The process of change in the treatment of personality disorder in a forensic inpatient setting

This thesis explores the question, what are the important change processes in the treatment of personality disorder in a male forensic inpatient setting? A number of empirically supported therapies for personality disorder stress the importance of the therapist-client relationship in the change process. Therapist-patient relationships are therefore an important focus in this thesis. However, given the lack of research into change processes in this population, the focus is not limited to the therapist-patient relationship, but also considers other relationships and other aspects of the treatment milieu. A model of change processes for this patient group is developed through a series of studies. The first study, in chapter 3, is a qualitative investigation of patients’ perceptions of the process of change and the factors involved. Twelve patients completed a semi-structured interview and the results were analysed using thematic analysis. The study concludes that the cognitive dissonance between how patients expect to be treated and how they are actually treated is an important factor in motivating them to engage in treatment. It also concludes that the therapist-patient relationship and the wider interpersonal environment are both important to therapeutic change with this population. Chapters 4 and 5 describe the process of developing an appropriate dependent outcome measure for the thesis. Social functioning was selected as the dependent outcome variable. Chapter 4 is a systematic review of social functioning measures used with people with a diagnosis of personality disorder and concludes that there is a need to develop a new self-report measure specifically for people with a diagnosis of personality disorder in inpatient settings. Chapter 5 describes the development and validation of this new measure, the Hospital Social Functioning Questionnaire (HSFQ). Fifty-four patients completed a range of measures including the HSFQ. The HSFQ shows good internal consistency, test-retest reliability and concurrent validity with other measures. It appears to measure different aspects of social functioning from the Global Assessment of Functioning (GAF), the most widely used social functioning measure, and the two measures appear to complement each other. Chapter 6 is a quantitative study using the HSFQ and a self-report measure of patients’ perceptions of therapeutic change processes to test the initial model of change developed in chapter 3. Fifty patients completed a checklist about how they had changed during treatment and the factors that had contributed to that change, as well as measures of social functioning. Self-reported levels of change were highly correlated with measures of patient functioning, though significant levels of change did not occur until the latter stages of treatment. The behaviour of therapists was particularly important throughout treatment, though participants in the final stage of therapy reported that the behaviour of other staff was as important as that of therapists, suggesting that, by this stage of treatment they are able to extend their range of supportive and therapeutic relationships. The results support a limited reparenting attachment-based model of therapeutic change. Chapter 7 is a pattern matching study that tests and refines the model of change. Ten patients completed a semi-structured interview about their interactions with their therapist. Their responses were analysed using a modified version of pattern matching to test hypotheses generated by the limited reparenting attachment-based model of change. The results support the limited reparenting model and suggest that patients’ attachment relationships with their therapists are an important change process for this population, particularly in the earlier stages of treatment. Chapter 8 presents a three-stage model of change based on the results of this thesis. On first admission, patients enter the orienting/ cognitive dissonance phase, in which they start to engage in treatment after perceiving a consistent improvement in how they are currently regarded and treated compared to how they have been regarded and treated previously, particularly in prison. Next, they enter the reparenting phase, during which their relationship with their therapist is the most important factor affecting change. Many features of the therapist-patient relationship during this phase parallel attachment processes between children and caregivers. Finally, patients enter the exploration/ generalisation phase in which they are able to explore from the secure base of their relationship with their therapist and develop supportive and therapeutic relationships with other staff members. This model provides a useful framework for working therapeutically with this patient group