A number of authors have described suggestions for improving clinicians’ attitudes, knowledge and behaviours towards people with BPD. Suggestions for assisting
clinicians to improve inpatient care of people with BPD include the need to identify clearly the goals of treatment, provision of in-services for staff members, regular supervision and regular staff meetings (Johnson & Silver, 1988). Bowers (2002) highlights the importance of focused psychoeducation for clinicians in conjunction with a supportive team environment and regular clinical supervision. In reporting on a phenomenological study exploring the experience of nurses providing inpatient care for people with BPD, O’Brien and Flote (1997) make a number of recommendations designed to address the difficulties experienced. They point out that, ‘nursing staff caring for people with BPD need the support of cohesive, supportive teams that have comprehensive models of care in place, and need to have adequate education and ongoing supervision’ (O'Brien & Flote, 1997, p. 145). Furthermore, they suggest that all staff working with clients with BPD, including nurses, should be able to access clinical supervision similar to that provided within traditional psychotherapeutic models of therapy. The implementation of these recommendations is further reinforced by predictions of the likelihood of a continuing lack of suitable care without changes in practice. O’Brien (1998, p. 181) strongly asserts that a failure to adequately provide comprehensive treatment programs for people with BPD will ‘result in the continuation of reactive responses that are ineffective, expensive and cause considerable occupational stress’.
In the light of the research to date on directions and strategies for dismantling the barriers to effective practice in managing and treating BPD; it is clear that we need to ask if the use of DBT as a treatment model meets the needs of clinicians for education, support and supervision. It has been suggested that Linehan’s focus in developing DBT has not been restricted to developing an efficacious therapy for people with BPD. Rather, as Swenson (2000) has pointed out:
Linehan has from the beginning aimed explicitly to engage the mental health treatment community in changing its attitudes and practices towards this oft misunderstood and maligned client group (p. 88).
The DBT structure has all the ingredients required for improving practice as described above and is consistent with Roth and Fonagy’s (2005, p. 484) assertions that successful approaches for treating BPD ‘emphasize the importance of structure’ and have a ‘coherent theoretical base’ (p. 484) The biosocial theory of BPD provides an understanding of the aetiology of this disorder that enables clinicians to move from a view of the person as ‘bad’ to that of someone who has missed out on the opportunity to develop the skills to regulate painful emotions. Accordingly, DBT is based on assumptions designed to challenge punitive clinician behaviours towards clients. For instance, one of DBT’s major tenets is that the person is doing the best that they can.
Further, clinicians are supported to adopt an optimistic stance towards client difficulties. A highly structured process that provides support for both clients and clinicians is a hallmark of DBT. The treatment includes individual therapy, skills training and phone coaching supporting the client as they progress through a very challenging therapy process. Weekly group supervision/consultation in which the group applies DBT to the therapist is designed to ‘hold the therapist inside the treatment’ (Linehan,1993a p. 101). This provides a space in which clinicians can reflect upon their use of self as a therapeutic tool and examine the impact of their own reactions upon the therapeutic relationship. . One of the primary functions of clinical supervision is to provide a space that allows or encourages ‘reflective practice’.
Hawkins and Shohet (1989) describe this as the provision of a ‘regular space for the supervisees to reflect upon the content and process of their work’ (p. 43). A participant in this study suggests reflective practice is a capacity to ‘consciously reflect (ing) on who you are, how you’re reacting and what you’re doing’ (R1: p.3).
Mantzoukas and Watkinson (2008) contrast reflective practice (RP) with evidence-based practice (EBP). They suggest that these terms constitute ‘two very distinct and very different episteimologies, where reflection represents the contextual, subjective and explanatory type of knowledge and EBP the acontextual, generalized, unbiased and predictive type of knowledge’ (p. 132). These authors argue that these two discourses are complementary rather than ‘mutually exclusive as portrayed by most of the literature’ (Mantzoukas & Watkinson, 2008, p. 129). DBT as an evidence-based practice promotes therapists’ capacity for reflective practice as a vital component of the therapy. The inclusion of this regular consultation/supervision process recognizes the challenges of working with clients whose behaviour often provokes ‘anxiety and rage’ and whose sensitivity and vulnerability are easily provoked into escalating emotional distress.
While it is possible to argue the usefulness of DBT as a tool for changing practice and supporting clinicians in working with clients with BPD, little research exists exploring the usefulness of this therapy for this purpose outside of the specialist research unit staffed by highly trained DBT therapists. Hawkins and Sinha (1998) sought to examine whether clinicians in a public department of mental health in Connecticut could master the conceptual complexities of DBT. Using a formal examination format, 109 clinicians participated in the exam near to the commencement of training in DBT and again at or about 6 months after commencing training. The researchers report that their ‘data indicates that a diverse cross-section of mental health clinicians were able to make considerable progress towards the acquisition of a sophisticated understanding of DBT’
(p. 384). This result does not, however, indicate any change in practice or explore the professional or personal experience of clinicians using DBT as a therapy.
In a Swedish study, the only study of its kind to date (Perseius et al., 2003), the experiences of 10 clients who had participated in a minimum of 12 months of DBT and 4 therapists actively practising as DBT therapists were explored using a qualitative approach. The clients overwhelmingly described DBT as ‘life-saving’. The therapists described their work as DBT therapists as positively changing their view of people with BPD. The importance of adhering to the model was seen as crucial to ensure success when using DBT. It was described as tough, hard work demanding that the therapist be consistently ‘focused and engaged’. The impact upon the therapists’ personal lives was also noted as indicated in the following comment: ‘…When I think about my private life and DBT, it has given me very much more than it has taken’ (Perseius et al., 2003, p. 225).
Likewise in the area health service in which this research was conducted, an unexpected impact of the DBT implementation project commenced in 2003 was a number of statements from clinicians indicating the positive impact of learning DBT not only upon clinical practice but also upon their personal well-being. ‘An unexpected finding…was the extent to which the…DBT training had had an impact on participants’
personal lives’ (Hazelton et al., 2006). Research by Perseius et al. (2003) supports the anecdotal evidence of a positive impact upon clinician well-being.
Conclusion
Borderline personality disorder is a disabling condition that permeates the daily lives of people experiencing it. At the same time, the literature reviewed above suggests that mental health clinicians involved in treating BPD face enormous difficulties, not the least of which is inadequate education and training. National directives, human rights concerns and a responsibility to practise ethically, in conjunction with constraints on
Although recommendations for changing practice have been described in the literature for several decades, therapeutic pessimism and pejorative attitudes continue to pervade public mental health services. DBT has been described as a potential tool for addressing these difficulties because it proceeds from a strong theoretical basis and practice in which services are delivered to people with BPD in an optimistic manner. It is proposed that not only does training in DBT benefit the recipients of the therapy; it may also provide a means of supporting clinicians as they face both the professional and personal challenges of working as mental health professionals. In some cases it is possible that psychotherapeutic work, such as that entailed in the provision of DBT, also has broader health and wellbeing benefits for therapists.