Video feedback for young babies and maternal perinatal mental illness: intervention adaptation, feasibility and acceptability.

AIMS/BACKGROUND: We aimed to adapt, pilot and explore experiences of receiving and delivering the video feedback intervention for positive parenting (VIPP) for 2 to 6 month old babies, mothers experiencing moderate to severe perinatal mental health difficulties and perinatal mental health clinicians. DESIGN/METHODS: The VIPP intervention was adapted to include developmentally appropriate activities and developmental psychoeducation for 2 to 6 month olds, alongside psychoeducation on emotion regulation, and then piloted in 14 mothers experiencing moderate to severe perinatal mental health difficulties (registration ISRCTN64237883). Observational and self-reported pre-post outcome data on parenting and parent-infant mental health was collected, and post-intervention qualitative interviews were conducted with participating mothers and clinicians. RESULTS: Consent (67%), intervention completion (79%) and follow-up rates (93%) were high. Effect sizes on pre-post outcome measures indicated large improvements in parenting confidence and perceptions of the parent-infant relationship, and a medium-size improvement in maternal sensitivity. In qualitative interviews, clinicians and mothers described how mothers' initial anxieties about being filmed were allayed through receiving positive and strengths-focussed feedback, boosting their self-confidence, and that the video feedback facilitated identification of young babies' subtle behavioural cues and moments of mother-infant connection. Streamlining the information provided on maternal emotion regulation, and allowing increased use of clinical judgement to tailor intervention delivery, were suggested to optimise intervention feasibility and acceptability. CONCLUSION: It is feasible and acceptable to implement VIPP with very young babies and their mothers experiencing perinatal mental health difficulties. A fully powered randomised controlled trial is required to establish intervention efficacy.

Severe COVID anxiety among adults in the United Kingdom: cohort study and nested feasibility trial.

BACKGROUND: People with severe COVID anxiety have poor mental health and impaired functioning, but the course of severe COVID anxiety is unknown and the quality of evidence on the acceptability and impact of psychological interventions is low. METHODS: A quantitative cohort study with a nested feasibility trial. Potential participants aged 18 and over, living in the UK with severe COVID anxiety, were recruited online and from primary care services. We examined levels of COVID anxiety in the six months after recruitment, and factors that influenced this, using linear regression. Those scoring above 20 on the short Health Anxiety Inventory were invited to participate in a feasibility trial of remotely delivered Cognitive Behavioural Therapy for Health Anxiety (CBT-HA). Exclusion criteria were recent COVID-19, current self-isolation, or current receipt of psychological treatment. Key outcomes for the feasibility trial were the level of uptake of CBT-HA and the rate of follow-up. RESULTS: 204 (70.2%) of 285 people who took part in the cohort study completed the six month follow-up, for whom levels of COVID anxiety fell from 12.4 at baseline to 6.8 at six months (difference = -5.5, 95% CI = -6.0 to -4.9). Reductions in COVID anxiety were lower among older people, those living with a vulnerable person, those with lower baseline COVID anxiety, and those with higher levels of generalised anxiety and health anxiety at baseline. 36 (90%) of 40 participants enrolled in the nested feasibility trial were followed up at six months. 17 (80.9%) of 21 people in the active arm of the trial received four or more sessions of CBT-HA. We found improved mental health and social functioning among those in the active, but not the control arm of the trial (Mean difference in total score on the Work and Social Adjustment Scale between baseline and follow up, was 9.7 (95% CI = 5.8-13.6) among those in the active, and 1.0 (95% C.I. = -4.6 to 6.6) among those in the control arm of the trial. CONCLUSIONS: While the mental health of people with severe COVID anxiety appears to improve over time, many continue to experience high levels of anxiety and poor social functioning. Health anxiety is highly prevalent among people with severe COVID anxiety and may provide a target for psychological treatment. TRIAL REGISTRATION: Retrospectively registered at ISRCTN14973494 on 09/09/2021.

Crisis and acute mental health care for people who have been given a diagnosis of a 'personality disorder': a systematic review.

BACKGROUND: People who have been given a diagnosis of a 'personality disorder' need access to good quality mental healthcare when in crisis, but the evidence underpinning crisis services for this group is limited. We synthesised quantitative studies reporting outcomes for people with a 'personality disorder' diagnosis using crisis and acute mental health services. METHODS: We searched OVID Medline, PsycInfo, PsycExtra, Web of Science, HMIC, CINAHL Plus, Clinical Trials and Cochrane CENTRAL for randomised controlled trials (RCTs) and observational studies that reported at least one clinical or social outcome following use of crisis and acute care for people given a 'personality disorder' diagnosis. We performed a narrative synthesis of evidence for each model of care found. RESULTS: We screened 16,953 records resulting in 35 studies included in the review. Studies were published between 1987-2022 and conducted in 13 countries. Six studies were RCTs, the remainder were non randomised controlled studies or cohort studies reporting change over time. Studies were found reporting outcomes for crisis teams, acute hospital admission, acute day units, brief admission, crisis-focused psychotherapies in a number of settings, Mother and Baby units, an early intervention service and joint crisis planning. The evidence for all models of care except brief admission and outpatient-based psychotherapies was assessed as low or very low certainty. CONCLUSION: The literature found was sparse and of low quality. There were no high-quality studies that investigated outcomes following use of crisis team or hospital admission for this group. Studies investigating crisis-focused psychological interventions showed potentially promising results.

The association of severe COVID anxiety with poor social functioning, quality of life, and protective behaviours among adults in United Kingdom: a cross-sectional study.

BACKGROUND: Anxiety about COVID-19 is common. For most people this is an appropriate response to the loss of livelihoods and loved-ones, disruptions to social networks, and uncertainty about the future. However, for others these anxieties relate to contracting the virus itself, a phenomenon termed COVID anxiety. Little is known about the characteristics of people with severe COVID anxiety or the impact it has on their daily lives. METHODS: We conducted a two-phase cross-sectional survey of people aged 18 or over who were living in United Kingdom, self-identified as anxious about COVID-19, and had a score of ≥9 on the Coronavirus Anxiety Scale. We recruited participants nationally through online adverts and locally via primary care services in London. Data on demographic and clinical factors were used in multiple regression modelling to examine the greatest contributors to functional impairment, poor health-related quality of life and protective behaviours in this sample of individuals with severe COVID anxiety. RESULTS: We recruited 306 people with severe COVID anxiety between January and September 2021. Most were female (n = 246, 81.2%); they had a median age of 41 (range = 18-83). The majority of participants also had generalised anxiety (n = 270, 91.5%), depression (n = 247, 85.5%), and a quarter (n = 79, 26.3%) reported a physical health condition which put them at increased risk of hospitalisation with COVID-19. Half had severe social dysfunction (n = 151, 52.4%). One in ten reported never leaving their home, one in three washed all items brought into their house, one in five washed their hands constantly, and one in five of those with children reported not sending them to school because of fears of COVID-19. Increasing co-morbid depressive symptoms best explained functional impairment and poor quality of life after controlling for other factors. CONCLUSIONS: This study highlights the high degree of co-occuring mental health problems, and the extent of functional impairment and poor health-related quality of life among people with severe COVID anxiety. Further research is needed to establish the course of severe COVID anxiety as the pandemic progresses, and steps that can be taken to support people who experience this distress.

Predictors of Post-Traumatic Growth in a Sample of United Kingdom Mental and Community Healthcare Workers during the COVID-19 Pandemic.

Experiences of adversity can generate positive psychological effects alongside negative impacts. Little research to date has evaluated predictors of post-traumatic growth in mental or community healthcare workers during the COVID-19 pandemic. Following a survey of 854 community and mental healthcare staff in the United Kingdom in July to September 2020, multiple linear regression was used to determine the association between hypothesised risk and protective factors (personal, organisational and environmental variables) and total scores on the Post-traumatic Growth Inventory-Short Version. Positive self-reflection activities, black and minority ethnic status, developing new healthcare knowledge and skills, connecting with friends and family, feeling supported by senior management, feeling supported by the UK people, and anxiety about the personal and work-related consequences of COVID-19 each significantly independently predicted greater post-traumatic growth. Working in a clinical role and in mental healthcare or community physical healthcare predicted lower post-traumatic growth. Our research supports the value of taking an organisational growth-focused approach to occupational health during times of adversity, by supporting staff to embrace opportunities for personal growth. Valuing staff's cultural and religious identity and encouraging self-reflective activities, such as mindfulness and meditation, may help to promote post-traumatic growth.

Mother and clinician experiences of a trial of a video feedback parent-infant intervention for mothers experiencing difficulties consistent with 'personality disorder': A qualitative interview study.

OBJECTIVES: We explored mothers' and clinicians' experiences of a video feedback intervention adapted for perinatal 'personality disorder' (VIPP-PMH) and the acceptability of a randomised controlled trial (RCT) examining its effectiveness. DESIGN: In-depth qualitative interviews with participants from a two-phase feasibility study of the VIPP-PMH intervention. Participants were mothers experiencing enduring difficulties in managing emotions and relationships, consistent with a 'personality disorder', and their 6- to 36-month-old children. METHODS: Forty-four qualitative interviews were conducted, including all nine mothers receiving VIPP-PMH during the pilot phase, 25 of the 34 mothers participating in the RCT (14 allocated to the VIPP-PMH arm and 9 from the control arm), 11 of the 12 clinicians delivering VIPP-PMH and one researcher. Interview data were thematically analysed. RESULTS: Mothers described feeling motivated to take part in the research and understood the need for randomisation. Research visits were largely experienced positively, with some suggestions for improvement in questionnaire timing and accessibility. Almost all mothers initially felt anxious about being filmed, but reported positive experiences of the intervention, particularly valuing its non-judgemental, positive and child-focussed nature, their supportive relationship with the therapist and the insights they gained on their child. CONCLUSIONS: The findings indicate the likely feasibility and acceptability of undertaking a future definitive RCT of the VIPP-PMH intervention in this population. In designing a future trial, a positive and non-judgemental therapeutic relationship will be important to allay mothers' anxieties about being filmed, and careful consideration should be given to the timing and accessibility of questionnaires used.

A Systematic Review of Training Interventions for Emergency Department Providers and Psychosocial Interventions delivered by Emergency Department Providers for Patients who self-harm.

OBJECTIVES: People who self-harm frequently present to the emergency department (ED) and are treated by generalist healthcare staff with no specialist mental health training. We systematically reviewed (i) training interventions for generalist ED providers and (ii) psychosocial interventions delivered predominantly by generalist ED providers for people who self-harm. METHOD: Five databases were searched for studies reporting on training interventions for generalist ED staff (at least 50% of the sample needed to be generalist ED staff) or psychosocial interventions for people who self-harm delivered predominantly by generalist ED staff. No limitations were placed regarding study design/country. Narrative synthesis was conducted. RESULTS: Fifteen studies from high-income countries were included. Nine studies of moderate methodological quality evaluated training for generalist ED providers (n = 1587). Six studies of good methodological quality evaluated psychosocial interventions for adults who self-harm (n = 3133). Only one randomized controlled trial was identified. Training was linked with pre-post improvements in staff knowledge, and less consistently with improvement in skills, attitudes, and confidence. Evidence on patient outcomes was lacking. Patient-level interventions involving common suicide prevention strategies-safety planning and follow-up contact-were consistently linked to pre-post reductions in suicide attempts. Effects on treatment engagement and psychiatric admissions were unclear. CONCLUSIONS: There is a clear need for further RCTs to improve the evidence base for ED generalist providers managing patients with self-harm. Evidence supports potential benefits of training for improving staff knowledge, attitudes, and skills, and of safety planning and follow-up contact for reducing repeat suicide attempts. HIGHLIGHTSMore RCTs are needed to improve the evidence base for ED providers managing self-harmSafety planning and follow up contacts are linked to reductions in repeat suicide attemptsFuture research should investigate the impact of staff training on patient outcomes.

Video feedback parent-infant intervention for mothers experiencing enduring difficulties in managing emotions and relationships: A randomised controlled feasibility trial.

OBJECTIVES: Parents experiencing mental health difficulties consistent with "personality disorder", often related to a history of complex trauma, may face increased challenges in parent-child relationships and child socioemotional development. There are no published randomised controlled trials (RCTs) evaluating perinatal parent-child interventions for this population. We evaluated the feasibility and acceptability of undertaking an RCT of the video feedback intervention for positive parenting adapted for perinatal mental health (VIPP-PMH). DESIGN: Feasibility study incorporating a pilot RCT. METHODS: Mothers with enduring difficulties in managing emotions and relationships, consistent with a "personality disorder", and their 6- to 36-month old infants were randomly allocated to receive six sessions of VIPP-PMH (n = 20) or usual care alone (n = 14). RESULTS: 76% of eligible mothers consented to participate. Intervention uptake and completion rates were 95% (≥1 VIPP-PMH session) and 70% (6 sessions), respectively. Follow-up rates were 85% at month 5 and 65% at month 8 post-baseline. Blinded observer-ratings of maternal sensitivity in parent-child interaction favoured the intervention group at month 5 (RR = 1.94, 95% CI 0.67-5.63) and month 8 (RR = 1.91, 95% CI 0.68-5.33). Small changes over time in self-rated parenting confidence and stress favoured the intervention group. There were no clear intervention effects on maternal non-intrusiveness or mental health, or on child behaviour problems, emotional functioning, or self-regulation. CONCLUSIONS: An RCT of VIPP-PMH is feasible and acceptable to implement with mothers experiencing difficulties consistent with perinatal "personality disorder". A fully powered definitive RCT should be undertaken.

Patient experiences of therapy for borderline personality disorder: Commonalities and differences between dialectical behaviour therapy and mentalization-based therapy and relation to outcomes.

OBJECTIVES: Dialectical behaviour therapy (DBT) and mentalization-based therapy (MBT) are widely used evidence-based psychological treatments for borderline personality disorder (BPD). The study aimed to establish evidence on common and unique, and helpful and unhelpful, treatment processes. DESIGN: Mixed-methods. METHODS: In-depth qualitative interview data on patient experiences during treatment were combined with quantitative outcome measures in 73 patients diagnosed with a personality disorder and receiving DBT or MBT. RESULTS: Across both DBT and MBT, accounts of learning not to react impulsively, learning to question one's thoughts and assumptions, learning to communicate more effectively, and exposure to painful emotions that may previously have been avoided were each associated with less baseline-adjusted self-harm at the end of treatment. Difficulties in interacting with other group members were more likely to be described by patients receiving MBT than DBT, whilst difficulties in the therapeutic relationship were equally common. Both of these types of difficult experience were associated with higher baseline-adjusted levels of BPD traits and emotional dysregulation, at the end of the 12-month study period. CONCLUSIONS: The findings identify novel evidence of common therapeutic processes across DBT and MBT that may help to reduce self-harm. The findings also highlight the potential iatrogenic effect of difficulties in the alliance with therapists or with other group members. This underscores the importance of listening to patients' voices about what they are finding difficult during therapy and working to address these relational challenges, so that the patient is able to progress and make best use of the treatment. PRACTITIONER POINTS: Regardless of whether dialectical behaviour therapy or mentalization based therapy is used, helping service-users to learn not to react impulsively, to question their thoughts and assumptions, and to communicate more effectively, may be beneficial for reducing self-harm. Across both types of therapy, exposure to painful emotions is a difficult experience for service-users, but may also be beneficial for reducing self-harm, if carefully managed. Whilst service-users' experiences across both types of therapy have much in common, accounts of mentalization based therapy stand out in more often describing both helpful and unhelpful experiences of interactions with therapy group members. Service-users across both types of therapy report the benefits of learning intrapersonal mentalization skills, whilst recipients of mentalization based therapy uniquely extend this to learning interpersonal mentalization. Ruptures in the therapeutic alliance, and distressing interactions with group members, may be iatrogenic and must be carefully managed.

Exploring the prevalence of personality disorder and the feasibility of using the SAPAS as a screening tool for personality disorder in an emergency department in India.

BACKGROUND: Personality disorders (PD) lead to frequent emergency department (ED) visits. Existing studies have evaluated high-risk ED populations in Western settings. PD screening tools, such as the Standardized Assessment of Personality - Abbreviated Scale (SAPAS), have thus far only been validated in Western populations. AIMS: This study aimed to establish the screened prevalence of PD, and to evaluate the performance of the SAPAS as a screening tool within an ED setting in India. METHODS: The study took place in the ED of a private multi-speciality hospital in Kolkata, India. All attendees were approached during two days per week over three months, except those who were medically unfit to participate. The SAPAS and the International Personality Disorder Examination (IPDE) were translated into Bengali and then used as screening tools for PD and as the reference standard for PD diagnosis. RESULTS: Out of 120 ED attendees approached, 97 participated (48 men and 49 women), of whom 24% met the criteria for a diagnosis of PD. A cut-off score of 4 on the SAPAS provided the best trade-off between sensitivity and specificity for detecting PD. CONCLUSION: The prevalence of PD was similar to Western samples, and the SAPAS showed promise for use in a non-Western setting.

Severe COVID-19 anxiety among adults in the UK: protocol for a cohort study and nested feasibility trial of modified cognitive-behavioural therapy for health anxiety.

INTRODUCTION: Some people are so anxious about COVID-19 that it impairs their functioning. However, little is known about the course of severe COVID-19 anxiety or what can be done to help people who experience it. METHODS AND ANALYSIS: Cohort study with a nested feasibility trial with follow-up at 3 and 6 months. We recruited 306 people who were aged 18 and over, lived in the UK and had severe COVID-19 anxiety (indicated by a score of 9 or more on the Coronavirus Anxiety Scale (CAS)). To take part in the nested feasibility trial, participants also had to have a score of 20 or more on the Short Health Anxiety Inventory. We excluded people from the trial if they had had COVID-19 within the previous 4 weeks, if they were currently self-isolating or if they were already receiving psychological treatment.We publicised the study nationally through adverts, social media and posts on message boards. We also recruited participants via clinicians working in primary and secondary care NHS services in London. All those in the active arm will be offered 5-10 sessions of remotely delivered modified cognitive-behavioural therapy for health anxiety (CBT-HA). We will examine the proportion of participants who remain above threshold on the CAS at 3 and 6 months and factors that influence levels of COVID-19 anxiety over 6 months using mixed effects logistic regression. The key feasibility metrics for the nested trial are the level of uptake of CBT-HA and the rate of follow-up. ETHICS AND DISSEMINATION: Approved by Leicester Central Research Ethics Committee (reference: 20/EM/0238). The results of the study will be published in peer-reviewed scientific journals. TRIAL REGISTRATION NUMBER: ISRCTN14973494.

Older adult experience of care and staffing on hospital and community wards: a cross-sectional study.

BACKGROUND: Recent major concerns about the quality of healthcare delivered to older adults have been linked to inadequate staffing and a lack of patient-centred care. Patient experience is a key component of quality care - yet there has been little research on whether and how staffing levels and staffing types affect satisfaction amongst older adult hospital inpatients. This study aimed to evaluate the association between registered nurse and healthcare assistant staffing levels and satisfaction with care amongst older adult hospital inpatients, and to test whether any positive effect of higher staffing levels is mediated by staff feeling they have more time to care for patients. METHODS: Survey data from 4928 inpatients aged 65 years and older and 2237 medical and nursing staff from 123 acute and community medical wards in England, United Kingdom (UK) was collected through the Royal College of Psychiatrist's Elder Care Quality Mark. The cross-sectional association between staffing ratios and older adult patient satisfaction, and mediation by staff perceived time to care, was evaluated using multi-level modelling, adjusted for ward type and with a random effect for ward identity. RESULTS: Higher numbers of patients per healthcare assistant were associated with poorer patient satisfaction (adjusted ß = - 0.32, 95% CI - 0.55 to 0.10, p < 0.01), and this was found to be partially mediated by all ward staff reporting less time to care for patients (adjusted ß = - 0.10, bias-corrected 95% CI - 1.16 to - 0.02). By contrast, in both unadjusted and adjusted models, the number of patients per registered nurse was not associated with patient satisfaction. CONCLUSIONS: Older adult hospital patients may particularly value the type of care provided by healthcare assistants, such as basic personal care and supportive communication. Additionally, higher availability of healthcare assistants may contribute to all ward staff feeling more able to spend time with patients. However, high availability of registered nurses has been shown in other research to be vital for ensuring quality and safety of patient care. Future research should seek to identify the ideal balance of registered nurses and healthcare assistants for optimising a range of outcomes amongst older adult patients.

A Systematic Review and Meta-Analysis of Personality Disorder Prevalence and Patient Outcomes in Emergency Departments.

The objectives of this study were to perform a systematic review and meta-analysis of studies reporting prevalence of personality disorders (PDs) in emergency departments (EDs) and evaluate the effect of comorbid PDs on clinical outcomes. A systematic search of five databases along with manual searching and expert consultation was performed. A quality appraisal was conducted. A total of 29 articles were included. Prevalence of PDs in ED attendees varied depending on presenting complaint, Q(4) = 577.5, p < .01, with meta-analytic prevalence rates of suicide and self-harm at 35% and 22%, respectively. The assessment method had a significant effect on prevalence rates, Q(3) = 17.36, p < .01. Comorbid PD was a risk factor for repeating presenting complaint, subsequent ED return, and hospitalization. Better identification of PDs using screening tools in EDs could improve patient management and clinical outcomes. Future research should focus on PD prevalence in unselected ED populations using validated diagnostic interviews.

Factors influencing use of community treatment orders and quality of care that people receive: results of a national survey in England and Wales.

Aims and methodWe conducted a secondary analysis of data from the National Audit of Psychosis to identify factors associated with use of community treatment orders (CTOs) and assess the quality of care that people on CTOs receive. RESULTS: Between 1.1 and 20.2% of patients in each trust were being treated on a CTO. Male gender, younger age, greater use of in-patient services, coexisting substance misuse and problems with cognition predicted use of CTOs. Patients on CTOs were more likely to be screened for physical health, have a current care plan, be given contact details for crisis support, and be offered cognitive-behavioural therapy.Clinical implicationsCTOs appear to be used as a framework for delivering higher-quality care to people with more complex needs. High levels of variation in the use of CTOs indicate a need for better evidence about the effects of this approach to patient care.Declaration of interestNone.

A systematic review of interventions aimed at improving the cardiovascular health of people diagnosed with personality disorders.

PURPOSE: People with personality disorders have significantly reduced life expectancy and increased rates of cardiovascular disease compared to members of the general population. Given that more people die annually of cardiovascular disease across the globe than from any other cause, it is important to identify the evidence for interventions aimed at improving cardiovascular health among people with personality disorders. METHODS: Systematic literature review. PsycINFO, MEDLINE and EMBASE were searched using NICE Healthcare Databases, as well as CENTRAL and trial registries. We sought to identify randomised controlled trials of interventions pertaining to adults with a primary diagnosis of personality disorder, where the primary outcome measure was cardiovascular health before and after the intervention. RESULTS: A total of 1740 records were identified and screened by two independent reviewers. No papers meeting the inclusion criteria were identified. CONCLUSIONS: This systematic review did not identify any randomised controlled trials testing interventions aimed at improving the cardiovascular health of people with personality disorders. Research in this area could have important public health implications, spanning the fields of psychiatry and general medicine.

Processes of recovery through routine or specialist treatment for borderline personality disorder (BPD): a qualitative study.

Background: Recovery processes in borderline personality disorder (BPD) are poorly understood.Aims: This study explored how recovery in BPD occurs through routine or specialist treatment, as perceived by service users (SUs) and therapists.Methods: SUs were recruited from two specialist BPD services, three community mental health teams, and one psychological therapies service. Semi-structured interviews were conducted with 48 SUs and 15 therapists. The "framework" approach was used to analyse the data.Results: The findings were organized into two domains of themes. The first domain described three parallel processes that constituted SUs' recovery journey: fighting ambivalence and committing to taking action; moving from shame to self-acceptance and compassion; and moving from distrust and defensiveness to opening up to others. The second domain described four therapeutic challenges that needed to be addressed to support this journey: balancing self-exploration and finding solutions; balancing structure and flexibility; confronting interpersonal difficulties and practicing new ways of relating; and balancing support and independence.Conclusions: Therapies facilitating the identified processes may promote recovery. The recovery processes and therapeutic challenges identified in this study could provide a framework to guide future research.

Dialectical behaviour therapy v. mentalisation-based therapy for borderline personality disorder.

BACKGROUND: Dialectical behaviour therapy (DBT) and mentalisation-based therapy (MBT) are both widely used evidence-based treatments for borderline personality disorder (BPD), yet a head-to-head comparison of outcomes has never been conducted. The present study therefore aimed to compare the clinical outcomes of DBT v. MBT in patients with BPD. METHODS: A non-randomised comparison of clinical outcomes in N = 90 patients with BPD receiving either DBT or MBT over a 12-month period. RESULTS: After adjusting for potentially confounding differences between participants, participants receiving DBT reported a significantly steeper decline over time in incidents of self-harm (adjusted IRR = 0.93, 95% CI 0.87-0.99, p = 0.02) and in emotional dysregulation (adjusted ß = -1.94, 95% CI -3.37 to -0.51, p < 0.01) than participants receiving MBT. Differences in treatment dropout and use of crisis services were no longer significant after adjusting for confounding, and there were no significant differences in BPD symptoms or interpersonal problems. CONCLUSIONS: Within this sample of people using specialist personality disorder treatment services, reductions in self-harm and improvements in emotional regulation at 12 months were greater amongst those receiving DBT than amongst those receiving MBT. Experimental studies assessing outcomes beyond 12 months are needed to examine whether these findings represent differences in the clinical effectiveness of these therapies.

Staff and patient perspectives on therapeutic engagement during one-to-one observation.

WHAT IS KNOWN ON THE SUBJECT?: One-to-one observation uses continuous staff observation to safeguard patients judged likely to harm themselves or others. Policies increasingly mandate that staff engage therapeutically with patients during one-to-one observation. Yet not enough is known about factors facilitating or impeding such therapeutic engagement. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This study enriches existing literature on one-to-one observation through integrating the perspectives of staff of different levels of qualification, and patients of different diagnostic and risk profiles. Whilst previous research has highlighted the occurrence of counter-therapeutic staff-patient interactions, integration of patient and staff perspectives in the current study has demonstrated that patient and staff often attribute the causes differently, with each apportioning blame to the other, leading both parties to feel misunderstood, and staff lack confidence to overcome these challenges. A novel finding was that rapport-building via simple demonstrations of compassion and conversations about everyday things, was viewed as an essential prerequisite to encouraging patients to open up about their experiences of emotional distress, whilst implementation of techniques drawn from psychological interventions was viewed as less important than staff's core relational skills. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Therapeutic engagement during observation can enhance its risk management aims, providing thought is given to understanding and negotiating complex dynamics between staff and patients. Supervision for staff conducting observations should focus on building rapport in preference to emphasizing psychological intervention (e.g. DBT), and should enable staff to reflect on better understanding and managing their own emotions towards "hard-to-engage" patients. ABSTRACT: Introduction Policies increasingly focus on staff-patient interactions during one-to-one psychiatric nursing observations as an opportunity for therapeutic engagement - yet if and how this is feasible is unknown. Aim This study aimed to integrate staff and patient perspectives to determine what factors facilitate or impede therapeutic engagement during one-to-one observation. Method Thematic analysis of qualitative interviews with 31 psychiatric inpatient staff at different levels of seniority and 28 inpatients spanning a range of diagnoses and risk profiles. Results Negative experiences of observation were characterized by a reciprocal dynamic where both patients and staff withdrew from interactions, having felt the other did not want to engage with them. Staff and patients agreed that these difficulties could be overcome when staff showed patients that they cared, gradually building trust through simple demonstrations of compassion and 'normalizing' conversation about everyday things. This approach helped patients to feel safe enough to open up about their distress, which in turn helped staff to better understand their experiences and work with them to find solutions. Implications for practice Engagement during observation could be facilitated if staff receive more supervision in understanding difficult dynamics that impede rapport-building and in managing their emotions towards patients they experience as "hard-to-engage".

Posttraumatic Stress Disorder in Patients With Borderline Personality Disorder: Treatment Outcomes and Mediators.

Posttraumatic stress disorder (PTSD) is highly comorbid with personality disorder (PD). We evaluated whether comorbid PTSD has a negative effect on patients' ability to benefit from evidence-based psychological treatments for PD and tested potential mediators of any effect. The effect of PTSD on self-harm and borderline PD symptoms was evaluated in 90 patients with borderline PD who were receiving dialectical behavior therapy or mentalization-based therapy. Self-report and interview measures were administered every 3 months over a 12-month period. Three-quarters of participants met criteria for PTSD. In the 12 months after beginning treatment, participants with PTSD did not engage in self-harm more often or present with more severe borderline PD symptoms. However, a higher level of PTSD symptom severity at baseline was associated with more frequent self-harm during follow-up, incidence rate ratio = 1.03, 95% CI [1.01, 1.06], p = .005. Participants whose PTSD did not improve or worsened were more likely to still self-harm, odds ratio (OR) = 0.91, 95 % CI [0.85, 0.97], p = .004, and report more severe borderline PD symptoms, b = 0.53, 95% CI [0.34, 0.73], p < .001, at the end of 12 months. The negative effects of PTSD symptoms remained significant after adjusting for potential confounders and were partially mediated by high ongoing levels of emotional dysregulation, indirect effect b = 0.32, 95% CI [0.19, 0.50]. These findings identify subgroups at risk of poorer outcomes from evidence-based psychological treatments for PD and support the idea that treating PTSD may improve outcomes.