Perceptions By Clients with Cluster-B Personality Disorders As Compared to Their Clinicians in the Assessment of Emotion Regulation Problems and Self-Harm

Background and purpose:  The quality of the therapeutic alliance between a client and their clinician has been shown to be one of the most important predictors of positive treatment outcomes. Comparison studies of client perceptions versus clinician perceptions about the therapeutic process generally conclude that differences in perceptions may influence the quality of this alliance, with incongruence in perceptions increasing the likelihood of poor treatment outcomes and dropout. To date, no studies have addressed similarities and differences in client and clinician perceptions with individuals with personality disorders, in particular, perceptions about the nature and degree of client emotion regulation problems and self-harm, key therapeutic targets with this population. This paper reports findings from an exploratory study using a sample of individuals diagnosed with DSM-IV Cluster-B personality disorders (borderline, antisocial, narcissistic, histrionic) to examine the differences between the clients' perceptions and their clinicians' perceptions about the clients' reactions to and ability to manage difficult emotions and self-harming thoughts and behavior. 

Method: A sub-sample of client-clinician pairs was drawn from a larger study of 100 individuals diagnosed with DSM-IV Cluster-B personality disorders who were recruited from three inpatient units and five outpatient clinics at a large university hospital system in an eastern state. Almost one-third of the clients interviewed consented to have their treating clinician also interviewed (n=32 client-clinician pairs). Semi-structured client interviews, consisting of multiple established measures of emotion and behavior, including an original measure of emotion regulation problems, lasted approximately 90 minutes; the abbreviated clinician interviews lasted 30 minutes.

Results: Client subjects were predominantly female (88%); 56% White/non-Hispanic, 44% African-American; and had been in treatment with their clinician an average of 23 months. The majority (66%) were diagnosed with Borderline Personality Disorder. A content analysis of the open-ended questions comparing client-clinician responses showed significant perceptual congruence, suggesting that the majority (82%) of the clinicians had perceptions similar to their client regarding the way their client behaves in response to negative emotions, the client’s ability to look at emotionally provocative situations objectively, and how he/she manages physical reactions to overwhelming emotions. However, on the quantitative General Emotion Dysregulation Measure, means comparisons of items showed clinicians significantly (p<.05) underestimated the intensity of  clients’ emotion regulation problems and only half had accurate knowledge about clients’ self-harm thoughts and behaviors.

Conclusions and implications:  Individuals with Cluster-B personality disorders commonly evidence substantial problems with emotion regulation and self-harm, which impacts successful psychosocial adjustment and recovery in the community. Social workers are the primary providers of treatment to individuals with serious mental illness, including those with a personality disorder. Establishing a positive therapeutic alliance characterized by congruence in client-clinician perceptions, combined with targeted treatments, is associated with client improvement and achievement of recovery. Underestimating emotion regulation problems and inaccuracy about a client’s self-harm thoughts and behavior may affect treatment effectiveness and outcomes. This may then lead to greater psychological and interpersonal burden for both clients and their families. Future research should test the extent to which client-clinician perceptual congruence predicts therapeutic outcome in this population.