Holland, Hannah Sophia
(2024)
Acceptance and commitment therapy for people experiencing multiple disadvantage and emotionally unstable personality disorder: Adapting a manual through consultation.
DClinPsy thesis, University of Nottingham.
Abstract
Background: Of the estimated 289,000 people facing homelessness in the UK, 42.6% experience mental health and substance misuse difficulties, and 36.6% have a diagnosis of Emotionally Unstable Personality Disorder (EUPD). National guidance recommends psychological therapies for the treatment of EUPD; however, individuals who also misuse substances and face homelessness are often excluded by services due to inappropriate modes of delivery. Current guidance recommends that individuals receive support for what they feel are their priority needs; however, this is not always enacted. Previous research has shown that consulting with People With Lived Experience (PWLE) can be valuable in shaping services to maximise delivery to such marginalised populations. Another barrier to accessing therapies is that they are often delivered by specialist professionals such as Clinical Psychologists, of which there is a national shortage. In addition, the services supporting this population of people predominantly rely on professionals without specialist therapeutic training. The evidence-base is limited regarding the effectiveness of therapies for this population; however, Acceptance and Commitment Therapy (ACT) has been shown to be effective in individuals who misuse substances, and individuals diagnosed with EUPD. ACT posits that mental health difficulties can be avoided through developing ‘psychological flexibility’ and can be delivered by professionals without specialist training; however, no tailored ACT interventions exist for this population.
Study Aims: Identify existing ACT interventions that could be adapted for this population, consult with professionals and PWLE regarding required adaptations, and develop a draft manual for this population.
Method: Literature was reviewed to identify existing ACT interventions related to the target population in adherence with manual development guidance. A rating measure was developed to assess existing interventions’ strengths and inadequacies, and to encapsulate a range of needs related to the target population. Four relevant professionals and two PWLE each attended two semi-structured interviews and provided quantitative and qualitative data regarding the existing interventions. Quantitative analysis was conducted to dictate the order of excerpts and identify significant differences between first and second interview data to assess for conformity bias. Framework analysis was used to analyse qualitative data and three main themes were identified: acceptability, facilitators, and barriers. Data was interpreted by mapping the range and nature of responses, identifying key dimensions, identifying associations, formulating explanations, and developing strategies for the adapted manual.
Results: Excerpts with higher rating measure scores were selected to present in participant interviews. Forty-one excerpts across five manuals were identified in the literature. There were no significant differences between first and second interview scores. All 41 excerpts were included within the adapted manual.
Discussion: This study was a first attempt at consulting with professionals and PWLE to develop an adapted ACT manualised intervention. It provides clinical and research opportunities related to this population and it can be delivered by non-psychologists. Future research is required to explore the feasibility, effectiveness, and acceptability of the adapted manual, and to evaluate whether the intervention improves psychological flexibility and quality of life and reduces EUPD symptoms and substance misuse. Limitations include sample characteristics, which limit generalisability.
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