Friday Factoid: Stability When Unstable: Borderline Personality Disorder May Have Elements that Change Over Time

Borderline Personality Disorder is generally perceived as an unchanging condition which has very little ebb and flow to its course. However, longitudinal data presents a different perspective when looked over a 10-year time span. The Collaborative Longitudinal Personality Disorders Study conducted research on at least 668 patients administering 5 semi-structured interviews over the course of a decade (Conway, Hopwood, Morey, & Skodol, 2018). Through analyzing these interviews, it was determined that about 45% of the individual differences in the disorder’s severity is determined by stable elements. Of these stable elements, they were associated with personality traits such as neuroticism and environmental factors such as childhood abuse. As for the time-varying elements, these factors wax and wane depending on other factors, such as substance abuse. Overall, the study shows that there are varying elements to a condition that otherwise is thought of as a trait based and stable condition.

Conway, C. C., Hopwood, C. J., Morey, L. C., & Skodol, A. E.  (2018). Borderline personality disorder is equally trait-like and state-like over ten years in adult psychiatric patients. Journal of Abnormal Psychology, 127 (6), 590-601.

Andrew Goebel, MS, LPA (Temp)
WKPIC Doctoral Intern

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Friday Factoid: Combating Stress with Mindfulness

Stress is the most significant risk factor for expenditures in healthcare (Azagba & Sharaf, 2011). Mindfulness-based (MB) interventions, specifically Mindfulness-Based Stress Reduction (MBSR) are one approach to efficiently dealing with stress (Shapiro, Astin, Bishop, & Cordova, 2005). Jon Kabat-Zinn developed MBSR at the University of Massachusetts Medical School in 1979 with the goal of helping patients with chronic pain and illness cope more effectively with their distressing symptoms (Dobkin, Irving, & Amar, 2011). Since 1979, over 24,000 individuals have completed this formal training program. The program focuses on incorporating intensive mindfulness training into daily life and has demonstrated reproducible reductions in both psychological and medical symptoms across a wide range of conditions. In many instances, these changes remain for up to four years after treatment (University of Massachusetts Medical School, 2017). MBSR research, supporting benefits of its practice, has steadily accumulated over the past thirty-seven years (Malpass et al., 2011).

References

Azagba, S., & Sharaf, M. F. (2011). The effect of job stress on smoking and alcohol consumption. Health Economics Review, 1(1), 15. doi:10.1186/2191-1991-1-15

Dobkin, P. L., Irving, J. A., & Amar, S. (2011). For whom may participation in a mindfulness-based stress reduction program be contraindicated? Mindfulness, 3(1), 44-50. doi:10.1007/s12671-011-0079-9

Malpass, A., Carel, H., Ridd, M., Shaw, A., Kessler, D., Sharp, D., Wallond, J. (2012).Transforming the perceptual situation: A meta-ethnography of qualitative work reporting patients’ experiences of mindfulness-based approaches. 60–75. https://doi.org/10.1007/s12671-011-0081-2

Shapiro, S. L., Astin, J. A., Bishop, S. R., & Cordova, M. (2005). Mindfulness-Based Stress Reduction for health care professionals: Results from a randomized trial. International Journal of Stress Management12(2), 164-176. doi:10.1037/1072-5245.12.2.164

University of Massachusetts Medical School. (2017). History of MBSR. Retrieved from http://www.umassmed.edu/cfm/mindfulness-based-programs/mbsr-courses/about-mbsr/history-of-mbsr/

Blake Palmer, MA, LPA
Doctoral Psychology Intern

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Friday Factoid: Engagement in Mindfulness-Based Interventions

Like most psychological interventions, mindfulness-based interventions cannot help when individuals fail to engage in them. A randomized clinical trial (RCT) conducted by Barkan et al. (2016) examined 100 individuals (62% female, sample mean age = 72) in a community sample of older adults. The study used four mindfulness-based stress reduction (MBSR) techniques including body scanning, informal meditation, sitting meditation, and yoga. The 60-item NEO Five-Factor Inventory-3 was used to measure dimensions of personality. In this study, 50% of the sample failed to engage in the program. The personality constructs of agreeableness and openness predicted greater use of the techniques in the MBSR program during treatment and at follow-up. The study controlled for differences in demographics such as age, sex, and education level. The study did not address barriers to participation, which can skew the interpretation of participant’s perceived acceptability of the intervention based on their willingness to engage in the treatment.

References

Barkan, T., Hoerger, M., Gallegos, A. M., Turiano, N. A., Duberstein, P. R., & Moynihan, J. A. (2016). Personality predicts utilization of mindfulness-based stress reduction during and post-intervention in a community sample of older adults. The Journal of Alternative and Complementary Medicine, 22(5), 390-395. doi:10.1089/acm.2015.0177

Blake Palmer, MA, LPA
Doctoral Psychology Intern

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Article Review: Moor, D., & Hermsen, M. (2018). Achieving happiness at care farms in the Netherlands.

Picture of a farm I took on my trip to Netherlands in 2014

A few years ago, I took a trip to Amsterdam in the Netherlands. I spent some time in the city, but I also spent several days in the countryside. The Netherlands are well known for dairy and cheese products. One of the more interesting social institutions I witnessed on my trip was the emergence of care farming. Care farming is a wonderful example of multifunctional agriculture that connects two different purviews, agriculture and health care. In pre-industrial society, agriculture and health care were closely intertwined to local and small-scale communities, but the two sectors drifted apart with the emergence of modern society.  Care farming allows individuals with disabilities to engage in farming activities to improve their health, social, and educational circumstances. Care farms are inclusive communities that allow individuals to connect with themselves, connect with nature, and foster personal growth. Moor and Hermsen’s (2018) article underscores the value of care farming as a therapeutic tool that fosters happiness.

The aim of care farms is to help provide support in a positive setting. Care farming has identified synergy between agriculture and care (Moor & Hermsen, 2018). In the Netherlands, farming has not only provided food products but emerged as a supplier of other services including recreation, energy, education, and day (care) services for elderly groups. The number of care farms in the Netherlands has increased tremendously, from 75 in 1998 to 1100 in 2017. Furthermore, statistics show that farms have become a regular provider of day care services in the Netherlands for aging adults.

The authors applied Dijksterhuis’s (2015) framework of happiness in order to study three separate care farms in the Netherlands (as cited in Moor & Hermsen, 2018). Dijksterhuis describes six components that contribute to happiness. The authors merged the happiness components of 5 and 6. Component 1 involves the hedonic treadmill whereby satisfaction is preferred over maximization of consumer goods. The hedonic treadmill symbolizes the automatic and unsatisfying nature of our tendency to consume. Component 2 involves inclusion with the right group size and connection with the transcendent. The large brain size of humans is attributed to the social nature of humans and tendency to take part in complex group structures (Moor & Hermsen, 2018). Group sizes of around 15 people allow enough intimate activity for such activities as games or playing music and foster the production of endorphins. Taking part in group activities or a greater whole leads to happiness via a shared experience or flow. Component 3 is about finding a satisfying way to spend time. Active forms of physical effort produce more happiness than passive activities. Activities that lead to a flow experience make us happy. Flow is a state whereby self-awareness and awareness of time are lost and replaced by a specific activity whereby behavior and consciousness merge. Flow leads to fulfillment. The fourth component is focusing on the right goals and preferences in determining an individual’s true needs. People want to feel included, perform based upon their potential, and prefer autonomy. Farming activities allow all three of these. The fifth and final component is training consciousness to find peace of mind. This is done by the examination of one’s own inner thought patterns and training the conscious mind to transcend space and time. Enhancing the ability to become more mindful in turn leads to an increase in happiness.

Three farms were chosen by the authors in the article (Moor & Hermsen, 2018). Each farm encompassed all five components of Dijksterhuis’s framework of happiness. The first farm was “De Ark” in the town of Bloemendaal in western Netherlands. The De Ark farm presented as inclusive community with a focus for people with and without disabilities that connects individuals to live and work together. Connection was a central theme anchored at the De Ark care farm. The Ark puts the principle into action by inviting customers to travel and harvest crops themselves, where they interact with and receive assistance from the people who work there. The customers connected with people with disabilities and relationships are formed. Often, people with disabilities are rarely in a helping role, but the De Ark farm reverses this role and allows members of the public to interact with those with various intellectual and physical disabilities.  The “Het Liessenhuus” care farm grows food exclusively for the less fortunate via food banks (Moor & Hermsen, 2018). Connection with the local community is achieved by producing and selling food. The staffs at Het Liessenhuus are recognized for their contribution to society and everyone is a “co-farmer”. Meaningful tasks are designed to ensure satisfaction at the farm for the co-farmers. Activities with inert motivational values are offered such as animals, crafts, woodworking, and gardening which allows each co-farmer to discover their passion. Passion in turn provides strength. That in turn leads to flow and enjoyable pleasure which is derived from the pursuit of meaningful goal directed intrinsic tasks. The third farm examined by the authors study included “Boerderij Ruimzicht” care farm (Moor & Hermsen, 2018). In contrast to mass production farming methods and economic profit, the Boerderij Ruimzicht farm emphasizes a biodynamic connection. The connection between the soil, plants and animals is considered equally important as producing food. Consciousness as a component of happiness is a major theme found at Ruimzicht. Thus, the farmers attempt to stay connected with all forms of life and the earth itself.

The aim of therapeutic psychological services is to improve the functionality of individuals which in turn creates a positive influence on a patient’s physical, mental, and social wellbeing. Unlike traditional healthcare and psychological services, care farming allows clients to become part of a social working community instead of a client with limitations in a traditional institutionalized setting (Moor & Hermsen, 2018). The prevalence of care farming in the Netherlands appears to have a positive impact on the elderly and those with intellectual disabilities by allowing individuals to work inclusively, experience nature, and develop intrinsic meaning. Modern society places a heavy burden on production and the acquisition of consumer goods. These social constructs place a heavy burden on the members of society whose disability limits their economic output. Thus, society has a moral obligation to the less fortunate members of society for activities that promote health and social inclusion. Care farming is a successful therapeutic tool that does both.

References
Moor, D., & Hermsen, M. (2018). Achieving happiness at care farms in the Netherlands. Journal of Social Intervention: Theory and Practice, 27(6), 4-23. https://doi.org/10.18354/jsi.545

Chris Morrison, MA, M.Ed.
WKPIC Doctoral Intern

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Article Review: El-Mallakh, P., & Findlay, J. (2015). Strategies to improve medication adherence in patients with schizophrenia: The role of support services.

Antipsychotic medications are effective in 70% to 80% of individuals with Schizophrenia, yet 50% of these individuals are medication non-adherent (El-Mallakh & Findlay, 2015). Medication adherence is associated with medication-related factors along with environmental and provider-related factors. Patient-related factors include newly starting an antipsychotic medication, disordered substance use, early onset of illness, low levels of social support, and financial constraints (inability to afford medication). Some research suggests that patient’s with higher IQs are also less adherent when compared to patients with higher levels of medication adherence (El-Mallakh & Findlay, 2015). Medication-related factors affecting medication adherence include metabolic side effects such as weight gain. Patient’s experiences in the admissions process to psychiatric hospitals was also found to be a significant predictor of medication non-adherence, along with the perception of coercion to engage in treatment and lack of collaboration with the patient in treatment. Some predictors of medication adherence in patients with Schizophrenia include initial reduction in positive symptoms when starting an antipsychotic medication, a strong therapeutic alliance, an accurate explanation of potential side effects of newly started medications, and provider collaboration with patients in the treatment process . Psychiatric medication non-adherence was associated with an increased risk of relapse into psychosis, persisting symptoms, and suicide attempts (El-Mallakh & Findlay, 2015).

El-Mallakh and Findlay (2015) found that patients with comorbid medical illnesses demonstrated increased adherence to medications for hypertension, hyperlipidemia, and diabetes was higher among patients who were adherent to antipsychotic medications. This correlation suggests that providers should address psychiatric medication adherence in patients with Schizophrenia prior to addressing adherence to medication for medical illnesses due to the relationships between stable psychiatric symptoms and adherence to medical medications. This study also found that effective methods for improving psychiatric medication adherence include Treatment Adherence Therapy (TAT) that is comprised of motivational interviewing (MI), medication optimization, and behavioral training. Medication adherence was also increased when patients were able to speak with a registered nurse to help identify patient-specific barriers for medication adherence along with active problem solving. The most effective methods of promoting medication adherence involve TAT, active problem solving with providers, and addressing ambivalence toward adherence to psychiatric medications. The preliminary component necessary to achieve effectiveness of any intervention aimed at promoting adherence to psychiatric medications in patients with Schizophrenia is collaboration with the patient and establishment of a strong therapeutic alliance.

References

El-Mallakh, P., & Findlay, J. (2015). Strategies to improve medication adherence in patients with schizophrenia: The role of support services. Neuropsychiatric Disease and Treatment, 1077. doi:10.2147/ndt.s56107

Blake Palmer, MA, LPA
Doctoral Psychology Intern

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Friday Factoid: Utilization of Restraints: Examining Contributory Factors

The practice of psychiatry has changed substantially over course of its existence, however, the utilization of restraints in adult psychiatric inpatient units has continued to remain a constant (Jacob et al., 2016). Various studies have shown that there are several factors that lead to the persistent use of these mechanisms (Jacob et al., 2016). Interestingly, these factors have been shown to include, but are not limited to, elements involving the patient (Jacob et al., 2016).

For a patient, the kind and severity of his or her mental illness are the most important factors for being subjected to any form of physical or chemical restraint. Male patients are typically more aggressive, whereas females are more inclined to engage in self-harm. Acts of self-harm and/or attempted suicide during current admissions significantly correlate with young persons whom have a history of harming themselves. Such occurrences typically transpire during evening hours, with antecedents of a distressing psychological state, threatening behaviors, and conflict with staff noted to occur beforehand (Jacob et al., 2016). Additionally, patients who were admitted involuntarily were restrained and secluded at significantly higher levels than those who willingly admitted themselves, and minority persons and immigrants were more likely to be subjected to coercion (as cited in Jacob et al., 2016).

Relatedly, in a study examining the trend of restraint episodes occurring over the course of a six-year period, Jacob et al. (2016) found that males were typically restrained for significantly longer periods than females. Likewise, episodes that were accompanied by medication administration, versus those that were not, were noted to last longer (Jacob et al., 2016). Similar trends were also reported to occur with respect to restraint episodes that involved verbal redirection being given compared to incidents with no redirection and episodes that occurred during evening shifts versus those that took place earlier in the day (Jacob et al., 2016). Overall, each of these episodes was noted to be incited by an outward display of aggression (Jacob et al., 2016).

Reference

Jacob, T., Sahu, G., Frankel, V., Homel, P., Berman, B., & McAfee, S. (2016). Patterns of restraint utilization in a community hospital’s psychiatric inpatient units. Psychiatric Quarterly, 87, 31-48. doi: 10.1007/s11126-015-9353-7

Shirreka Mackay, LPC
WKPIC Pre-Doctoral Practicum Student

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Friday Factoid: To Restrain or Not Restrain? That is the Question.

For more than three centuries, physical restraints have been utilized to manage psychiatric patients (as cited in Allen et al., 2018). However, despite increased regulatory pressure and legal action being taken regarding its use, the practice of using physical restraints to prevent patients from harming themselves continues to prevail in acute psychiatric settings (Allen et al., 2018). Physical restraints, according to the Centers for Medicare and Medicaid Services (CMS) are defined as “any manual method or physical or mechanical device, material, or equipment attached to or adjacent to the resident’s body” which restricts an individual’s freedom to move or have normal access to his or her body (as cited in Allen et al., 2018, p. 1).

Conducting a systematic review of the literature, Allen et al. (2018) identified various methods that could be used to decrease the use of physical restraints on acute psychiatric inpatients. Multiple alternative interventions that could be implemented were identified. These methods included using de-escalation techniques taught to hospital personnel, implementing debriefings following restraint episodes, and employing individualized or patient-specific crisis management plans or tools (Allen et al., 2018). Other methods that were identified included encouraging increased reporting and data sharing, implementing the use of restraint chairs, and forming a team of crisis responders along with instituting a formal policy change which necessitated prior authorization being attained to apply restraints from the chief medical officer (Allen et al., 2018). Utilization of these alternative approaches were shown to substantially decrease the rate of restraints over the course of a 2 to 3-year period. For example, Bell and Gallacher reported a 50% decrease in the hours of restraint use per 1,000 patient bed days, whereas Godfrey et al. (2014) reported a 98% decrease during a 3-year study (as cited in Allen et al., 2018).

References

Allen, D. E., Fetzer, S., Siefken, C., Nadler-Moodie, M., & Goodman, K. (2018). Decreasing physical restraint in acute inpatient psychiatric hospitals: A systematic Review. Journal of American Psychiatric Nurses Association, 1-5. doi: 10.1177/1078390318817130

Shirreka Mackay, LPC
WKPIC Pre-Doctoral Practicum Student

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Friday Factoid: Severe Mental Illness: A Close and Personal Perspective

Generally speaking, persons who suffer from mental illness oftentimes perceive themselves similar to the way they are seen in their respective environments. Therefore, listening to their narratives and hearing their perspective on personal experiences is likely to increase our understanding of the complexity of their illness (as cited in Vila, Pallisera, & Fullana, 2016).

Interestingly, health and social science research has placed increasing value on the views and experiences as told by individuals with mental illness (as cited in Vila et al., 2016). One such study conducted by Kinn, Holgersen, Borg, and Fjaer (2011) provided participants with the opportunity to explore themselves, their daily life, and their work potential. A few major themes emerged during the study, including “all it takes to have a life, being on the right track, and asking for feedback” (Kinn et al., 2011).

In another case study, Thompson et al., (2008) found that individuals suffering from severe mental illness (SMI) especially highlighted the need to feel productive, enhance their self-esteem, feel that they are of value, feel listened to, jokingly interact with others, and experience physical and emotional safety. These needs were directly related to participants’ existing personal supports (i.e., family and/or professional) (Thompson et al., 2008). Similarly, Wahl found that persons with SMI who experienced discrimination and stigma associated with their symptoms, tended to cope better when advocating and speaking out against the judgments and negative perceptions they encountered (as cited in Vila et al., 2016).

References

Kinn, L. G., Holgersen, H., Borg, M., & Svanaug, F. (2011). Being Candidates in a transitional vocational course: Experiences of self, everyday life, and work potentials. Disability & Society, 26(4), 433-448. doi: 10.1080/09687599.2011.567795

Thompson, N. C., Hunter, E. E., Murray, L., Ninci, L., Rolfs, E. M., & Pallikkathayil, L. (2008). The experience of living with chronic mental illness: A photovoice study. Perspectives in Psychiatric Care, 44(1), 14-24. doi: 10.1111/j.1744-6163.2008.00143x

Vila, M., Pallisera, M., & Fullana, J. (2016). Exploring the present and projecting the future: People with severe mental illness speaking for themselves. International Journal of Qualitative Studies in Education, 29(9), 1118-1130. doi: 10.1080/09518398.2016.1201164

Shirreka Mackay, LPC
WKPIC Pre-Doctoral Practicum Student

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Friday Factoid: Is Likeness of Mental Health Experiences a Potential Avenue for Treatment Interventions?

Organized peer support with individuals diagnosed with mental illness builds upon naturally occurring encouragement. Maintenance of another’s wellbeing is oftentimes encouraged as a way to promote shared recovery experiences for anyone who has been diagnosed with mental illness, regardless of the diagnosis given ( as cited in Lloyd-Evans et al., 2014). This shared experiential experience is assumed to promote self-efficacy and hope and, likewise, to provide a socialization of coping strategies (Salzer & Shear, 2002).

In a thematic analysis of interviews conducted with peer-related supporters, Salzer and Shear (2002) found individuals who delivered peer support services via the principle of the helper therapy model reported that facilitating another’s recovery was something they both liked and benefited from. Such gains were noted to include a sense of empowerment, increased self-awareness, and facilitation of their own recovery (Salzer & Shear, 2002).

Over time, provision of peer support services has become an increasingly common facet of mental health services, with twenty-seven states in the United States permitting reimbursement of peer-related assistance (Lloyd-Evans et al., 2014). However, the efficacy of these services (e.g., mutual support groups; unidirectional peer-support services, peer mental health service providers) as an addendum to standard care remains in question.

Lloyd et al. (2014) conducted a systematic review and meta-analysis of randomized controlled trials of these peer-provided services. The investigation consisted of evaluating the effects of peer-related interventions across eighteen trials, totaling 5,597 adult participants (Lloyd et al., 2014).  Participants who were included in the investigation were diagnosed with schizophrenia spectrum or bipolar disorder, or were a mixed population of persons who utilized secondary mental health services (Lloyd et al., 2014). Interventions typically lasted from three weeks to two years (Lloyd et al., 2014). Interestingly, findings showed that there was little current evidence regarding the effectiveness of these services in improving outcomes in hospitalizations (Lloyd et al., 2014). However, similar to Salzer and Shear’s (2002) findings, there were some positive results for outcomes related to self-recovery, hope, and empowerment (Lloyd et al., 2014).

References

Lloyd-Evans, B., Mayo-Wilson, E., Harrison, B., Istead, H., Brown, E., Pilling, S., Johnson, S., & Kendall, T. (2014). A systematic review and meta-analysis of randomized controlled trials of peer support for people with severe mental illness. BMC Psychiatry, 14(1), 1-12. doi: 10.1186/1471-244X-14-39

Salzer, M. S., & Shear, S. L. (2002). Identifying consumer-provider benefits in evaluations of consumer-delivered services. Psychiatric Rehabilitation Journal, 25(3), 281-288. doi: 10.1037/h0095014

Shirreka Mackay, LPC
WKPIC Pre-Doctoral Practicum Student

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Friday Factoid: Cool Beans, Drinking Coffee with Coworkers Improves Group Participation

Move over water cooler talk and bring in the coffee break. Research with 72 undergraduates demonstrated that caffeinated beverages improve one’s views on those around us. These research participants were separated into two groups where one half had a “coffee tasting” before reading and discussing a controversial political topic, while the other half discussed the topic before having a coffee tasting. Those who had a caffeinated beverage beforehand rated their co-discussants and themselves in a more positive manner and were more willing to participate in the group activity compared with those who had the “coffee break” after the discussion. It was theorized that the positive impact of these moderately caffeinated coffees was moderated by a sense of increased level of alertness as those given decaffeinated coffee were less likely to rate their co-discussants as positively.

References:
Unnava, V., Sing, A.S., & Unnava, H. R. (2018). Coffee with co-workers: Role of caffeine on evaluations of the self and others in group settings Journal of Psychopharmacology DOI: 10.1177/0269881118760665

Andrew Goebel, MS, LPA (Temp)
WKPIC Doctoral Intern

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