Attitudes to Personality Disordered patients
Attitudes of most of the psychiatric professions towards the personality disordered (PD) have been shown to be generally negative. Alienation of nurses from PD patients has frequently been described, and has been linked to completed suicide by inpatients. Psychiatrists have also been shown to dislike PD patients. This same phenomenon is reflected in the psychoanalytic literature where there is much discussion about the negative countertransference of therapists towards PD analysands. Even the more recent cognitive-behavioural literature has shown this to be an issue that needs to be managed by therapists, their teams, and their organisations.
Where assessed, attitudes of many of the psychiatric professions towards the personality disordered, has been shown to be negative. Alienation of nurses and psychiatrists from PD patients has frequently been described, and this negativity has been linked to some completed suicide by inpatients. Even the more recent cognitive-behavioural literature has shown this alienation to be an issue that needs to be managed by therapists, their teams, and their organisations.
The aims of our research in this area have been to:
(i) develop a scale to measure attitudes to personality disorder, to identify the factors underlying and maintaining nurses' positive therapeutic attitudes to patients with severe personality disorder
(ii) assess whether positive staff can be identified for recruitment
(iii) identify what events, experiences and factors in the course of daily work with PD patients influence the stated attitudes and beliefs of staff.
The Attitude to Personality Disorder Questionnaire (APDQ)
This questionnaire to measure attitudes to personality disorder was initially developed in 1998 and was inspired by Colson’s Hospital Treatment Rating Scale. It has been used with samples of nurses working in the High Secure Psychiatric Hospitals, Prison Officers working in the then Dangerous and Severe Personality Disorder (DSPD) units, and in a large sample of staff working in acute psychiatric wards as part of the City-128 study [link].
Factor Analysis of the feelings aroused in nurses by patients using the APDQ demonstrated an underlying structure consisting of enjoyment, security, acceptance, sense of purpose, and enthusiasm. This structure was confirmed in a subsequent sample. Test-retest reliabilities of the instrument were good to excellent.
The APDQ has a robust structure, good psychometric properties, and is useful for outcome studies, benchmarking between units, and regular audits of staff attitude. The scale is in the public domain, and is free for use. A link for downloading it can be found below.
Interviews of nursing staff
We have conducted interviews with a random sample of 121 nurses in three High Security psychiatric hospitals, with comparative analysis relating interview content to attitude to PD.
A content analysis of the interviews allowed the identification of a large number of factors correlated with positive attitudes. These factors existed at the level of organisational systems (the operations of the complaints system, multidisciplinary relationships, management methods etc.) and at the level of the individual nurse. For the nurse, what seemed to influence attitudes were their beliefs (e.g. on cause of PD), knowledge (e.g. psychological understanding and models of PD behaviour), moral commitments (e.g. to nursing professionalism), who they identified with (e.g. patient or victim) and the self management methods they used to contain their emotional reactions to patients.
These interviews led to many findings and understandings, which have been described in full and published as a book, the link for which can be found below. The model derived from this work is known as the ‘City Model’, and appears to have applicability to how nurses respond to all patients who are challenging and difficult to manage. This model and its testing have been the basis for several subsequent studies in acute psychiatry: the City-128 study [link]; the Tompkins Acute Ward study [link]; and City Nurses [link].
Change of attitude over time
We conducted a longitudinal follow up study of staff on a newly opened DSPD Unit, with repeated use of the APDQ and repeated interviews of staff. This was in order to discover critical events, influences and changes in attitudes to personality disorder.
Attitude to Personality Disorder did vary over the course of time, and changes in attitude were linked to events experienced by individual officers. More positive attitude to personality disorder was associated with improved general health and job performance, decreased burnout, and favourable perception of managers. Positive influences on attitude were: greater understanding about personality disorder and the prisoners’ individual circumstances; improvement in inmate behaviours; education on personality disorder and related issues; the staff counselling programme; the support and skills shared between staff; the challenge and purpose of the new role; and having their views asked and interest taken in them as part of this study. Negative influences were due to: difficulties in establishing the treatment programme leaving staff feeling frustrated and lacking in direction; inmate behaviour, in particular manipulation; fear and concern over their new roles; and the way staff are negatively portrayed in the media.
Measurement of attitude to personality disorder is not useful for staff selection, because of low stability over lengthy time periods. In order to maintain a high overall staff positive attitude to personality disorder, units should have: a unified and pervasive direction, philosophy and treatment regime; substantial investment in staff training programmes; and provide clinical supervision to frontline staff.
Factors underlying positive attitudes to PD The original research report to the research funders (NPFMHR&D). This report has been superseded by the book "Dangerous and Severe Personality Disorder" which contains a much fuller account of the research and its findings.
The Right People for the Job The Right People for the Job: choosing staff that will adjust positively and productively to working in the new personality disorder (PD) services. Report to the Home Office.
Dangerous and Severe Personality Disorder: Reactions and Role of the Psychiatric Team
APDQ package This zip file contains the Attitude to Personality Disorder Questionnaire, incorporating a sample questionnaire, psychometric data, and scoring instructions. The scale is free for use so long as no changes are made to the non-demographic section.
Bowers, L. (1998) The Social Nature of Mental Illness. London: Routledge.
Bowers, L. (2002) Dangerous and Severe Personality Disorder: Response and Role of the Psychiatric Team. London: Routledge.
Bowers, L. (2003) Manipulation: description, identification and social ambiguity. Journal of Psychiatric and Mental Health Nursing 10:323-328
Bowers, L. (2003) Manipulation: searching for an understanding. Journal of Psychiatric and Mental Health Nursing 10:329-334
Bowers, L. and Allan, T. (2006) The Attitude to Personality Disorder Questionnaire: psychometric properties and results. Journal of Personality Disorders 20(3)281-293
Bowers, L. and Carr-Walker, P. (2002) Working Positively and Productively in a DSPD Unit. Prison Service Journal 143:21-23
Bowers, L., Carr-Walker, P., Allan, T., Callaghan, P., Nijman, H., Paton, J. (2006) Attitude to personality disorder among prison officers working in a dangerous and severe personality disorder unit. International Journal of the Law and Psychiatry 29:333-342
Bowers, L., Carr-Walker, P., Paton, J., Nijman, H., Callaghan, P., Allan, T., Alexander, J. (2005) Changes in attitudes to personality disorder on a DSPD unit. Criminal Behaviour and Mental Health 15(3)178-190
Bowers, L., Simpson, A., Alexander, J., Ryan, C. and Carr-Walker, P. (2007) Student psychiatric nurses' approval of containment measures: relationship to perception of aggression and attitudes to personality disorder. International Journal of Nursing Studies 44(3)349-356
Carr-Walker, P., Bowers, L., Callaghan, P., Nijman, H., Paton, J. (2004) Attitudes Towards Personality Disorders: Comparison Between Prison Officers and Psychiatric Nurses. Legal and Criminological Psychology 9:265-277