The Development and Validation of a Self-Report Measure of Staff Attitudes to Borderline Personality Disorder

Emma Arora

Submitted for the Degree of

Doctor of Psychology

(Clinical Psychology)

School of Psychology

Faculty of Health and Medical Sciences

University of Surrey

Guildford, Surrey

United Kingdom

September 2016

Abstract

Mental health professionals (MHPs) attitudes towards people with borderline personality disorder (BPD) have been found to be consistently negative (Winship, 2010). This is concerning given the potential impact on the therapeutic relationship and treatment outcomes for people with BPD. A review of the literature (McQuillan, 2013) revealed limitations in the measurement of MHPs attitudes towards people with BPD and the need for a new measure with validated psychometric properties. The aim of the study was to develop and validate a new self-report measure of staff attitudes to people with BPD, based on cognitive, affective and behavioural components of attitudes.

The attitudes to borderline personality disorder questionnaire (ABPDQ) was developed based on a comprehensive literature review and consultation with service users/carers and MHPs. The preliminary measure was assessed to have good face and content validity by a panel of experts in the field of personality disorders. Exploratory factor analysis (EFA) was conducted as a data reduction technique and to establish construct validity on a large sample (N=289). Three underlying factors were identified consisting of a general attitude towards people with BPD which is either optimistic or pessimistic, the feelings evoked and stereotypes. Construct validity of the new measure was further verified through correlational analysis with existing measures. The ABPDQ was demonstrated to have excellent reliability (internal consistency, =0.9).

The ABPDQ is a unique measure which addresses inadequacies in the measurement of staff attitudes to people with BPD. It has the potential to be utilised widely in future research studies and clinical practice. The ultimate aim being to improve negative attitudes and the quality of care people with BPD receive.

Acknowledgements

I would like to thank the PsychD course team at the University of Surrey particularly my clinical tutors Louise Deacon, Nan Holmes and Fiona Goodwin and my research tutor Jason Spendlow. I have been lucky to have fantastic clinical supervisors over the course of training and would like to thank them for offering interesting placement opportunities. It would not have been possible to complete the course without the continued support of my family especially my loving husband and mum.

Contents

Major research project (MRP) empirical paper4

MRP empirical paper appendices62

MRP research proposal120

MRP literature review142

Overview of clinical experience191

Table of assessments195

Major Research Project Empirical Paper

The development and validation of a self-report measure of staff attitudes to borderline personality disorder.

By

Emma Arora

Submitted in partial fulfilment of the degree of Doctor of Psychology

(Clinical Psychology)

School of Psychology

Faculty of Arts and Human Sciences

University of Surrey

April 2016

Emma Arora 2016

Word count: 9978

Contents

Statement of journal choice6

Abstract7

Introduction8

Method15

Results25

Discussion39

References50

Appendices62

Statement of journal choice

This paper is targeted at the Journal of Personality Disorders and the guidelines for authors are attached (Appendix A). This is an established international journal which focuses on the empirical study of personality disorders. The impact rating is 2.619, one of the highest rated journals in this field. The editor (Robert Krueger) was approached and agreed that the study was relevant for submission to this journal. The Journal of Personality Disorders was selected due to its relevant subject matter and multidisciplinary focus which targets both practitioners and researchers. It is hoped that the measure developed in this study will be useful for a wide range of practitioners and researchers alike. By targeting a personality disorders journal as opposed to a journal focusing specifically on measure development (e.g. Psychological Assessment) the new measure is more likely to reach the target audience.

Abstract

Mental health professionals (MHPs) attitudes towards people with borderline personality disorder (BPD) have been found to be consistently negative (Winship, 2010). This is concerning given the potential impact on the therapeutic relationship and treatment outcomes for people with BPD. A review of the literature (McQuillan, 2013) revealed limitations in the measurement of MHPs attitudes towards people with BPD and the need for a new measure with validated psychometric properties. The aim of the study was to develop and validate a new self-report measure of staff attitudes to people with BPD, based on cognitive, affective and behavioural components of attitudes.

The attitudes to borderline personality disorder questionnaire (ABPDQ) was developed based on a comprehensive literature review and consultation with service users/carers and MHPs. The preliminary measure was assessed to have good face and content validity by a panel of experts in the field of personality disorders. Exploratory factor analysis (EFA) was conducted as a data reduction technique and to establish construct validity on a large sample (N=289). Three underlying factors were identified consisting of a general attitude towards people with BPD which is either optimistic or pessimistic, the feelings evoked and stereotypes. Construct validity of the new measure was further verified through correlational analysis with existing measures. The ABPDQ was demonstrated to have excellent reliability (internal consistency, =0.9).

The ABPDQ is a unique measure which addresses inadequacies in the measurement of staff attitudes to people with BPD. It has the potential to be utilised widely in future research studies and clinical practice. The ultimate aim being to improve negative attitudes and the quality of care people with BPD receive.

Introduction

Borderline personality disorder (BPD) is characterised by instability in interpersonal relationships, self-image, affect and impulsivity, often including self-harm (NICE, 2009). The prevalence of BPD in the general population is 0.2 to 1.8% (Swartz, Blazer, George & Winfield, 1990). However 10-20% of clinical populations meet diagnostic criteria (American Psychiatric Association, 2000). Working with people with BPD is recognised to be challenging (Gunderson, 2001) and can have a strong emotional impact on staff (Linehan, 1993). Staff attitudes towards people with BPD are widely reported to be negative (Winship, 2010).

The structure of attitudes

An attitude is defined as a psychological tendency to evaluate an entity with a degree of favour or disfavour (Eagly & Chaiken, 1993, p.1).

There are a number of theoretical viewpoints about the structure of attitudes focusing on cognitive, affective and behavioural processes. The traditional tri-component model (Rosenberg & Hovland, 1960) views attitudes as a single entity consisting of cognitive, affective and behavioural components. A high degree of consistency between components is predicted. Moderate to strong correlations have been reported in studies focusing on attitudes toward snakes (Brecker, 1984) and participating in laboratory research (Bagozzi, Tybout, Craig & Sternthal, 1979). However empirical support for this model is dated and there is limited evidence to support this model in relation to attitudes towards stigmatised groups. Further limitations are this model requires all attitudes to have each of the three components (Ozkamp & Schlutz, 2005) and does not allow for individual differences. Individual differences in the structure of attitudes have been identified (Huskinson & Haddock, 2004), with some people relying on cognitive and others on affective information.

The separate entities viewpoint considers cognitive, affective and behavioural processes to be distinct. Attitudes are thought to consist of affective processes or feelings towards the attitude object. Fishbein & Ajzen (1975) argued that affect towards an attitude object is always highly related, whereas cognitions and behaviours are not. This approach has been criticised for being over-simplistic as it rules out cognitions and behaviours from the construct of attitudes (Oskamp & Schlutz, 2005).

The latent process model (DeFleur & Westie, 1963) proposes that attitudes are the result of hidden (latent) cognitive, affective or behavioural processes triggered by a stimulus event. Attitudes result in observable responses which are also cognitive, affective or behavioural. This approach is more flexible than the tri-component model as it does not require all three processes to be present or highly consistent. It also allows for individual differences. However there is limited empirical support for this model. The models discussed all consider cognitive, affective and behavioural processes relevant to the construct of attitudes but differ in the way the components form attitudes. A limitation of attitude measurement research is that few studies discuss findings in relation to theoretical models of attitudes.

Mental health professionals attitudes to people with borderline personality disorder

A review of the literature (McQuillan, 2013) found that mental health professionals (MHPs) attitudes towards people with BPD are often negative. These findings are concerning given the relationship between attitudes (cognitive and affective) and behaviour (Oskamp & Schlutz, 2005). MHPs attitudes have the potential to impact on the therapeutic relationship, which is recognised to have an impact on treatment outcomes (Clarkson, 2003).

Studies of MHPs attitudes to people with BPD are predominately quantitative, focusing on psychiatric nurses (e.g. Markham, 2003). However the attitudes of psychiatrists (Lewis & Appleby, 1988) and clinical psychologists (Millar, Gillanders & Saleem 2012) have been studied and professional groups compared (Black et al., 2011). The construct of attitudes to BPD is poorly defined and there is a lack of standardised measurement instruments. Therefore what is meant by negative attitude varies across studies. Consequently researchers developed their own questionnaires, often without testing reliability or validity.

Experimental studies have found that people with PD are evaluated more negatively than other groups. Lewis and Appleby (1988) found psychiatrists attitudes towards people with PD were significantly more negative than to those with depression or no diagnosis. Psychiatrists evaluated people with PD as more attention seeking, manipulative, annoying and more in control of suicidal tendencies. The study implied that a PD diagnosis led to judgemental, rejecting and pejorative attitudes.

Markham (2003) found similar results when comparing psychiatric nurses attitudes to people with BPD to those with depression and schizophrenia. Nurses were more likely to socially distance themselves from people with BPD and were more likely to perceive them as dangerous. They were less optimistic about working with people with BPD and rated their experiences more negatively. This study indicated that a diagnosis of BPD resulted in a labelling effect. Nurses were more likely to hold stereotypical beliefs about people with BPD than those with other diagnoses. More recently there have been advances in psychological treatment and specialist personality disorder teams have been established. It is hoped that such findings would not be replicated today.

Cleary, Siegfried and Walter (2002) carried out a descriptive survey of 229 MHPs. The majority (84%) found working with people with BPD more difficult than working with other client groups. Finding people with BPD more difficult to work with is not necessarily indicative of a negative attitude. This study highlighted a lack of resources in this field which may have contributed to the findings. It was promising that most staff (95%) were willing to engage in further training about BPD. Differences in MHPs attitudes to people with BPD across professional groups have been identified. Bodner, Cohen-Fridel and Iancu (2011) found nurses expressed significantly less empathy and psychologists made significantly less antagonistic judgements about people with BPD. This study highlighted the need for staff training to improve interactions with people with BPD, particularly for nurses working on the frontline.

A number of studies have investigated whether MHPs attitudes to people with BPD can be improved through training. Despite methodological limitations all studies reviewed reported significant improvements, implying that negative attitudes can be changed (McQuillan, 2013). In a randomised controlled trial (Common-Treloar, 2009) MHPs were randomly allocated to training (CBT or psychodynamic) or control groups. Attitudes significantly improved in both the CBT (p=.02) and psychodynamic groups (p