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Is There a Positive Correlation Between Teaching Positive Reframing and Inherent Value

of Mental Illness and Reducing Stigma?

Amber Boudreau

Adler University

Research Methods 503-A

Jennifer Carroll

April 25, 2021

Is There a Positive Correlation Between Teaching Positive Reframing and Inherent Value

of Mental Illness and Reducing Stigma?

In Canada, the general population recognizes the link between mental health, stigma and

the "Bell Let's Talk" initiative since its launch in September of 2010. The initiative began a

national conversation about mental illness; the response was well-received, resulting in far-

reaching positive social impacts beyond the initial conversation. As of 2020, "…every region

received new funding for access, care and research from Bell Let's Talk and from governments

and corporations that have joined the cause" (Bell, n.d.-a, para. 2).

The telecommunication company, "Bell," opened the conversation with goals to support

Canadians and be a beacon for change. As termed by Bell, the pillars are to fight stigma, improve

access to care, support world-class research, and lead by example in workplace mental health.

They achieve this through community funding and service delivery, and their numbers continue

to grow. As for dollar amounts, $121,373,806.75 are committed to mental health. Throughout all

the positive impacts, the website suggests 82% of Canadians believe there is an overall reduction

in mental health stigma since "Bell Let's Talk" began (Bell, n.d.-b, Impact section).

The stigmatization of Borderline Personality Disorder and many other diagnoses can

correlate to limited and primarily negative information consisting mainly of misconstrued

characteristics

Borderline Personality Disorder (BPD) is characterized as pervasive and versatile

instability starting in early adulthood. It is often associated with an inability to manage one's

emotions, along with acts of violence and a disregard for the safety and concern of themselves or

others. Having experience with young people living with this disorder and witnessing or being
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party to systematic stigmatization and the boxes that service providers try to put these young

people into, there is a personal desire to understand further and facilitate change.

Common traits or perceptions of BPD include anger and aggression, anti-social

behaviours such as criminal versatility, self-harm behaviours (cutting, excessive piercing,

burning, picking, any intentional harm), sexual promiscuity and substance abuse (American

Psychological Association [APA], 2014). While this may match a patient profile to a degree,

these traits and the full Diagnostic and Statistical Manuel of Mental Disorders V (DSM-V) fail to

tell the whole story. Not only are these traits common in other diagnoses, but they are also

multifaceted.

The Responsibility and Opportunity is Now

The population of people diagnosed with BPD is growing, and the requirements for the

diagnosis seem to be relaxing. For instance, a pre-diagnosis label of "BPD traits" for those

younger than 18 years of age (personality type disorders historically require a developed adult

brain as a prerequisite) is popping up in the mental health community. The intended use of a pre-

diagnosis is to give a medical label to open doors to programs and services if there were any.

Proactive, preventative action is not only more cost-effective but has lasting generational

implications. Education is a community necessity. Accessing it and reducing stigma should be a

shared investment of individuals and governments alike to better current and future generations.

What the Current Research is Saying About Stigma and Mental Health

Gamache et al. (2021) aim to reduce the stigmatization around Borderline Personality

Disorder (BPD) as a primarily aggressive illness. Additionally, the hope is to share potentially

mind-altering findings and information with the public, shifting perception and understanding of

BPD from being a disorder lacking dimension. The study presents BPD as a multifaceted
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diagnosis requiring further in-depth analysis, and the researchers intend to share and inform the

masses.

Using the Diagnostic and Statistical Manuel of Mental Disorders V (DSM-V), researchers

tested the combination of criterion A (level of severity) and criterion B (pathology) to create

profile types with these variables. Determining subtypes could positively affect program

development and service delivery while also informing treatment options for clinicians and

providers, ensuring they have the appropriate tools to help clients manage their symptoms.

(Gamache et al., 2021).

Another study had a similar goal as the above, 'Gamache' study, to find subtypes in the

BPD diagnosis. Kleindienst et al. (2020) proposed a classification of the Borderline traits using

an existing scoring system clinician use for diagnosis. Classifying this information is intended to

offer a deeper understanding of the disorder; this article offers six levels of severity to

understand the disorder through the classification.

A critical difference between these two articles is the presentation of information. Both

use the same patient questionnaire for data analysis, the BSL-23; however, this study pays no

mind to the stigmatization of clients or mental health. The questionnaire could also hold negative

confirmation biases in many of the questions as they often related to aggressions and emotions

(Kleindienst et al., 2020).

Research Methods: Effect of Participant Perception of Self on Stigma

Many people are not fully aware of this, but what comes from within a living brain is not

necessarily true. That stands for clinicians, people with mental health issues, and people sharing

experiences and interactions—the colour of perspective changes with experience, knowledge,

and even mood. So, education far and wide to colour the perspective with empathy and

awareness. Education is the first step to reducing stigma and any positive change.

The question is, does education reduce the stigma of Borderline Personality Disorder

(BPD)? The answer is most likely yes. We find the answer through an ecological lens, learning

and understanding their interactions in the world. Understanding how they see themselves in the

world gives a clearer picture of their needs and how best to approach relationship building

authentically.

As participants learn their skills and positive traits, potential discussions and focus groups

on the value of self would likely demonstrate the increased positive self-image and decreased

self-stigma among participants. Effecting self-stigma is primary to the overarching goal. With

each participant's understanding of needs comes the development of a baseline. With an

established baseline, the opportunity to teach new skills and monitor self-perceptions compared

to past versions is available.

Research Methods: Relationships, Inclusivity and Creativity

Strong relationships with trust and authenticity will go far in reaching a point in research

when observers can have open discussions with participants. Conversations can quickly become

vulnerable, self-reflective, and possibly mind-altering. A sturdy, consistent relationship is

essential for the safety of these moments. It would be ideal to have consistent researchers.

These relationships can continue in a professional setting beyond the initial interviews

and participant curriculum. As the research continues, measuring stigma and educating in various

communities, the hope is for these participants to take an active leading role in the education of

the general populace (practitioners/clinicians). A leading role in the general curriculum can take

many forms and adapt as needed, whether it be a letter or audiovisual input.

The active participatory model will invite newly recruited participants to learn how to

make infographics and share them on the dedicated social media site (archived when no longer in

use) where they located the study. Infographics offer control as each person who writes one will

choose how much and what to share. Not only do they learn a new skill (potentially), but they

have also taken a step towards rewriting the narrative for Borderline Personality Disorder.

Research Methods: Self-Stigma, Participation, Education

Having a solid group of participants who share in discussions and who understand who

they are, how they came to these behaviours (ecological perspective should shed light on a lot of

this), and how they are different. What this self-awareness will hopefully be accompanied by is a

decrease in self-stigma. The positivity might correlate with participation and education, which

would factor into the design of the next group or the general curriculum.

Research Instruments: How to Measure Stigma and Other Variables

To analyze, a correlation-type, linear regression that predicts the dependent variable from

the independent or multiple linear regression, which uses multiple correlations to predict a

dependent variable from two or more independent variables, could be effective for this study

(Martin & Bridgmon, 2012). Focus groups, interviews and questionnaires will be offered many

times: pretest, midtest and post-test. The timing for these will depend on the flow of the

participants, and it may differ for participants compared to clinicians or community workers (A.

Boudreau, personal communication, March 21, 2021).

Data collection for this study will be multimodal mixed methods. Questionnaires will be

sent out and dropped off at various community services with a note or conversation about the

research and its goals to reduce stigma. The questionnaire will also be available on the social

media site. These questionnaires are primarily to gain a baseline understanding of community
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levels of awareness and mental health stigmatization. Secondary use is to gather support for the

cause from community organizations for social media publicity. These questionnaires will be

repeated as necessary and similarly adapted if the researcher sees fit to do so.

Community organizations found as supporters help boost the page with hashtags and

mentions. A questionnaire will be available for potential candidates. Options to remain

anonymous or receive a call back for participation will be embedded in the link. Again, these

questionnaires will be repeated as necessary and adapted if the researcher sees fit. This study is

likely to evolve with the goals and curriculum. There is nothing off-limits as far as

documentation unless, of course, unethical, or inappropriate.

As a bottom-up research design that encourages participants to have a leading role in the

study from start to finish, the participants themselves are instruments. There will be opportunities

to learn new skills and see how the data correlates at appropriate intervals and have direct input

in curriculum design and implementation.

Possible Areas of Concern

Ethical considerations for this research question come to mind; the questionnaire and

interviews need to be particularly neutral and specific to adhere to best practices. Persons with

Borderline Personality Disorder (BPD) can experience heightened emotions; a questionnaire that

asks about their experiences with stigma could be triggering.

The inability to properly support a participant should an interview or questions be remote,

and the significantly higher likelihood of self-harm behaviours associated with this disorder

(supposedly). Questions should have safety built-in while also gathering adequate data. A pre-

screening interview might have to be in place to ensure candidate stability and support available

at the time of the questionnaire to accomplish candidate safety and ethical interviewing. Ideas
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might include video interviews, ensuring five sense distractions available, and a mood

assessment.

Self-report data as unreliable had come to mind. However, storytelling could be a trait of

BPD. There would be little to no skew if documented and categorized as self-stigma or another

symptom. Going back to the relationship, the least amount of storytelling will present when the

listener does so with authenticity and intention. The validity or truthfulness of a person's

experience is not the observers' job to verify.

Intended Results

By the end of this study, the aim is further understanding Borderline Personality Disorder

(BPD) for clients, families, and service providers. Participants will know that there are positive

traits to the diagnosis and reframe negative thoughts or labels society has thrown on them.

Through that, education developed with the help of participants will be circulating and available

to mental health practitioners and community service providers. Determining results of overall

stigma reduction will be done by anonymous follow-up surveys and pre and post curriculum

questionnaires.
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References

American Psychological Association. (2014). Personality disorders. In Diagnostic and statistical

manual of mental disorders, 5th edition (5th ed.). American Psychiatric Publishing, Inc.

https://doi.org/10.1176/appi.books.9780890425596.295735

Aviram, R. B., Brodsky, B. S., & Stanley, B. (2006). Borderline personality disorder, stigma, and

treatment implications. Harvard Review of Psychiatry, 14(5), 249–256.

https://doi.org/10.1080/10673220600975121

This article gives excellent consideration to tools for identifying and limiting the impact

of stigmatization of individuals with Borderline personality disorder (BPD) as BPD is

often associated with negative traits by the public and even mental health practitioners.

BPD has a stigma that goes beyond that of other mental illnesses. It has the potential to

affect practitioner-client interactions as well as possibly leading to dismissing symptoms

and devaluing strengths. The distance that occurs because of stigma is particularly

problematic for patients with BPD as there is a tendency to have a negative confirmation

bias in interactions. The study suggests that consequences could be self-injurious

behaviours and further inability to access services as the perception of difficulty to work

in a therapeutic relationship increases.

Barr, K. R., Jewell, M., Townsend, M. L., & Grenyer, B. S. (2020). Living with personality

disorder and seeking mental health treatment: Patients and family members reflect on

their experiences. Borderline Personality Disorder and Emotion Dysregulation, 7(1), 21.

https://doi.org/10.1186/s40479-020-00136-4

As researchers investigating gaps in services and areas in mental health that would

benefit from improvement, Barr et al. (2020) dive into emotional and multifaceted topics
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to break down barriers with the hopes of getting people the help they need and have a

right to access. Some facets delved into, some have a seemingly dichotomous opposition

as they might be thought-provoking or otherwise toe stomping. To offer a few examples,

topics such as creating a safe environment, sharing appropriate and non-judgmental

information, ensuring appropriate training regarding personality disorders for healthcare

professionals, and the ethical care and safety of clients. What has come from this study is

that personality disorders are of a unique group accessing services. They often access

multiple services to meet their needs while being disappointed on all fronts, and this just

seeking to have basic needs met that all humans have a right to and should have access to

stability, routine, and attachment. This research also found that those with personality

disorders are met with stigma when seeking treatment. Suggestions for training and

treatment guidelines are not new, and further suggestions are in review.

Bell. (n.d.-a). Our initiatives | bell lets, talk. Bell Let's Talk. Retrieved April 4, 2021, from

https://letstalk.bell.ca/en/our-initiatives/

Bell. (n.d.-b). Results and impact | bell lets, talk. Retrieved April 4, 2021, from

https://letstalk.bell.ca/en/results-impact/

Gamache, D., Savard, C., Leclerc, P., Payant, M., Côté, A., Faucher, J., Lampron, M., &

Tremblay, M. (2021). Latent profiles of patients with borderline pathology based on the

alternative DSM-5 model for personality disorders. Borderline Personality Disorder and

Emotion Dysregulation, 8(1), 4. https://doi.org/10.1186/s40479-021-00146-w

The team that came together to document these findings comprises interdisciplinary

researchers in psychology working out of Quebec, Canada. Their goal is to define unique

and meaningful subgroups in patients with Borderline Personality Disorder (BPD). The
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research is a continuation of previously unsuccessful or negatively correlated studies in

this area. As BPD relaxes, it may be possible to define subgroups that could lead to a

potential increase in program development and awareness and reduction in stigma.

Kleindienst, N., Jungkunz, M., & Bohus, M. (2020). A proposed severity classification of

borderline symptoms using the borderline symptom list (BSL-23). Borderline Personality

Disorder and Emotion Dysregulation, 7(1), 11. https://doi.org/10.1186/s40479-020-

00126-6

The authors of this article looked at classifications of Borderline Personality Disorder

(BPD), including severity and correlations of variables that would lend to severity when

ecological perspectives were considering. For this study, severity was not limited to

overall diagnosis but instead included severity of individual criterion, each of the seven

DSM markers measured against healthy controls. The intended audience of this study is

clinicians and to provide a classification of severity for the current method of self-testing

score worksheet, the BSL-23/95.

Knaak, S., Szeto, A., Fitch, K., Modgill, G., & Patten, S. (2015). Stigma towards borderline

personality disorder: Effectiveness and generalizability of an anti-stigma program for

healthcare providers using a pre-post randomized design. Borderline Personality

Disorder and Emotion Dysregulation, 2(1), 9. https://doi.org/10.1186/s40479-015-0030-0

With a unified goal of removing stigma, these researchers are educating and providing

healthcare providers training to come together to prove effectiveness and counter

negativity. What this study found in the process is essentially a negative feedback loop of

experiences. Service providers perceive clients to have inappropriate or overly emotional

reactions, which result in counter-therapeutic beliefs and conditions. Interactions like this
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add to aggravation in the therapy process. The therapist only sees one side of a very

complex individual who cannot receive service because of their perceived combativeness.

People with BPD receive labels associated with negative assumptions and traits such as

"powerful, unrelenting, dangerous, manipulative and more in control of their behaviors

than other patients" (para. 5). Education for service providers and therapists has proven to

reduce stigma significantly and increase therapeutic recovery rates.

Mayo Clinic Staff. (2021, January 21). Positive thinking: Stop negative self-talk to reduce stress.

Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-

depth/positive-thinking/art-20043950

Salters-Pedneault, K. (2020, May 15). Here's what may cause borderline personality disorder.

Verywell Mind. https://www.verywellmind.com/borderline- personality-disorder-bpd-

causes-425154

Martin, W. E., & Bridgmon, K. D. (2012). Quantitative and statistical research methods: From

hypothesis to results (2nd ed.) [e-book]. Wiley Professional Development (P&T).

Sandhu, H. S., Arora, A., Brasch, J., & Streiner, D. L. (2019). Mental health stigma: Explicit and

implicit attitudes of Canadian undergraduate students, medical school students, and

psychiatrists. The Canadian Journal of Psychiatry, 64(3), 209–217.

https://doi.org/10.1177/0706743718792193

In a study comparing implicit and explicit stigma, Sandhu et al. (2019) assessed whether

education level was associated with attitudes toward mental illness. The demographic of

participants included university students ranging from undergrad to psychiatry. The study

concludes that increased education as well as experience with mental health show

significantly lower explicit stigma.

Addendum

Through multiple reviews of this proposal, adjustments and edits were made to clarify the

hypothesis, problem statement, research methods and several other parts of research.

The title was changed to define the question that is being examined. The initial title was “Effect

of Bottom-Up Approach to Reducing Mental Health Stigmatization: Teaching Positive

Reframing and Inherent Value of Borderline Personality Disorder”. The new title asks a question

of the possible correlation.

The problem statement was more defined after the introductory paragraphs. Initially the next

section had stated “A Highly Stigmatized, Feared and Avoided Mental Illness: Borderline

Personality Disorder”. It has now been changed to “The stigmatization of Borderline Personality

Disorder and many other diagnoses can be linked to limited and primarily negative information

consisting mainly of misconstrued characteristics” which is a clearly stated issue.

Beyond this, the changes throughout the document consists of technical APA formatting.