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International Journal of Mental Health Nursing (2013) 22, 465–471

doi: 10.1111/inm.12009

Feature Article

Improving services for people with personality disorders: Views of experienced clinicians Mahnaz Fanaian,1 Kate L. Lewis1 and Brin F.S. Grenyer1,2 1

Illawarra Health and Medical Research Institute and 2School of Psychology, University of Wollongong, Wollongong, New South Wales, Australia

ABSTRACT: People with personality disorders are frequent users of both inpatient and outpatient psychiatric services, representing a significantly large proportion of all mental health clients. Despite this, most services find it a challenge to offer the most appropriate and effective treatment models for people with personality disorders. This paper is a report of a study of clinician opinions about how organizations can improve the delivery of services to people with personality disorders. Data was collected from experienced clinicians attending a personality disorders clinical and scientific meeting who were asked to work together in groups and present solutions for how organizations can improve the services provided to people with personality disorders. Qualitative data was collected and thematically and semantically analyzed using Nvivo and Leximancer. The Nvivo analysis revealed five main areas in which clinicians believe organizations can improve services for people with personality disorders. These focused on: (i) more training and education for health professionals and carers; (ii) better support through supervision and leadership; (iii) adoption of a more consistent evidence-based approach to client management and treatment; (iv) clearer guidelines and protocols; and (v) changed attitudes about personality disorder to decrease stigma. The Leximancer analysis of responses indicated the identified themes were not distinct; rather they were interconnected and related to one another, semantically. In summary, clinicians across a large and diverse geographical area developed a consensus that mainstream management of personality disorder is largely poor and inadequate. The findings lend support to an integrative and collaborative whole-service approach that enhances evidence-based practice in the community. KEY WORDS: clinician perspectives, mental health, personality disorder, psychiatric services, qualitative research.

INTRODUCTION Personality disorders are highly prevalent, affecting approximately 11.4% of the population (Lenzenweger et al. 2007) and 31.4% of all clients with a mental illness

Correspondence: Brin Grenyer, School of Psychology, University of Wollongong, Wollongong, NSW 2522, Australia. Email: grenyer@ uow.edu.au Mahnaz Fanaian, BSc (Nurs), MSc (Cardiac Nurs), PhD (Public Health and Nutrition), RN. Kate L. Lewis, Bpsyc. Brin F.S. Grenyer, BA (Psyc), MSc, PhD Clin Psyc. Accepted November 2012.

(Zimmerman et al. 2005). As a group, people with personality disorders, particularly borderline personality disorder, have frequent psychiatric hospitalizations (Leichsenring et al. 2011) and represent significantly more visits to outpatient facilities than other clinical groups (Bender et al. 2001). People with personality disorders, because of the nature of their interpersonal deficits, can present challenges to health services (Aviram et al. 2006; Deans & Meocevic 2006; Kealy & Ogrodniczuk 2010). Unfortunately, the diagnosis of personality disorder has been associated with negative perceptions and attitudes on behalf of mental health professionals (Newton-Howes et al. 2008).

© 2013 The Authors International Journal of Mental Health Nursing © 2013 Australian College of Mental Health Nurses Inc.

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Despite the availability of evidence-based treatment protocols, international studies have reported that the provision of services to people with personality disorders is suboptimal (Fallon 2003; Hayward et al. 2006; Koekkoek et al. 2009). A recent study (Ogrodniczuk et al. 2009) surveyed clinicians and found that almost all perceived the availability of treatment for personality disorders to be ‘very poor’. Interestingly, they also found a discrepancy between what clinicians thought was optimal treatment for persons with borderline personality disorder and what clinicians and services were providing. Although the majority of the clinicians in the latter study believed a combination of group and individual therapy was optimal, a significantly lower proportion of clinicians reported that their services provide this type of therapy. These studies, along with others (Holmes et al. 2006; NIMHE 2003), suggest that mainstream mental health services are poorly equipped or do not have the capacity to manage the complex needs of persons with personality disorders. Although there is empirical support for the effectiveness of evidence-based treatment protocols such as dialectical behavioural and dynamic therapies (Bateman & Fonagy 2009; Clarkin et al. 2007; GiesenBloo et al. 2006; McMain et al. 2009), they are not widely available in community settings (Kealy & Ogrodniczuk 2010). Further, almost all publicly funded mental health services are time-limited, which is a challenge for providing adequate psychotherapy as is best practice for personality disorders (Bender et al. 2001). Some of the barriers to the effective delivery of personality disorder programs include the lack of available resources, education, and support for clinical staff, and also the lack of clinician confidence in treating these clients. The effects of negative clinician attitudes and stigma surrounding the diagnosis is also perceived by some clinicians to be a barrier to the delivery of effective services (Koekkoek et al. 2009; Ogrodniczuk et al. 2009). While there is a considerable amount of work investigating the effectiveness of various treatment interventions and approaches (McMain et al. 2009), no studies known to the authors have commented on the feasibility of implementing these approaches in mainstream community mental health services, although some work has been done in specialist settings such as forensic settings. This is despite the existence of informative international clinical guidelines (APA 2001; NICE 2009). This qualitative study aims to explore the views of mental health clinicians with expertise in personality disorders on how mainstream mental health organizations can improve the services provided to people with personality disorders.

MATERIALS AND METHODS Participants Participants were 60 clinician experts who came together for a specialist personality disorders clinical and scientific meeting in November 2010. Attendance was by invitation only, and based on the clinician’s recognized specialized involvement in the treatment of people with personality disorders in the community. After a complete description of the study to the participants, written informed consent was obtained following Institutional Review Board approval.

Data collection The personality disorders clinical and scientific meeting had a major emphasis to evaluate the opinions of experienced clinicians working in the local health sector. As a part of this, participants were instructed to form groups of approximately four clinicians (resulting in 15 groups), and were subsequently asked to formulate responses to the following question: ‘How could organizations improve how they provide services for people with personality disorders? Brainstorm priorities for change’. Participants had approximately 1 hour to discuss amongst their group, and were asked to record their responses in writing.

Data analysis Qualitative data obtained was transcribed and thematically analysed using QSR Nvivo ver. 8 (QSR-International 2008), a software package designed to assist with coding and organizing qualitative data. The text responses of the groups were also examined using Leximancer, a qualitative data-mining program (Smith & Humphreys 2006) designed to quantify and graphically represent the main concepts in a text and semantically explore their relationship to one another. Leximancer was used to build upon the understanding of the Nvivo analysis because it allows a more detailed view of the semantic proximity and linkages between the nodes. Researchers can use Leximancer automatically to identify and map concepts in a text, or they can manually seed concepts from the text that they are interested in exploring. In this instance, we manually seeded the nodes identified in the Nvivo analysis as concepts to further explore their semantic relationship to one another. It is important to note, a ‘concept’ in Leximancer does not represent a single word, but rather a constellation of related thesaurus words. In a standard Leximancer analysis (automatically identified concepts), thesaurus words are automatically generated from the text, however, as we were essentially interested in further exploring the nodes identified in the Nvivo analysis, we manually generated the thesaurus


IMPROVING SERVICES FOR PERSONALITY DISORDERS

word list. These were determined by examining the text content falling within the Nvivo nodes, and identifying key words which were descriptive of the node it fell within. Two researchers worked together and agreed on the thesaurus word lists. The sentences per context block for the Leximancer analysis was changed from three (default) to one, as the dataset represented independent summary points rather than continuous text, and certain word variants were merged to simplify the findings (i.e. ‘acknowledge’, ‘acknowledges’ and ‘acknowledgement’). There is good evidence supporting the use of Leximancer in textual analysis (Cretchley et al. 2010; Hepworth & Paxton 2007; Hewett et al. 2009; Travaglia et al. 2009), and it has been shown to have satisfactory face validity, stability, and reliability (Smith & Humphreys 2006).

RESULTS Participants Participants were predominantly female (76.7%), with a mean age of 43.7 years (standard deviation = 10.70, range = 26–65). Level of experience and employment characteristics of the sample are described in Table 1. Participants came from a wide variety of both public and private mental health services, spread across a geographically diverse area encompassing the populations of TABLE 1: Level of experience and employment characteristics of clinicians

Experience Years qualified in occupation (n = 60) Years of experience in working with personality disorders (n = 59) Employment characteristics Current employment status (n = 59) Full-time Part-time Other Occupation type (n = 60) Psychiatrist Psychologist Clinical psychologist Social worker Counsellor Mental health nurse Other Work sector (n = 59) Private Public Both

Mean

Standard deviation

Range

12.20 8.93

7.93 6.31

2.5–38.0 2.5–30.0

n

%

42 16 1

71.2 27.1 1.7

3 20 25 6 1 1 4

5.0 33.3 41.7 10.0 1.7 1.7 6.7

7 35 17

11.9 59.3 28.8

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Sydney, Newcastle, and Wollongong, Australia, representing approximately 6.3 million residents from the wealthy to the disadvantaged.

Nvivo analysis Each group submitted between 6 and 15 summary points (M = 9.4) on the topic. A total of 143 summary points were analyzed. The overall results overwhelmingly confirmed that current treatment practices in mainstream services were both ‘poor’ and ‘inadequate’. Nvivo analysis revealed that content from the summary points fell into five dominant nodes that represented 50% of the data. These are described below. The proportion of data reflected in each of the nodes is provided in parentheses next to the title of each. Through the Leximancer semantic analysis, we were then able to explore the relationship between these nodes by examining the frequency of word occurrences with others. 1. More training and education for health professions and carers (14%)

Almost all groups of clinicians reported the need for more training in working with persons who have a personality disorder, particularly for generalist mental health workers and frontline and ancillary staff. Similarly, several groups of clinicians also emphasized the need for a coordinated and cross-agency approach to training, including staff from other government agencies that have more frequent contact with clients with personality disorders, such as social service organizations. This is in order to encourage an intensive and integrated case management approach (e.g. ‘coordinated whole of team training’, and ‘crossagency training within local areas: health, police, community mental health, custodial services, community services’). Clinicians also indicated that they felt training and education was needed for carers (families, friends, and partners of people with personality disorders) to help improve management and outcomes. Other comments around training included improving funding for clinicians and allied health professionals to attend relevant training, more exposure to personality disorders during university courses, and also training to address the barrier of a ‘crisis only, move on: we don’t want them’ mentality. 2. Better support through supervision and leadership (12%)

Participants reported the need for more clinician support, particularly in the form of supervision, both individually and as a group. For example, one group of clinicians indicated that there should be ‘more supportive


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supervision for working with personality disorders and more supportive and regular treatment team meetings’. Clinicians also indicated there is a need for more accessible consultancy services to assist clinicians, and stronger leadership and management support systems, via the provision of initiatives such as service-funded specialist supervision and training. The need for peer support through collaborative networking was also acknowledged. Other service and policy matters in relation to support included providing better local health network internet access to download resources and assessment instruments, addressing the high levels of staff burnout and workloads. The provision of better support for clients and carers from governments and services was also noted (e.g. ‘subsidized treatment for people with personality disorders who often cannot afford long-term treatment’, ‘long waiting lists for people wanting to access services. Provide more opportunities for treatment’, and ‘family training and support, including friends’). 3. Adoption of a more consistent client-centred, collaborative recovery approach to management and treatment (10%)

Clinicians made suggestions for modifying the management and treatment provided to people with personality disorders. Most comments related to crisis and risk management. Clinicians wanted more evidence-based community psychological approaches, and less focus on resources provided to acute treatments, including inappropriate hospitalization. Some suggestions included ‘re-evaluating preoccupation with risk management, i.e. hospitalization is not always appropriate: investigate and establish alternatives to hospitalization’ and ‘changes to acute crisis management: avoid admissions to psychiatric facilities’. Clinician groups also made comments related to comprehensive case management, emphasizing the importance of ‘an intensive integrated multidisciplinary case-management approach’. The introduction of different treatment models and formats was also raised with some groups indicating that treatment providers should embrace a combined psychological and medical treatment model, and that there needs to be ‘longer therapy options’ but also brief interventions as an alternative to hospitalization. Continued longitudinal outcome research was also indicated as a means of monitoring the progress and improvement of treatments. 4. Clearer guidelines and protocols (8%)

Many clinicians referred to the need for establishing a more systematic approach to using protocols and procedures, and clear procedures for assessment, crisis situations, and

clinical care pathways of clients with a personality disorder, ensuring consistent delivery across different teams of health professionals. For example, one group stated the need for ‘documented approaches and strategies implemented for consistency and evaluations’. Some groups also emphasized the need for clear and consistent plans for ways of dealing with difficult crisis situations (e.g. ‘clear clinical care pathways across the various service sectors from crisis care to emergency to clinical support’ and ‘increased communication and plans on how to deal with difficult acute situations, i.e. suicide: consistent approach across the team’). There was also identified the need for easy referral and clinical care pathways across sectors to ensure clients receive the most appropriate care (particularly on discharge from treatment). Adherence to published and reputable clinical guidelines (e.g. UK NICE guidelines (NICE 2009)) was also identified. 5. Changed attitudes about personality disorder to decrease stigma (6%)

The stigma associated with the personality disorder diagnosis was perceived to be an important barrier to the delivery of effective personality disorder services. Several groups raised the issue about the existence of a negative culture in the health service in relation to personality disorders, and indicated that initiatives should address the negative attitudes and prejudices felt by staff. For example, one group stated that an ‘attitudinal change is needed throughout the service towards clients with personality disorder’ to improve services provided. Another group indicated that there needs to be an ‘intensive effort to change the “crisis only, move on: we don’t want them” mentality within the mental health system’, further suggesting that there needs to be an investment in the training of local mental health teams with regard to developing awareness of the stigma surrounding the diagnosis. One group even suggested modifying the diagnostic thinking to emphasize more ‘complex trauma’ or ‘developmental trauma’ as a means of improving the service response.

Other content categories (50%) Another theme that emerged was the need for better acknowledgement of the existence of personality disorder as a diagnostic group, and a recognition of the costs and time required to help these clients (e.g. ‘acknowledge the disorder: it exists, is treatable, worthwhile, and economically good to treat’, ‘seeing treatment of personality disorder as core business, alongside mood and psychotic disorders’, and ‘recognition of the enormous cost of the disorder in terms of health service resources, clinician time, [and] administration’). The importance of early intervention



was also mentioned several times, along with the need for long-term research initiatives to inform the development of models, protocols, and evidence-based practice, and the challenges of trying to reduce waiting-lists.

Leximancer analysis The Leximancer analysis using the Nvivo nodes as ‘concepts’ and key words from text within the node as ‘thesaurus words’ was able to generate a concept map to enable visual representation of how the concepts semantically relate to one another in the text (see Fig. 1), and identify the most frequently occurring concepts in relation to the five main Nvivo nodes identified. The concept map shows the relationship between the use of one concept and its proximity to other concepts. The larger dots on the map indicate more prominent concepts, with the most prominent being support and training. Similarly, the proximity of concepts to one another on the map, reflect the semantic proximity within the text. Leximancer concept usage statistics vary the size of the dots based on frequency across all five main nodes. To illustrate, the map demonstrates that the concept ‘support’ links closely to ‘staff ’, ‘supervision’, ‘responsi-

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bility’, and ‘treating’, which indicates they were all used close together in the text. In numerical terms, ‘support’ and associated thesaurus words were used 59 times within the ‘training and education’ node, 41 times in the ‘consistent use of evidence-base’ node, 23 times in the ‘guidelines and protocols’ node, and 14 times in the ‘changing attitudes’ node. These findings indicate that prominent concepts such as support and training are considered by clinicians to be central to improving the service capability to treat personality disorders. Similarly, the ‘training’ concept links closely to the need for resources and funding supported by research and leadership, and suggests that training should be well linked to guidelinebased assessment and therapy practices.

DISCUSSION The data obtained in this study was generated by experienced clinicians who have a genuine interest in helping clients to better manage and recover from mental illness, as demonstrated by voluntary attendance at a personality disorders clinical and scientific meeting. Participants came from many different services and settings, across a

FIG. 1: Leximancer concept map: semantic representation of the Nvivo identified nodes, and relationships between one another. Larger dots indicate higher frequency of these concepts across the five nodes (training and education, supervision and support, consistent use of evidence-base, guidelines and protocols, changing attitudes).


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large and diverse geographical area. This paper describes their views regarding how services can improve the provision of treatment to people with personality disorders. Because these clinicians had experience in this area (with an average of 9 years), the data generated is likely to represent an informed view about the current status and limitations of services that may be generalizable beyond the region this data was collected. Clinicians identified five main areas in which they believe services can be improved. They felt there was a need for more training and education for health professions and carers, better support through supervision and leadership, adoption of a more consistent evidence-based approach to client management and treatment, clearer guidelines and protocols, and changed attitudes about personality disorder to decrease stigma. Several other suggestions were made, including better recognition of the disorder, improved early intervention, more research, and more resources. Semantic analysis using Leximancer further indicated that the five main themes were frequently co-occurring and closely related to one another in the text, emphasizing the interconnectedness and relatedness of the ideas raised. Overall, the findings lend support to the need for an integrative and collaborative whole of service model for the treatment of personality disorders. For example, clinicians indicated that consistent training and education needs to be available to all relevant health professionals across different health sectors and for carers and families. Similarly, several groups of clinicians also indicated the importance of offering training to other government bodies from services frequently utilized by persons with personality disorders, and these agencies along with the relevant health professionals need to work collaboratively across disciplines to best manage the client and their needs. Several studies have reported the success of a collaborative approach (Huband & Duggan 2007). However, to gain benefit from a whole-service approach for the treatment of personality disorders, all staff need to be trained according to a consistent model (Bateman & Tyrer 2004). In this study, there was also an emphasis on the availability and implementation of clear and consistent guidelines and protocols, including referral pathways. Clinicians indicated that consistent guidelines and protocols are necessary to effectively manage clients with personality disorders, particularly those in crisis. Such an approach can improve outcomes for people with personality disorders and minimize the burden on services by reducing presentations at emergency departments and overreliance on hospitalization. The development of referral guidelines would also ensure that clients are

receiving the most appropriate care available, and prevents individuals from being ‘lost in the system’. A more consistent and evidence-based approach to client management and treatment was also suggested, emphasizing the collaboration and connectedness of a whole-service approach. Clinicians advocated for more support for treating people with personality disorders. Types of support included specialist supervision, peer support, regular treatment meetings, consultancy services, funded training, and professional development initiatives. Clinicians who see people with personality disorders often experience high levels of burnout and feel helpless in relation to treating these people (Cleary et al. 2002), thus, treatment may be compromised. The stigma associated with the diagnosis is also perceived as a barrier to the delivery of effective treatments (NIMHE 2003). Clinicians in this study indicated that there is a need for attitudinal change within the mental health system. This study has limitations. First, clinicians who took part in this study were invited to attend a clinical and scientific meeting based on their involvement and expertise with personality disorders; therefore, their views might differ from those who were not invited to attend. Similarly, the prevalence of psychologists (75%) in this sample may limit the generalizability of the findings to ‘clinicians’ at large. Second, although anecdotal evidence indicates the provision of services for people with personality disorders is generally poor, findings may be limited in applicability to other countries and regions. This study supports the need for developments in how personality disorders are managed and treated in mainstream mental health services. Almost all clinicians in this sample indicated that there is a poor availability of effective treatments for people with personality disorder. Future research exploring the views of service users could also strengthen this finding. A view that emerged from clinicians was that there was value in considering changing practice from a reliance on hospital inpatient treatments to community-based services, and to better support staff to provide evidence-based services. A strong consensus was that clinical leaders and managers need to work with frontline staff to enhance support, and to foster more hopeful views of the effectiveness of community psychological treatment for people with personality disorders.

ACKNOWLEDGEMENTS This study is funded by the NSW Ministry of Health. The authors have no interests to disclose. The authors would also like to thank the clinicians who participated in the current study.



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