings. Little guidance is available on models to evaluate the effectiveness or sustainability of training and implementation efforts. Residential programs have much to gain from introduction of evidence-based practices, but present their own challenges in implementation. This paper presents a low-cost process evaluation model to assess DBT training piloted in residential programs. The model targets staff and organizational factors associated with successful implementation of evidence-based practices and matches data collection to the four stages of the DBT training model. The strengths and limitations of the evaluation model are discussed.

Exploring dialectical behaviour therapy clinicians' experiences of team consultation meetings

BACKGROUND

This article presents a detailed idiographic analysis of Dialectical Behaviour Therapy (DBT) clinicians' experiences of team consultation meetings. DBT is an evidence-based psychological intervention with a demonstrated efficacy in the treatment of borderline personality disorder (BPD). Team consultation meetings encompass one of the primary components involved in this treatment model; where DBT clinicians regularly meet to discuss client work and enhance further learning. The present study's aim was to assess what are DBT clinicians' experiences of the consultation meeting component and whether it is useful or not.

METHOD

Semi-structured interviews were completed with 11 DBT clinicians (nine females, two males) from three different consultation teams. The research project utilised an interpretative phenomenological analysis (IPA) framework. Audio-recorded interview data was analysed using this framework.

RESULTS

Four superordinate themes emerged from the interview data, which included ten subordinate themes. The superordinate themes focused on: (1) the acquisition of DBT technical knowledge and other MDT related expertise (2) participants' emotional experiences of DBT and consultation meetings, and how this can evolve over time (3) the underlying processes that occur in the consultation team including the development of a team bond and the impact of membership changes and (4) the largely consistent and reliable nature of consultation meetings and how they help maintain clinician motivation.

CONCLUSIONS

Team consultation meetings were found to be supportive; playing an important role in maintaining clinician motivation through the availability of team support, opportunities to reflect and learn, and assistance in regulating emotions. Challenges arose in relation to team membership changes and acclimatisation to the type of feedback utilised in team consultation. The study's implications for practise are considered.

Interpersonal barriers to recovery from borderline personality disorder: A qualitative analysis of patient perspectives

Social-environmental factors have been found to be an integral part in the recovery process for individuals with psychiatric disabilities. There are few studies that have obtained patient perspectives of how their social and treatment environments help facilitate or impede the recovery process. The following study examined the self-reported interpersonal barriers to recovery among a sample of individuals (N = 31) with borderline personality disorder who were receiving dialectical behaviour therapy. The goal of study was to identify self-reported problematic behaviour that interferes with recovery goals and identify types of family, friend and/or provider behaviours that increased the likelihood of patients engaging in these problematic behaviours. A content analysis yielded three themes of problematic behaviour, and how these behaviours were reinforced by others, including (1) avoidance behaviours, (2) encouragement of negative coping and (3) communication of low behavioural expectations. Implications for the impact of these patterns of reinforcement within behavioural health settings are discussed. Copyright © 2017 John Wiley & Sons, Ltd.

Personality disorder: its impact on staff and the role of supervision

Over the past decade attention to the provision of healthcare for individuals with personality disorder, particularly those who pose a risk to others, has substantially increased. Keeping pace with such developments with a suitably trained, consistent and motivated workforce, interfacing health and criminal justice systems where necessary, presents an enormous challenge. Staff must be experts in managing conflict at every level, while sustaining an optimistic and therapeutic orientation. Boundaried relationships provide the context for recovery for patients. Key principles and practices likely to promote resilience in personality disorder services, with a focus on the role of supervision, are outlined in order to support staff in keeping themselves afloat, their patients safe, and their services on target.

Switching roles: a qualitative study of staff experiences of being dialectical behaviour therapists within the National Health Service in England

Many National Health Service (NHS) Trusts in England have invested in dialectical behavioural therapy (DBT) for mental health service users. The experiences of NHS staff delivering DBT were explored using semi-structured interviews with six dialectical behaviour therapists working in secondary mental health services within the NHS. The aim was to consider the impact on staff of adding the DBT therapist role onto their existing job role. Interview data were analysed using thematic analysis. Six themes were inductively generated from the data: DBT as a useful framework; DBT as the most satisfying part of the job; ‘Worzel Gummidge heads’– conflicts in roles; ‘DBT buddies’– the importance of informal support; uncertainty about the future; and recursivity – using DBT skills personally. Interactions between themes, implications for the service and future research directions are discussed. Key findings suggest that the addition of the DBT therapist role, as well as the recursive nature of DBT, has a positive impact professionally and personally. However, the service context within which participants were working can lead this additional role to cause increased demands and therefore stress, reducing that positive impact.

Clinical Observations About the Potential Benefits and Pitfalls of Between-Session Contacts with Borderline Patients

Borderline Personality Disorder (BPD) has a reputation for being a challenging disorder to treat due to the nature of the illness. With the development of evidence-based treatments, therapists are becoming more skilled at successfully helping this cohort of patients. A common factor associated with all validated treatments for BPD is the active involvement of therapists. For example, DBT is one treatment where therapists are expected to be available to patients for coaching outside of sessions. However, understanding the benefits and pitfalls associated with therapists' accessibility in between sessions is relevant to any treatment with intersession contact. In this article, three benefits of intersession contact are described: to generalize the use of skills, to improve understanding of the patient's needs, and to facilitate an alliance. This article also addresses the pitfalls of therapists being so accessible to patients. Both the benefits and pitfalls of intersession contact are illustrated using case vignettes. Assessing the function served by a patient's contact in between sessions is an important way to determine whether such contact is a productive part of treatment. Recommendations are provided to avoid detrimental outcomes for both the therapist (therapist burnout) and the patient.

The Relationship Between Burnout and Occupational Stress in Genetic Counselors

Burnout represents a critical disruption in an individual's relationship with work, resulting in a state of exhaustion in which one's occupational value and capacity to perform are questioned. Burnout can negatively affect an individual's personal life, as well as employers in terms of decreased work quality, patient/client satisfaction, and employee retention. Occupational stress is a known contributor to burnout and occurs as a result of employment requirements and factors intrinsic to the work environment. Empirical research examining genetic counselor-specific burnout is limited; however, existing data suggests that genetic counselors are at increased risk for burnout. To investigate the relationship between occupational stress and burnout in genetic counselors, we administered an online survey to members of three genetic counselor professional organizations. Validated measures included the Maslach Burnout Inventory-General Survey (an instrument measuring burnout on three subscales: exhaustion, cynicism, and professional efficacy) and the Occupational Stress Inventory-Revised (an instrument measuring occupational stress on 14 subscales). Of the 353 respondents, more than 40 % had either considered leaving or left their job role due to burnout. Multiple regression analysis yielded significant predictors for burnout risk. The identified sets of predictors account for approximately 59 % of the variance in exhaustion, 58 % of the variance in cynicism, and 43 % of the variance in professional efficacy. Our data confirm that a significant number of genetic counselors experience burnout and that burnout is correlated with specific aspects of occupational stress. Based on these findings, practice and research recommendations are presented.

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

INTRODUCTION

Working with people with a personality disorder (PD) can arouse strong feelings, and cause difficulties as well as different attitudes among mental health workers (MHWs). While attitudes towards people with PD and the difficulties experienced by MHWs have been previously investigated, the reciprocal relationship between the two has not been thoroughly investigated.

AIM/QUESTION

This study aims to investigate (1) affective reactions of MHWs to people with personality disorders, (2) the difficulties that MHWs experience while working with these patients, (3) their attitudes towards these patients, and (4) the interaction between these variables.

METHOD

The data for this study were collected through a Personal Information Questionnaire, the Difficulty of Working with Personality Disorders Scale and the Attitudes towards Patients with Personality Disorders Scale from 332 MHWs from several mental health clinics in Turkey, all of whom were experienced in working with people with PD.

RESULTS

The results indicate that the participants described 'difficulty in forming a relationship, understanding the client, and establishing cooperation' among the primary reasons of difficulties. This study also shows that there is a strong relationship between MHWs' feelings of boredom/discontent, guilt/pity and a tendency to display positive behaviours/an inability of establishing borders against people with PD.

DISCUSSION

The findings of this study imply that the level of education, expertise, psychotherapy treatment and clinical supervision of MHWs all affect perceived difficulties and attitudes towards people with PD. It is also noted that among nurses, a higher level of education results in reduced experience of difficulties while working with patients with PD.

IMPLICATION FOR PRACTICE

The results foreground the need for specific skills to be developed in MHWs through theoretical training, case-focused supervision and receiving personal psychotherapy for MHWs.

Effects of dialectical behavior therapy skills training on outcomes for mental health staff in a child and adolescent residential setting

Training in Dialectical Behavior Therapy (DBT) skills coaching is desirable for staff in psychiatric settings, due to the efficacy of DBT in treating difficult patient populations. In such settings, training resources are typically limited, and staff turnover is high, necessitating brief training. This study evaluated the effects of a brief training in DBT skills coaching for nursing staff working in a child and adolescent psychiatric residential program. Nursing staff (n = 22) completed assessments of DBT skill knowledge, burnout, and stigma towards patients with borderline personality disorder (BPD) before and after a six-week DBT skills coaching training. Repeated measure ANOVAs were conducted to examine changes on all measures from pre- to post- treatment and hierarchical linear regressions to examine relationships between pre- training DBT knowledge, burnout, and BPD stigma and these same measures post-training. The brief DBT skill coaching training significantly increased DBT knowledge (p = .007) and decreased staff personal (p = .02) and work (p = .03) burnout and stigma towards BPD patients (p = .02). Burnout indices and BPD stigma were highly correlated at both time points (p < .001); however, while pre-training BPD stigma significantly predicted post-training client burnout (p = .04), pre-training burnout did not predict post-training BPD stigma. These findings suggest that brief training of psychiatric nursing staff in DBT skills and coaching techniques can result in significant benefits, including reduced staff burnout and stigma toward patients with BPD-related problems, and that reducing BPD stigma may particularly promote lower burnout.

Meanings of caring for people who self-harm as disclosed in narratives of dialectical behaviour therapy professionals

ACCESSIBLE SUMMARY

This paper adds a phenomenological hermeneutic perspective on meanings of caring for adult people who self-harm as disclosed in narratives of dialectical behaviour therapy (DBT)-trained professionals. This paper shows that providing DBT care for people who self-harm means embarking an unpredictable journey, sometimes lonely, but also often together with the person who self-harm and with the DBT team. This paper emphasizes professionals' benefits of the tools and structure offered by DBT; however, the text points to the importance of the genuine meeting, including confirmation, as a prerequisite to recovery. This paper suggests that further research might focus on the meanings of genuine meetings and their organizational prerequisites.

ABSTRACT

In this paper, we aim to explore meanings of caring for adult people who self-harm as described in the narratives of professionals trained in dialectical behaviour therapy (DBT). We conducted narrative interviews with nine professionals working in a DBT team and used a phenomenological hermeneutical method to analyse their narratives. Our comprehensive understanding cast the caring relationship as an unpredictable journey, in which the professionals were guides or companions who aimed to walk side-by-side with the person who self-harms, prove to be trustworthy, and keep on track. They sometimes saw the journey as lonely and sometimes as a joint endeavour. Our analysis was informed by Martin Buber's writings on the 'genuine meeting' and confirmation. The professionals emphasized the importance of the tools and structure offered by DBT; however, the text points to the importance of the genuine meeting, including confirmation, as a prerequisite to recovery. Mental health nurses need opportunities for continuous training and counselling.

Psychometric Properties of Difficulties of Working with Patients with Personality Disorders and Attitudes Towards Patients with Personality Disorders Scales

INTRODUCTION

In this study, we aimed to develop two reliable and valid assessment instruments for investigating the level of difficulties mental health workers experience while working with patients with personality disorders and the attitudes they develop tt the patients.

METHODS

The research was carried out based on the general screening model. The study sample consisted of 332 mental health workers in several mental health clinics of Turkey, with a certain amount of experience in working with personality disorders, who were selected with a random assignment method. In order to collect data, the Personal Information Questionnaire, Difficulty of Working with Personality Disorders Scale (PD-DWS), and Attitudes Towards Patients with Personality Disorders Scale (PD-APS), which are being examined for reliability and validity, were applied. To determine construct validity, the Adjective Check List, Maslach Burnout Inventory, and State and Trait Anxiety Inventory were used. Explanatory factor analysis was used for investigating the structural validity, and Cronbach alpha, Spearman-Brown, Guttman Split-Half reliability analyses were utilized to examine the reliability. Also, item reliability and validity computations were carried out by investigating the corrected item-total correlations and discriminative indexes of the items in the scales.

RESULTS

For the PD-DWS KMO test, the value was .946; also, a significant difference was found for the Bartlett sphericity test (p<.001). The computed test-retest coefficient reliability was .702; the Cronbach alpha value of the total test score was .952. For PD-APS KMO, the value was .925; a significant difference was found in Bartlett sphericity test (p<.001); the computed reliability coefficient based on continuity was .806; and the Cronbach alpha value of the total test score was .913. Analyses on both scales were based on total scores.

CONCLUSION

It was found that PD-DWS and PD-APS have good psychometric properties, measuring the structure that is being investigated, are compatible with other scales, have high levels of internal reliability between their items, and are consistent across time. Therefore, it was concluded that both scales are valid and reliable instruments.

Dialectical behavior therapy training to reduce clinical burnout in a public behavioral health system

There is a risk of experiencing clinical burnout among therapists providing treatment to clients with borderline personality disorder (BPD), a complex, costly and difficult-to-treat psychiatric disorder. Dialectical behavior therapy (DBT) is an evidence-based treatment of BPD that has been widely disseminated. There is only one published study that has examined pre and post scores of burnout among clinicians who receive training in DBT, and none that have taken place within a public behavioral health system in the United States where resources for community-based agencies are limited and demands are high. The current study examined the rates of burnout among therapists treating clients with BPD within a large, urban public behavioral health system. The study included a sample of nine clinicians and showed significantly decreased scores of burnout after participants attended a series of DBT trainings over a period of 13 months. There were several key limitations to internal validity including the lack of a control group. Similar evaluations of training outcomes are needed to address the widespread occurrence of burnout among community-based clinicians providing treatment to clients with BPD in order to enhance the quality of patient care.

What must you know and do to get good outcomes with DBT?

Because little research has been conducted on which therapist-client interactions lead to intermediate and end-point improvements in Dialectical Behavior Therapy (DBT), we have a small evidence-base from which to specify what therapists must know and do in order to obtain good outcomes using DBT. As with other evidence-based practices, dissemination of DBT has defaulted to assumptions and methods from the "psychotherapy technology model," which emphasizes transfer of the validated treatment package from the research clinic to routine settings with high fidelity (Morgenstern & McKay, 2007). However, serious limitations of the psychotherapy technology model require pursuit of alternative complementary models to guide dissemination. One complementary approach is to use well-designed practice-based training research. In this approach, therapists learn modular competencies linked to a highly structured yet flexible clinical decision-making framework. Modular training of therapist competencies emphasizes the continuity of the component therapist strategies across evidence-based protocols rather than emphasizing the packages or manuals as separate and distinct. Key hypotheses about the change processes responsible for client change and the associated treatment strategies used to influence these change processes should be specified and measured at the level of client, therapist, and service delivery setting. Adopting this approach may offer advantages that apply to the dissemination and implementation of DBT and other evidence-based practices (EBPs).

Working with the 'difficult' patient: the use of a contextual cognitive-analytic therapy based training in improving team function in a routine psychiatry service setting

The clinical management of 'difficult' patients is a major challenge which exposes mental health teams to an increased risk of frustration and stress and may lead to professional burnout. The aim of the present study was to investigate whether a cognitive-analytic therapy (CAT) based training undertaken by a mental health team working with 'difficult' patients reduced professional burnout symptoms, improved patients' service engagement and increased the levels of team-cohesion. Twelve mental health staff members from different professional and educational backgrounds took part in five 2-hour sessions providing a basic CAT training intervention, an integrative and relational model of psychotherapy for the treatment of borderline personality disorders. Participants were administered the Maslach Burnout Inventory (MBI), the Service Engagement Scale (SES) and the Group Environment Questionnaire (GEQ) before (T0) and after (T1) CAT training, and at 1-month follow-up (T2). A significant decrease were found, at T2, on the MBI Emotional Exhaustion scores, the SES Availability subscale, the GEQ Attraction to Group-Social and Group Integration-Social, while the MBI-Personal Accomplishment scores increased from baseline.The results of this study suggest that a CAT-based training can facilitate team cohesion and patient engagement with a service and reduce burnout levels among mental health team members dealing with 'difficult' patients.

Report of a feasibility study of a Mindfulness group for clients, carers and staff of an early intervention in psychosis service

Mindfulness meditation is developing momentum as a mental health promoting activity in clinical and non-clinical settings. Our Early Intervention in Psychosis (EIP) service wished to determine its acceptability and utility among a mixed group of participants. All clinical team members, their patients and their carers were offered an 8-week Mindfulness group. Participants rated acceptability before and after. They prospectively identified, then monitored, distress associated with areas of their lives they hoped might improve. Nineteen participants provided a mean attendance of 11.25 per group. The group was overwhelmingly positively perceived and distress associated with participants’ items significantly improved. Findings support further implementation. The goal of inclusion was achieved with some reservation about staff preparation.

It's not you, it's me: an examination of clinician- and client-level influences on countertransference toward borderline personality disorder

Individuals with borderline personality disorder (BPD) appear more likely than individuals with other mental disorders to evoke negative countertransference reactions. The current study examined countertransference toward BPD across client- (e.g., client age and gender) and clinician-level (e.g., age, discipline, clinical experience, training) factors. Participants (N = 560) completed an anonymous online survey in which they read case information describing a client with BPD and answered questions to assess their reactions toward the client. The study used a 2 × 2 between-subjects design in which client age and gender were experimentally manipulated. Despite receiving the same vignette, clinicians were more accurate in diagnosing the female client with BPD than the male client, and clinician reactions differed as a function of client age and clinician experience. Specifically, clinicians viewed adolescent clients with BPD as less ill, less trustworthy, and more dangerous than adults with BPD; more clinical experience among clinicians was associated with more positive reactions to clients. Findings help to better understand countertransference reactions and the ways they may impact diagnostic choices and treatment decisions. The implications of these findings for facilitating better clinician-client matching, reducing clinician burnout, and improving treatment experiences for individuals with BPD are discussed.

Treating borderline personality disorder as a trainee psychologist: Issues of resistance, inexperience and countertransference

Clients with borderline personality disorder are viewed as difficult to work with. They also have high drop-out rates and unpredictable treatment outcomes. The characteristics of patients with borderline personality disorder often have a negative effect on the therapeutic process and on clinicians themselves. Challenges are likely magnified for trainee psychologists, given their lack of experience in implementing treatment plans and their inadequate understanding of underlying dynamics. However, to date, no studies have focused on the particular challenges experienced by trainee psychologists. This article attempts to address the gap in literature by exploring the difficulties experienced by a trainee psychologist in treating a patient with borderline personality disorder. A case study is used to highlight the challenges experienced by a novice psychologist in using specific therapeutic modalities recommended in the treatment of borderline personality disorder (BPD), namely dialectical behaviour therapy (DBT) and mentalisation based therapy (MBT). The aim of the study was to help better identify, understand and normalise the countertransference experiences and other difficulties experienced by trainee psychologists in treating clients with BPD. The article highlights observations regarding the context of the supervisory process, the importance of personal psychotherapy, the potential for harm of pejorative views, and the complications arising from a mismatch between the treatment modality and the treatment context.

Treatment completion in psychotherapy for borderline personality disorder: a systematic review and meta-analysis

OBJECTIVE

Psychotherapy for borderline personality disorder (BPD) has been associated with problematically low treatment completion rates.

METHOD

PsycInfo and Medline were systematically searched to identify studies providing information on treatment completion in psychotherapy models that have been shown to be effective for BPD. A meta-analysis of treatment completion rates and a narrative analysis of factors predicting dropout were conducted.

RESULTS

Forty-one studies were included, with completion rates ranging from 36% to 100%- a substantial between-study heterogeneity. Random effects meta-analyses yielded an overall completion rate of 75% (95% CI: 68-82%) for interventions of <12 months duration, and 71% (95% CI: 65-76%) for longer interventions. Egger's test for publication bias was significant for both analyses (P ≤ 0.01). Study characteristics such as treatment model and treatment setting did not explain between-study heterogeneity. In individual studies, factors predicting dropout status included commitment to change, the therapeutic relationship and impulsivity, whilst sociodemographics were consistently non-predictive.

CONCLUSION

Borderline personality disorder should no longer be associated with high rates of dropout from treatment. However, the substantial variation in completion rates between studies remains unexplained. Research on the psychological processes involved in dropping out of treatment could further improve dropout rates.

[Professional stress in general practitioners and psychiatrists--the level of psycologic distress and burnout risk]

BACKGROUND/AIM

So far, studies of stress have shown that physicians are at a high risk of sickness from psychic and somatic disorders related to professional stress, that can lead to important disturbance of personal, familiar and professional functionating. The aim of this study was to investigate the doctors exposition level to professional stress, to compare stress level in general practitioners (GP) group with that in the group of psychiatrists and risk level for the apperance of burnout syndrome.

METHODS

This cross-section study included subjects recruited by a random sample method. Thirty General Practice doctors and 30 psychiatrists (totally 60 doctors) filled the set of 3 questionnaires: Sociodemographics features, General Health Questionnaire (GHQ; Goldberg D, 1991), and Maslach Burnout Inventory (MBI; Maslach C, 1996). Appropriate statistical procedures (Pearson test, t-test, variance analysis) in interpretation of the results were used.

RESULTS

A total level of psychic distress measured with the GHQ test in both groups of physicians was very low implying their good mental health. A difference in Burnout risk based on MBI test between the groups was statistically significant (chi2 = 4,286; p < 0.05) only at subscale Personal Accomplishment (MBI-PA); it was a consequence of a higher number of GPs with medium burnout risk (13.3 : 0.0%). However, even 35 physicians from the sample were affected with a high burnout risk measured with subscales Emotional Ehausation (MBI-EE) and MBI-DP, showing that both groups of physicians had risk for the appearance of burnout syndrome.

CONCLUSION

The obtained results showed a high burnout risk level in both, GPs and psychiatrists, groups. In both groups there was no presence of psychic disorders (anxiety, depression, insomnia), while there was a high level of emotional ehausation and overtension by job, and also a lower total personal accomplishment. Level of exposition to professional stress is higher in GPs than in psychiatrists, but the difference was not statistically significant.

A Pilot Study of Psychotherapist Trainees' Alpha-Amylase and Cortisol Levels During Treatment of Recently Suicidal Clients With Borderline Traits

Psychotherapists often experience stress while providing psychotherapy, in particular when working with difficult presentations such as suicidality. As part of a larger study on the treatment of recently suicidal college students with borderline traits, 6 therapists in training collected their own salivary samples for alpha-amylase (AA) and cortisol (C) analyses immediately before and after sessions with 2 selected clients. On average, samples were collected for the same therapist-patient dyad throughout the year-long study to ensure that data reflected therapist responses across stages of treatment. Therapists also completed a working alliance questionnaire and rated perceived session difficulty immediately after each selected session. Contrary to expectations, therapists demonstrated elevated levels of stress as measured by AA and C at presession relative to postsession levels. Greater session difficulty was related to more pronounced declines in AA, whereas a stronger working alliance was linked to more pronounced reductions in C. Results suggest that physiological stress responses while working with recently suicidal clients with borderline traits occur primarily in terms of session anticipatory anxiety, whereas AA and C changes may be affected differently by factors such as session difficulty and working alliance. This is a pilot study, limited by its sample size, but the design, findings, and inclusion of physiological measures present an initial step in an essential line of research.

Job satisfaction and burnout among staff working in community-based personality disorder services

AIMS

To examine levels of burnout among staff working in community-based services for people with personality disorder (PD) and to explore factors which add to or lower the risk of burnout among people working in such services.

METHODS

In-depth interviews with staff working at 11 dedicated community-based personality disorder services in England together with a cross-sectional staff survey using the Maslach Burnout Inventory.

RESULTS

Levels of burnout were generally lower than those reported in previous studies among mental health workers and levels of personal accomplishment were higher. Staff reported positive as well as negative experiences of working with people with PD. Strong team-work, clear leadership and opportunities for reflective practice were thought to protect staff from burnout.

CONCLUSIONS

The low levels of burnout we found may reflect the early stage of the development of these services. However, it is also possible that working with people with PD does not in itself lead to burnout, especially when services are organized to share and contain work-related anxiety.