Attitudes towards people with borderline personality disorder: Integrating a theoretical framework, measurement, and the perspectives of people with borderline personality disorder
Abstract
People with borderline personality disorder (BPD) face some of the highest levels of mental health stigma. This thesis argues that addressing stigma towards people with BPD requires understanding the negative attitudes, or prejudice, that underlie it. Existing instruments used to measure attitudes towards people with BPD, however, have limitations, including a lack of conceptual clarity regarding the construct itself and limited evidence of either construct validity or forms of reliability (e.g., internal consistency). This thesis aimed to provide an improved instrument to measure attitudes towards people with BPD. The secondary aim was to determine whether the instrument encompassed attitudes relevant to the prejudice towards people with BPD that is experienced by people who report having BPD.
To achieve these aims, the Prejudice towards People with BPD (PPBPD) scale was adapted from the Prejudice towards People with Mental Illness scale. The study in Chapter 3 tested the 28-item PPBPD scale in two student samples and one general population sample (total N = 834). Confirmatory factor analysis (CFA) supported the expected four-factor structure of Fear/Avoidance, Malevolence, Authoritarianism, and Unpredictability. Development of a nomological network showed that the four dimensions had differential associations with theoretically related variables, such as social ideologies, personality traits, and empathy, and provided further evidence for construct validity.
Chapters 4 and 5 present interviews conducted with 13 Australians who reported that they have BPD, which investigated if the four PPBPD dimensions were reflective of the experiences shared by people living with BPD. Interviewees also discussed the impacts and sources of both prejudice and support, as well as barriers to care and their perspectives on future prejudice reduction efforts. In Chapter 4, codebook analysis found that the experiences shared by the interviewees corresponded with one or more of the four prejudice dimensions, and no additional dimensions were identified. Furthermore, the associated themes of sources of prejudice, impacts of prejudice, people with BPD face more prejudice than people with other mental health conditions, and BPD literacy, provided context regarding how each of the four dimensions are experienced.
Additional thematic analysis of the interviews in Chapter 5 demonstrated that each dimension had distinctive consequences for the interviewees. Fear/avoidance attitudes related to difficulties initiating and maintaining relationships. Malevolence attitudes increased feelings of shame and invalidation, and reduced trust and desires to seek help. Authoritarianism attitudes were associated with unsuccessful treatment. Unpredictability attitudes led to increased isolation and negative self-image. Furthermore, interviewees highlighted stigma reduction within healthcare as a research priority.
Consequently, Chapter 6 presents the empirical testing of the PPBPD scale in a sample of 593 healthcare providers. CFA replicated the four-factor structure. The nomological network was expanded, with each dimension demonstrating differential associations with external variables, such as recognition of treatment options and belief that a person can control whether they develop BPD.
Finally, Chapter 7 discusses how the research project provides a psychometrically sound measure of prejudice towards people with BPD for both healthcare and general populations. The results of the thesis provide meaningful contributions for understanding attitudes towards people with BPD and the broader BPD discourse. The general discussion outlines the implications and limitations of the research, as well as the hopes for promoting future research.