Borderline personality disorder : studies of suffering, quality of life and dialectical behavioural therapy

Abstract

The aims of the present thesis were: 1. To investigate how women patients with borderline personality disorder (BPD) perceive their suffering, quality of life and encounter with psychiatric care (paper II and III). 2. To describe BPD patients' and psychiatric professionals' perceptions of receiving and giving dialectical behavioural therapy, DBT (paper I). 3. To investigate how starting treatment of BPD patients with DBT affected the psychiatric professionals' experience of occupational stress and professional burnout (paper IV).

Due to the different types of research questions the thesis deal with, it uses a mix of qualitative and quantitative research methods. In two of the studies (II and III) the main methods were qualitative. Data from free format questionnaires, individual- as well as group interviews and biographical texts, were analysed with content analysis or a hermeneutic approach. In study Ill the methods were quantitative. A summated rating scale measuring health-related quality-of-life (HRQOL) was analysed with descriptive and inferential statistics. In study IV quantitative and qualitative methods were combined. Two burnout inventories were analysed with descriptive and inferential statistics, and data from free format questionnaires and group interviews were analysed with qualitative content analysis.

The main findings were that BPD patients suffer to an extent that is often unendurable, leading to deliberate self-harm (DSH) and suicide attempts to relieve suffering or just try to get away from it all (paper II). In study Ill the BPD patients showed significantly poorer quality-of-life (even physical) than normal population controls of comparable age. The suffering, suicide attempts, DSH and poor quality-of-life (paper II and III) put the patients in a position of voluntarily or involuntarily getting involved with psychiatric care. Study II revealed a double role of the psychiatric care in relation to BPD patients. On one hand, psychiatric professionals can add to the suffering by not being understanding and being disrespectful, on the other hand they can be helpful and relieve suffering by being respectful, understanding and validating.

There was a clear relationship between the patients' experience of validation and the experience of being helped. DBT seems (both from the patients' and psychiatric professionals' perspective) to be a treatment with a philosophy, content and structure being able to relieve BPD patients suffering and helping them to independence and a bearable life-situation (paper I). Study IV confirms previous findings that psychiatric professionals experience treatment of self-harming patients as profoundly stressful. DBT was seen as stressful in terms of learning demands, but decreased the experience of stress in the actual treatment of the patients due to its high degree of structure and specific techniques. The DBT team-work and supervision were felt to be supportive, as was one particular facet of DBT, namely mindfulness training which some professionals felt also improved their handling of other work stressors not related to DBT. This finding also corresponds to BPD patients' perceptions of the mindfulness component in DBT, which they reported as particularly helpful (paper I).

It should be noted that the patient samples in the thesis may be considered as a "worse off" subgroup among BPD patients, as they usually entered special treatment programs after a period of escalating symptoms, which standard psychiatric services had had difficulties handling. The rather small number of participants and the lack of equivalent and/or concurrent control groups in the quantitative studies limit the generalization of the results.