Problem solving for personality disorder

Mary McMurran and Stephen Coupe describe a promising approach to a distressing disorder

Problem-solving therapy has a solid evidence base for alleviating distress and improving social functioning in people with a range of psychological and health problems. This approach has considerable appeal for both therapists and clients, in that its basic principles are easy to understand, it does not pathologise individuals, and it empowers people to solve those problems that they prioritise. Applications of problem-solving therapy for people who are diagnosable with personality disorders have been pioneered by researchers and clinicians in the UK. The research underpinning this approach for this client group is described in this article.

Personality disorders are enduring and problematic patterns of thinking about oneself and the outside world that are associated with distress and impaired social functioning. In a British Psychological Society report Understanding Personality Disorder (Alwin et al., 2006), personality disorders were described as extreme variants of normal personality that are associated with significant dysfunction or distress. Personality disorders are associated with wide-ranging adverse consequences, such as suicide, self-harm, addiction, family breakdown and social exclusion.

The problem is not a rare one. The prevalence of personality disorder in the UK general population is 4.4 per cent (Coid et al., 2006), in primary care attenders the prevalence is 24 per cent (Moran et al., 2000), and in community mental health team service users it is 40 per cent (Newton-Howes et al., 2010). Of course, like other psychiatric diagnoses, the diagnosis of personality disorder is a contentious one for psychologists (Boyle, 2007). Nonetheless, this group of disorders does identify many distressed people who have been marginalised by health and other public services.

The development of effective treatments for people diagnosed with personality disorders was given a boost in 2003, with the publication by the Department of Health of a directive entitled Personality Disorder: No Longer a Diagnosis of Exclusion (National Institute for Mental Health in England, 2003). This document offered guidance for health services to develop multidisciplinary, specialist personality disorder treatment teams, whose task would be to develop ways of working with service users diagnosed with personality disorder. These specialist teams could be informed by evidence of what service users, clinicians and academics consider important for people diagnosed with personality disorders; namely that services should aim to reduce the stigma associated with the diagnosis, provide a range of psychological and psychosocial interventions to help people improve their coping skills, social functioning and quality of life, and provide support for accessing education and employment (Crawford et al., 2008). One psychological intervention that contributes to this menu of options is problem-solving therapy.

What is problem-solving therapy?
Social problem solving is the process by which individuals attempt to discover and apply adaptive means of coping with the wide variety of stressful problems encountered in the course of everyday living (D’Zurilla & Nezu, 2007). There is abundant evidence of an association between social problem-solving deficits and psychological distress, physical ill health, substance misuse, hostility and aggression, and mental health problems. Problem-solving therapy can help people to cope better with everyday problems and can lead to better mental and physical health (see Malouff et al., 2007, for a meta-analysis).

Problem-solving therapy teaches the skills required for effective social problem solving. These are the ability to recognise problems when they arise, define the problem clearly and accurately, set realistic goals for change, produce a diversity of possible solutions, anticipate outcomes, devise effective actions plans that have stepwise stages, and carry out those action plans to solve problems effectively. Therapists must also attend to developing the client’s optimism about finding solutions to problems and improving the client’s confidence for working towards these solutions. Without attention to these cognitive-emotional matters, therapy is unlikely to be effective.

Why is problem-solving therapy appropriate?
We offer problem-solving therapy to people diagnosed with personality disorders. We take the approach that people need to learn to cope with life, taking into account their own personal characteristics: we are not trying to change who they are but how they are. 

We are confident that problem-solving therapy is relevant for this group. Our research has shown that people diagnosed with personality disorders are poorer on a test of social problem solving (the Social Problem Solving Inventory-Revised; D’Zurilla et al., 2002) compared to a sample of mature students (Hayward et al., 2008; McMurran, 2009; McMurran et al., 2002). We have also found that social problem-solving profiles vary across personality disorder subtypes (McMurran et al., 2010). For instance, borderline, histrionic and narcissistic personality traits are associated with a highly impulsive and careless problem-solving style, indicating poor impulse control. Additionally, narcissistic traits are associated with a high positive problem orientation, indicating perhaps misplaced confidence in their problem-solving abilities. Avoidant and dependent traits are associated with a high negative problem orientation, indicating feelings of threat when faced with problems and low self-efficacy in problem solving. This information gives us an indication of what to focus upon in problem-solving therapy with particular subgroups.

These results have led us to speculate upon the role that social problem-solving skills might have in mediating between basic personality dimensions and personality disorder. The personality dimensions of the five-factor model of personality (Costa & McCrea, 1992), namely Neuroticism, Extraversion, Openness to experience, Agreeableness, and Conscientiousness, have been shown to be differentially and predictably associated with different personality disorders (Samuel & Widiger, 2008; Saulsman & Page, 2004). The question of interest to us is how personality dimensions might relate to personality disorders. These basic dimensions might affect the development of social problem-solving skills, some adversely (e.g. high neuroticism) and some positively (e.g. high conscientiousness). The level to which a person acquires good social problem-solving skills may then influence the likelihood  of the development of a personality disorder. Failure to acquire good social problem-solving skills may lead to dysfunctional waysof operating in everyday life, particularly in highly charged emotional contexts. Persistent social dysfunction may then, in some cases, contribute to a diagnosis of personality disorder. Our evidence suggests that social problem solving does mediate between personality dimensions and personality disorders in some cases (McMurran et al., 2010). For example, high levels of neuroticism (i.e. negative emotionality) are associated with a lower rational problem-solving style, which in turn is associated with higher scores on avoidant personality disorder. Identifying such relationships begins to tell us more precisely how personality traits, problem solving, and personality disorders relate to each other, although a developmental model requires testing in longitudinal studies.

Stop and think!
Our findings support the view that social problem solving may be an important process in explaining personality disorder. Targeting social problem-solving skills in treatment for people diagnosed with personality disorder is, therefore, likely to be beneficial. Knowledge about combinations of personality dimensions and problem-solving orientations and styles may lead to tailored treatments for specific personality disorder types. This will need to build on information about effective problem-solving interventions.  

Since our research indicates that problem solving may be an important treatment target, we have developed a skills training approach called Stop & Think! The components, each of which is translated into a key question, phrased in plain English to guide the problem-solving process in clinical practice, are:
I     Problem recognition – Feeling bad?
I     Problem definition – What’s my problem?
I     Goal setting – What do I want?
I     Generation of alternatives – What are my options?
I     Decision making – What is my plan?
I     Evaluation – How am I doing?

In sessions, the focus is on each participant’s current concerns, aiming not only to solve existing problems but also to teach people the problem-solving strategy.

A pilot study with personality disordered offenders detained in a UK regional secure unit led to improvements in service users’ problem-solving scores on the self-report inventory (McMurran et al., 1999). In a survey of service users’ opinions, Stop & Think! was viewed as helpful intervention (McMurran & Wilmington, 2007). More recently, the effectiveness of Stop & Think! with community adults diagnosed with personality disorder has been evaluated in a pilot randomised controlled trial (Huband et al., 2007). In this trial, Stop & Think! was preceded by individual psychoeducation sessions, in which the client’s personality disorder diagnosis was clarified and linked with the problems in functioning experienced by the individual (Banerjee et al., 2006). Psychoeducation and problem solving together are called PEPS therapy. PEPS therapy was examined by allocating community-dwelling men and women with any personality disorder to either treatment or a waiting-list control. The treated group received, on average, nine Stop & Think! group sessions and a further three individual sessions supporting the implementation of action plans. At follow-up six months after treatment, the group who received PEPS therapy showed significantly better functioning on the primary outcome measure of self-reported social functioning in the domains of home, work, leisure, and relationships. Treated participants also showed better status on the social problem-solving inventory. After controlling for baseline social functioning, the best predictor of improvement was  a positive change in negative problem orientation, which points to the importance of improving people’s problem orientation so that they believe that they can solve problems effectively (McMurran et al., 2008). 

This research shows that a relatively brief intervention based upon psychoeducation and social problem-solving therapy is a promising intervention for people diagnosed with personality disorders. Commentators on the randomised controlled trial have identified the study as important in four ways (Crawford, 2007; Paris, 2007). First, the intervention was brief, this being more acceptable to many service users over lengthier interventions. Also, brevity likely reduces the number of participants dropping out of treatment, and is more acceptable to services with limited resources. Second, the intervention was delivered in real clinical settings, hence its likely effectiveness in everyday practice was indicated. Third, it was offered to people with any personality disorder diagnosis or combination of personality disorder diagnoses, so it was inclusive rather than exclusive. Fourth, it was delivered by non-specialist staff; hence it would be possible to deliver it relatively cheaply. These advantages notwithstanding, there is a need for further investigation into the respective contributions of psychoeducation and social problem-solving therapy in achieving good outcomes and an examination of the maintenance of gains over a longer-term follow-up period.

A larger, multi-site randomised controlled trial of PEPS therapy is now under way. Meanwhile, problem-solving therapy is used by a range of professionals. Training in Stop & Think! is well developed. The two-and-a-half day programme provides an overview of the evidence base supporting the application of problem-solving therapy with people presenting with personality disorder; an introduction to the Stop & Think! model; opportunity to practise the approach in a supervised setting; and working through the pitfalls and difficulties of delivering the programme with particular reference to their own place of work.

More than a hundred practitioners have been trained and their reports are beginning to appear in the practice literature (e.g. Asplin et al., 2009; Smith & Homewood, 2010). We have also raised awareness of problem-solving therapy more generally by providing conferences and workshops.

In conclusion, problem-solving therapy is a theoretically coherent, evidence-based approach, which helps people diagnosed with personality disorder to break repeating and dysfunctional patterns of behaviour. It provides staff with techniques to engage service users and empower them to address sometimes longstanding difficulties, challenge negative beliefs about problem solving, and provide them with skills that they can use when faced with problems in the future. It also provides a useful structure to contain the sometimes challenging behaviour exhibited by this client group and allows clinician and client to collaborate in seeking solutions to problems.

Mary McMurranis at the Institute of Mental Health, University of Nottingham
[email protected]

Stephen Coupeis at Praxis Psychological Therapies, Nottingham
[email protected]



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