Plain English Summary
Background and study aims
Patients diagnosed with a Personality Disorder (PD) are often described as difficult. The term appears frequently in the professional literature of, for example, psychiatric services, nursing and psychology. This characterisation of patients risks creating stigma towards them, which may undermine their care. In the UK, for example, the Department of Health found it necessary to issue policy guidelines to service providers, requiring that PD is no longer a diagnosis of exclusion. The present study compared the impact of two training programmes aimed at reducing staff stigma derived from two markedly different psychotherapeutic approaches. Acceptance and Commitment Training (ACTr), based on Acceptance and Commitment Therapy (ACT), uses the principles of acceptance, mindfulness, values, and action to help staff to manage their private thoughts and feelings that arise in working with PD patients. In contrast, (Dialectical Behavioural Training (DBTr), based on Dialectical Behavioural Therapy (DBT), teaches staff the skills necessary to manage their patients difficulties, based on the Biosocial Theory which provides a framework for understanding the nature of PD.
Who can participate?
Participants were healthcare staff working in UK state-funded or charitable institutions providing services for PD patients. All volunteered to take part in response to internal advertisements offering a free 2-day staff development course. After receiving an information pack outlining the study, those who wished to participate returned a signed consent form.
What does the study involve?
Both training interventions were delivered in the form of a 2-day staff workshop, the impact of which was assessed in terms of changes in staff stigmatizing attitudes, factors relating to staff-patient relations (therapeutic relationship, and social distancing) and staff wellbeing (burnout, psychological distress and flexibility). All measures in this study were self-report questionnaires. After being randomly allocated to one of the two training programmes, but before the first training session, participants privately completed a questionnaire pack. A post-training questionnaire pack was completed following the training, and again at 6-month follow-up.
What are the possible benefits and risks of participating?
Both workshops were expected to reduce stigmatising attitudes amongst staff, improve self-reports of their therapeutic relationships, and improve the well-being of staff. All participants were monitored throughout the study and had access to support from the two trainers both of whom are clinical psychologists - if they required this.
Where is the study run from?
All workshops were conducted away from staff workplaces at a single UK site in Bournemouth, Dorset. The research team were based at Dorset HealthCare NHS Foundation Trust and the Universities of Bournemouth and Southampton (UK).
When is the study starting and how long is it expected to run for?
May 2007 to January 2008
Who is funding the project?
The study was funded by the Health Foundation Leadership through Research Award, awarded to Prof Sue Clarke and also an ESRC Award Post Graduate studentship, awarded to Prof Bob Remington, and held by Dr Georgina Taylor.
Who is the main contact?
Prof Sue Clarke
Prof Susan Clarke
University Department of Mental Health
St Ann's Hospital
69 Haven Road
+44 (0)1202 492129
Ameliorating patient stigma amongst staff working with personality disorder: randomised controlled trial of self-management vs skills training
The study was designed to compare the impact of two training programmes aimed at reducing staff stigma derived from two different psychotherapeutic approaches; Acceptance and Commitment Training (ACTr), based on Acceptance and Commitment Therapy (ACT), and (Dialectical Behavioural Training (DBTr), based on Dialectical Behavioural Therapy (DBT).
UK National Health Service Research Ethics Committee, 02/11/2006, Dorset:06/Q2201/158
Randomised controlled trial with intention to treat analysis
Primary study design
Secondary study design
Randomised controlled trial
Patient information sheet
Not available in web format; please use the contact details below to request a participant information sheet
Patient stigma amongst staff working with personality disorder
Acceptance and commitment training (ACTr) intervention. This training intervention sought to help staff to understand the origins of the negative private experiences sometimes triggered by their patients, mindfully noticing them as they occurred, and understanding that they are unavoidable consequences of their challenging work. Once difficult thoughts could be self-compassionately accepted, the training moved towards helping staff to reconnect with their professional and personal values and letting these guide their actions. During the final part of the workshop we offered participants the opportunity to identify any aspect of their behaviour that they wanted to change in the service of leading a more values-consistent life, and make a public commitment to it.
Dialectical Behaviour Training (DBTr). In contrast with the ACTr program which focused on self-management, DBTr taught staff techniques for managing their patients. Drawing on Linehans account of severe PD and her skills training manual (Linehan,1993), training involved both experiential group and individual exercises, and didactic presentations. The validation component of DBTr taught participants ways in which they could validate their patients experience. The change component taught participants how to conduct behavioural chain analyses of target problems and identify DBT solutions.
Total duration of the actual interventions were 2 days. The study period was a total of 6 months (for both interventions).
Primary outcome measure
We used the 40-item Attitude to Personality Disorder Questionnaire (APDQ) to assess stigmatizing attitudes of staff towards PD patients. Staff perceptions of the quality of their therapeutic relationship with PD patients was measured using the 19-item Helping Alliance Questionnaire Therapist Version (HAQ-II). We assessed the degree to which staff distanced themselves from PD patients using the 7-item Social Distancing Scale (SDS), with all references to mental illness replaced with personality disorder.
All outcomes were measured at the same time points: baseline, post-intervention and at 6-month follow-up
Secondary outcome measures
1. Staff burnout and psychological distress were assessed using, respectively, the 22-item Maslach Burnout Inventory (MBI) and the 28-item General Health Questionnaire, (GHQ).
2. We also used the 7-item Acceptance and Action Questionnaire (AAQ-II) to assess staff psychological flexibility.
3. Credibility and Expectancy. The Credibility and Expectancy Questionnaire (CEQ) was used to determine the credibility of a described training approach and participants expectations of benefits from it. Two separate scales are summed to produce a total score, with higher scores reflecting a greater level of preconceived ideas about the training.
All outcomes were measured at the same time points: baseline, post-intervention and at 6-month follow-up. Credibility and Expectancy Questionnaire was measured at baseline only.
Overall trial start date
Overall trial end date
Reason abandoned (if study stopped)
Participant inclusion criteria
All mental health staff employed by NHS Trusts and staff from other agencies who come into contact with PD patients were eligible to volunteer to participate.
Target number of participants
The study aimed to recruit 150 participants
Participant exclusion criteria
1. Involvement in development or conduct of the study
2. Involvement in other PD-related research
Recruitment start date
Recruitment end date
Countries of recruitment
Trial participating centre
St Ann's Hospital
Dorset HealthCare University NHS Foundation Trust (UK)
11 Shelley Road
This research was primarily funded by a grant awarded by the Health Foundation awarded to Professor Sue Clarke (Reference No: 7232/4155) and a PhD Studentship from the Economic Social Research Council (ESRC) awarded to Dr Georgina Taylor.
Funding Body Type
Funding Body Subtype
Results and Publications
Publication and dissemination plan
Not provided at time of registration
Intention to publish date
Participant level data
Not provided at time of registration
Basic results (scientific)
2015 results in: http://www.ncbi.nlm.nih.gov/pubmed/25384419