Can deficits in social problem-solving in people with personality disorder be reversed?

Research evidence is beginning to emerge that social problem-solvingcan improve the social functioning of people with personalitydisorder. This approach is particularly important because itmay be relatively easy to train healthcare workers to deliverthis intervention. However, the costs and cost-effectivenessof social problem-solving need to be established if it is tobe made more widely available.

INTRODUCTION

TOP

INTRODUCTION

Over the past 50 years findings from many experimental studieshave established the effectiveness of pharmacological and psychosocial interventions for people with a range of mental health problems.In contrast, the evidence base for interventions for peoplewith personality disorder remains poor. Most research intothe impact of such interventions has focused on psychosocialtreatment of borderline personality disorder. There is little evidence to guide the management of people with other formsof personality disorder. Even in relation to the borderlinetype, few high-quality trials have been conducted. A recentsystematic review of psychological therapies for people withborderline personality disorder concluded that: ‘studiesare too few and too small to inspire full confidence in theirresults’ (Binks et al, 2006). Residential treatmentsfor people with personality disorder have been evaluated (Lees et al, 1999),but such services can inevitably only be offered to – and may only be suitable for – a minority of all thosewith this disorder.

CONSEQUENCES OF A WEAK EVIDENCE BASE

TOP

CONSEQUENCES OF A WEAK...

The relative absence of research into community-based interventionsfor people with personality disorder is matched by a paucityof services for such people (National Institute for Mental Health in England, 2003).Various reasons have been proposed to explain this state ofaffairs. It has been argued that interpersonal problems experiencedby people with personality disorder make it unrewarding for healthcare professionals to work with this group (Hinshelwood, 1999).Previous surveys have demonstrated professional ambivalenceto working with people with personality disorders: in a recentBritish study examining the views of general practitionersand psychiatrists about which patients should be referred fortreatment in secondary care, general practitioners were less likely to state that people with anxiety, depression and mostother mental disorders needed to be referred to secondary carethan were psychiatrists; in contrast, psychiatrists were lesslikely than general practitioners to state that people withpersonality disorders should be referred to secondary care (Walker et al, 2005).

An alternative explanation for the reluctance of psychiatristsand other mental health professionals to work with people withpersonality disorders is that they feel that they are not equippedto provide these people with satisfactory treatment. With theirfocus on monitoring mental states, psychotropic medicationand powers of compulsory treatment at times of crisis, generalmental health services were certainly not designed to meet theneeds of people with personality disorders. Although such peoplemay be referred to psychotherapy services, the limited availabilityof this resource, together with the relative lack of evidence,means that healthcare workers may be reluctant to refer peoplewith a primary diagnosis of personality disorder. Given thiscontext, findings from a randomised trial of social problem-solving therapy for people with personality disorder by Huband et al (2007; this issue) in this month’s journal are to bewelcomed.

SOCIAL PROBLEM-SOLVING THERAPY

TOP

SOCIAL PROBLEM-SOLVING THERAPY

Various attempts have been made to help people improve theirsocial problem-solving skills. Initial studies investigatingproblem-solving therapy for people who self-harm showed littleeffect (Gibbons et al, 1978). Since then, more structuredapproaches to helping people manage social problems have beendeveloped which synthesise cognitive–behavioural techniquesand elements of social skills training. These focus on helping people identify goals and exploring how existing patterns ofthinking and behaviour affect the chances of achieving these.Patients are encouraged to develop different approaches tosolving problems, to test them out both within and outsideof sessions, and to continually review whether the solutionsthey choose help them achieve their goals (McMurran et al, 2001).Results of a non-randomised evaluation of social problem-solvingfor a group of 52 out-patients with borderline personality disorderin Iowa in the USA demonstrated improved mood and reduced self-harmingbehaviour over the course of a 20-week programme (Blum et al, 2002).

In this new study Huband and colleagues randomised people withpersonality disorder to either three sessions of psychoeducationfollowed by 16 sessions of group-based social problem-solvingtherapy, or to a waiting-list control. Two-thirds of thoseoffered the intervention attended at least eight sessions andalmost half were still in treatment at 15 weeks. Improvementsin self-rated ability to cope with social problems were greateramong those offered the intervention than among the waiting-listcontrol group. Active treatment was also associated with aslight improvement in social functioning.

As a pilot study the trial had a range of limitations, suchas a relatively short follow-up period, resulting from thelimited resources that are usually available for such studies.Interventions delivered in groups are known to result in clusteringof outcomes resulting from both therapist factors and groupdynamics. Such factors limit the power of studies and shouldbe taken into consideration when analysing the impact of complexinterventions such as this (Lee & Thompson, 2005). Improvedsocial functioning among those who received social problem-solvingtherapy is noteworthy; however, the level of improvement was small, equivalent to less than two points on the social functioningscale, and further research is needed to establish whetherthis intervention results in sustained improvements in socialfunctioning that are clinically as well as statistically significant.

Nonetheless, findings from this trial are important for severalreasons. First, it included people with a range of personalitydisorders: 41% met diagnostic criteria for borderline disorder,40% for avoidant disorder, and 14% for antisocial disorder.Nearly all previous trials have focused exclusively on thosewith a primary diagnosis of borderline disorder. This trial,together with other recent studies, is therefore important in highlighting the potential impact of outpatient treatment forpeople with a range of other personality disorders (Emmelkamp et al, 2006).

TRAINING IN INTERVENTIONS FOR PERSONALITY DISORDER

TOP

TRAINING IN INTERVENTIONS FOR...

What gives the study by Huband et al (2007) special significanceis the manner in which active treatment was delivered. Ratherthan examining the efficacy of an intervention provided byexperts in social problem-solving therapy, the study team trainedmental health professionals who had no previous experienceof delivering this intervention. Mental health workers withexperience of working with people with personality disorderswere given 2 days of training before the start of the study.

With a community prevalence of approximately 5%, it is clearthat even if specialist services for people with personalitydisorders were greatly expanded, they would not have the capacityto provide services to all those with such disorders. In additionto exploring the effectiveness of social problem-solving therapy,this trial also provides important evidence that brief trainingfor healthcare workers might be sufficient to enable non-specialiststaff to deliver psychosocial interventions to people with personalitydisorders.

Pragmatic studies which evaluate the impact of interventionsdelivered by nonspecialists may have other advantages as well.It has been a feature of the development of complex interventionsranging from home treatment to cognitive–behaviouraltherapy for psychosis that large effect sizes found when theinterventions are delivered by pioneers tend not to be found when attempts are made to replicate them. By evaluating theimpact of social problemsolving therapy delivered by peoplewith no previous experience of this treatment, the study teamhave generated outcome data that provide a better estimateof the impact the intervention might achieve in a real-worldclinical setting (Schoenwald (Schoenwald & Hoagwood, 2001).

FUTURE RESEARCH

TOP

FUTURE RESEARCH

The use of three sessions of psychoeducation prior to the deliveryof the main intervention is another noteworthy aspect of thistrial. Levels of drop-out from treatment services for peoplewith personality disorder are notoriously high. As with previousstudies, these data show that those with the greatest levelof personality disturbance are those least likely to engage in treatment. Examining ways to increase retention is thereforeimportant, and the psychoeducational approach used in thisstudy has intuitive appeal. It is not possible to work outwhether the use of psychoeducation prior to the delivery ofsocial problem-solving made a difference to drop-out rates inthis study, but this hypothesis is amenable to experimentalevaluation and should be tested.

Concerns have rightly been expressed about the gap between theevidence base for psychosocial interventions for people withpsychosis and the extent of their delivery (Rowlands, 2004).Financial constraints are the main factor responsible for this‘therapy gap’, and new psychosocial interventionswill need to demonstrate cost-effectiveness if they are tobe implemented in clinical practice. This pilot study did notdemonstrate statistically significant reductions in serviceutilisation, but an important trend towards reduced contactwith emergency medical services was seen. These findings clearly provide a basis for further investigation of this potentiallyvaluable intervention. Should such studies demonstrate thecost-effectiveness of social problem-solving, they would notonly improve the evidence base for treatment of personalitydisorder, but they might also go some way towards challenging the ambivalence that some healthcare professionals continueto have about working with people with personality disorders.

REFERENCES

TOP