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. The rationale for the Psycho education Training (PETr) workshop was based on the principle that giving staff a better understanding of PDs would improve their service delivery for PD patients (DoH; The Personality Disorder Capabilities Framework, 2003).
Who can participate?
Participants were healthcare staff working in UK state-funded or charitable provision providing services for PD patients.
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 valued action). All measures in this study were self-report questionnaires. After being 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 NHS and University sites. The research team were based at Dorset HealthCare Foundation Trust and the Universities of Bournemouth and Southampton (UK).
When is the study starting and how long is it expected to run for?
The study took place between March 2009 and March 2010.
Who is funding the study?
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
The University Department of Mental Health
St Ann's Hospital
69 Haven Road
+44 (0)1202 492129
Acceptance and Commitment Therapy-based self-management versus Psycho education Training for staff caring for clients with a Personality Disorder: Randomised Controlled Trial
The aim of this study is to compare the impact of two training programmes aimed at reducing staff stigma derived from two different psychotherapeutic approaches, either Psycho education Training (PETr) as recommended by the Department of Health (DoH), or Acceptance and Commitment Training (ACTr), based on Acceptance and Commitment Therapy (ACT).
This is a follow up to the study described in ISRCTN18382289.
UK National Health Service Research Ethics Committee Dorset, 18/03/2009, ref: 09/H0504/17
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.
Psycho educational training (PETr) intervention. We focused our training efforts on providing an introductory understanding of the diagnosis and the treatment of PDs. We taught using informal presentations, pitched at the professional and educational demographic of our participants, with group discussion as required to clarify content. During the first day, we introduced DoH guidelines, reviewed types of PD and described how clinicians assess and classify them. We discussed theoretical accounts of the development of PDs, focusing on biosocial and genetic factors. During the second day, the evidence base for current treatments was reviewed. Additionally, we showed videos of PD patients describing their treatment experiences and reflecting on the kind of care they would like to receive. Overall, the content of PETr workshop emphasised participants work-related experiences of PD clients in terms of service-related issues, rather than their personal feelings about them.
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. A role play video of a staff member working with a PD patient was also shown to demonstrate some ACT principles. 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.
Total duration of the actual interventions were 2 days. The study period was a total of 6 months (for both interventions).
Primary outcome measure
1. Attitude to Personality Disorder Questionnaire (APDQ; Bowers & Allan, 2006). We used the 40-item APDQ to assess stigmatising attitudes towards clients with a PD.
2. Helping Alliance QuestionnaireTherapist Version (HAQ-II; Luborsky et al., 1996). We used the 19-item HAQ-II to measure the quality of the therapeutic relationship from the member of staffs perspective.
3. The Social Distancing Scale (SDS; Link, 1987). We modified the 7-item SDS by replacing all references to mental illness with personality disorder, and used the revised version to assess the extent to which staff distanced themselves from their PD clients.
All outcomes were measured at the same time points: baseline, post-intervention and at 6-month follow-up.
Secondary outcome measures
1. Maslachs Burnout Inventory (MBI; Maslach, Jackson, & Leiter, 1997) We used the 22-item MBI to measure staff burnout. Higher scores indicate higher burnout.
2. General Health Questionnaire (GHQ; Goldberg, 1997). The GHQ measures psychological distress were assessed using the 22-item scale, with higher scores indicating higher distress.
3. Valued Living Questionnaire (VLQ; Wilson, 2008). The VLQ assesses the degree to which respondents actions are consistent with their values. Lower scores indicate less discrepancy between values and actions.
1. Marlowe-Crowne Questionnaire (MCQ; Marlow-Crowne, 1964). The 8-item was used to assess the degree to which staff tended to act in socially desirable ways in their lives. In addition,
2. Credibility and Expectancy Questionnaire (CEQ; Devilly & Borkovec, 2000). The 6-item CEQ was administered before training to ascertain whether participants had any preconceived perceptions about the training.
All outcomes were measured at the same time points: baseline, post-intervention and at 6-month follow-up. The 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 200 participants
Total final enrolment
Participant exclusion criteria
Exclusion criteria included:
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
The University Department of Mental Health
Dorset HealthCare University NHS Foundation Trust (UK)
11 Shelley Road
+44 1202 277000
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 https://pubmed.ncbi.nlm.nih.gov/24963830/ (added 03/06/2020)