BPS Attitude Scale

Abstract

The BPS Attitude Scale (known natively in German as the BPS-Einstellungsskala or BPS Setting Scale; Schäfer et al., 2023) is an empirical psychometric instrument designed to quantitatively evaluate stigmatizing attitudes among psychiatric and mental health healthcare personnel toward individuals diagnosed with Borderline Personality Disorder (BPD). Clinicians and psychiatric staff historically report elevated levels of therapeutic pessimism, interpersonal frustration, and pejorative attributions when working with individuals with BPD, often impeding treatment alliance and clinical outcomes. To rigorously operationalize these attitudes in German-speaking clinical environments, Schäfer and colleagues adapted and synthesized two established English-language inventories developed by Bodner, Cohen-Fridel, and Iancu (2011): the Borderline Patient Cognitive Attitudes and Treatment Inventory (BPD-CAT) and the Borderline Patient Emotional Attitudes Inventory (BPD-EA). The adaptation process adhered strictly to the European Social Survey Translation Guidelines, initially translating 64 items (44 cognitive, 20 emotional) before systematically eliminating linguistic ambiguities and psychometrically redundant parameters. The resulting 22-item self-report questionnaire was validated in a multidisciplinary cohort of German psychiatrists, clinical psychologists, and psychiatric nursing professionals aged 21 to 62 years. Principal Component Analysis (PCA) demonstrated an interpretable four-component structure accounting for 63.60% of total variance: (1) BPD Treatment Difficulties, (2) BPD Assessment of Suicide Risk, (3) BPD Assumption of Manipulative Tendencies, and (4) BPD-Negative Emotions. The instrument exhibits robust internal consistency, featuring an overall Cronbach’s alpha of .90, with subscale coefficients ranging from .72 to .90. Criterion-related validity was confirmed through correlations with the validated Social Distance Scale (Angermeyer & Matschinger, 1997), evidencing pronounced relationships between perceived manipulation, treatment burden, and desire for social distance. The BPS Attitude Scale provides a reliable, theoretically anchored framework for evaluating institutional stigma, benchmarking professional training initiatives, and guiding anti-stigma interventions within psychiatric care settings.

Keywords

Borderline Personality Disorder, BPS-Einstellungsskala, psychiatric staff stigma, clinician attitudes, BPD treatment difficulties, assumption of manipulative tendencies, assessment of suicide risk, negative emotional reactions, social distance, psychometric validation

Authors

The BPS Attitude Scale was conceptualized, translated, and empirically validated by a multidisciplinary team of researchers affiliated with specialized health psychology and psychiatric academic institutions in Germany:

• Marvin Schäfer — Forschungsgruppe COPE, SRH Hochschule für Gesundheit, Gera, Germany. (Corresponding Author: [email protected]; Address: SRH Hochschule für Gesundheit GmbH, Forschungsgruppe COPE, Neue Straße 28–30, 07548 Gera, Germany).
• Claudia Luck-Sikorski — Forschungsgruppe COPE, SRH Hochschule für Gesundheit, Gera, Germany.
• Regine Hochrein — Forschungsgruppe COPE, SRH Hochschule für Gesundheit, Gera, Germany.
• Georg Schomerus — Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Leipzig, Leipzig, Germany.
• Sabine Gollek — Klinik und Poliklinik für Psychiatrie und Psychotherapie, Universitätsklinikum Leipzig, Leipzig, Germany.

Purpose

The primary clinical and scientific purpose of the BPS Attitude Scale is to provide a standardized, psychometrically validated methodology for capturing, quantifying, and deconstructing stigmatizing cognitions and emotional reactions held by psychiatric staff toward patients with Borderline Personality Disorder. Borderline Personality Disorder is characterized by pervasive patterns of affective dysregulation, unstable interpersonal relationships, identity disturbance, severe impulsivity, and recurrent suicidal or non-suicidal self-injurious behaviors (American Psychiatric Association, 2013). Within clinical psychiatry and mental healthcare settings, patients bearing a BPD diagnosis encounter some of the highest levels of institutional and provider-based stigma documented across psychiatric nosology.

Healthcare professionals across psychiatry, clinical psychology, and psychiatric nursing frequently report subjective feelings of helplessness, chronic frustration, moral fatigue, and therapeutic nihilism when managing BPD symptomatology. Historically, behavioral manifestations of emotional crisis, non-suicidal self-injury, and interpersonal volatility have been misattributed as deliberate, attention-seeking, or hostile manipulations rather than symptoms of profound neurobiological and psychological distress. This cognitive distortion fosters an adversarial therapeutic climate, prompting pejorative labeling, diagnostic overshadowing, excessive administrative restrictions, premature discharge, or covert rejection. Such clinician reactions directly impair treatment adherence, exacerbate the patient’s emotional rejection sensitivity, and substantially elevate longitudinal risks of treatment discontinuation and adverse psychiatric events.

Despite the severe clinical ramifications of provider stigma, German-speaking healthcare environments previously lacked an efficient, structurally validated psychometric scale specifically calibrated to measure these multidimensional attitudes among multidisciplinary clinical personnel. Existing general mental health stigma instruments fail to capture the unique interpersonal dynamics of BPD, such as parasuicidal crisis management, perceived manipulation, and chronic emotional countertransference. The BPS Attitude Scale addresses this critical methodological gap by offering a 22-item self-report scale capable of measuring both the cognitive appraisals (e.g., perceived untreatability, attributions of manipulative intent) and emotional states (e.g., anger, anxiety, professional helplessness) harbored by clinicians.

In applied clinical settings, the BPS Attitude Scale serves as an institutional diagnostic instrument. It enables psychiatric hospitals, outpatient clinics, and training centers to quantify baseline levels of staff stigma, identify high-risk institutional beliefs, and evaluate the empirical effectiveness of educational interventions, such as Dialectical Behavior Therapy (DBT) skills workshops, trauma-informed care seminars, and de-stigmatization modules. In empirical research, the scale facilitates structural equation modeling and longitudinal cohort investigations probing the systemic relationships among clinician burnout, institutional culture, professional experience, and patient-level therapeutic outcomes.

Psychological Construct

The BPS Attitude Scale conceptualizes healthcare provider stigma toward Borderline Personality Disorder not as a monolithic sentiment, but as a complex, four-dimensional psychological construct encompassing explicit cognitive attributions, emotional countertransference, risk evaluations, and behavioral predispositions. The four validated latent dimensions of the instrument reflect the cognitive-affective pathways that shape clinical interactions:

1. BPD Treatment Difficulties

This dimension quantifies the clinician’s perception of the complexity, strain, and anticipated therapeutic failure associated with treating patients with BPD. It captures attitudes of therapeutic nihilism, professional burden, and the belief that therapeutic interventions are disproportionately exhausting, unproductive, or destined to stall. Clinicians endorsing high scores on this component perceive BPD patients as inherently resistant to change, excessively demanding of ward resources, and intrinsically disruptive to the psychiatric care milieu. These cognitive appraisals often lead to provider disengagement and institutional gatekeeping, where patients are prematurely characterized as “untreatable” within general psychiatric frameworks.

2. BPD Assessment of Suicide Risk

This subscale evaluates the cognitive frameworks and evaluative standards healthcare professionals apply when appraising suicidal threats, gestures, and self-injurious behaviors in patients with BPD. Suicidal behavior in BPD presents a profound clinical challenge due to its recurrent, chronic nature combined with acute exacerbations. This dimension captures clinician tendencies to interpret crises as either genuine expressions of imminent lethality or as low-intent, operant communicative actions. Notably, in validation studies, this factor separated cleanly from interpersonal blame, representing an objective assessment dimension focused on the unpredictability, severity, and forensic anxiety surrounding acute suicidality and crisis containment.

3. BPD Assumption of Manipulative Tendencies

A core element of specialized BPD stigma is the attribution of hostile, exploitative, or calculating intentionality behind the patient’s emotional crises and relational instability. This dimension measures the extent to which staff perceive borderline behaviors—such as identity splitting, crisis generation, treatment boundary testing, and help-seeking—as conscious, manipulative maneuvers designed to control staff or extract special privileges. Attributing intentional manipulation fundamentally alters the professional’s empathy, shifting the clinical response from compassionate support to defensive boundary enforcement, disciplinary confrontation, and social distance.

4. BPD-Negative Emotions

Derived primarily from emotional countertransference dynamics, this affective dimension assesses the visceral, negative emotional states experienced by staff when interacting with BPD patients. Unlike the cognitive appraisal subscales, this dimension captures personal affective distress, including feelings of irritation, anger, apprehension, emotional exhaustion, and subjective feelings of dread before clinical encounters. High scores signify elevated emotional burnout and adverse countertransferential reactions, which, if left unexamined through clinical supervision, manifest behaviorally as avoidance, coldness, or premature discharge of the patient.

Theoretical Framework

The construction and validation of the BPS Attitude Scale are grounded in the convergence of three foundational psychological theories: Attribution Theory, the Social-Cognitive Model of Mental Illness Stigma, and Clinical Countertransference Models.

Weiner’s Attribution Theory of Motivation and Emotion

According to Bernard Weiner’s attribution theory, human behavioral and emotional responses to another person’s distress are directly dictated by causal attributions regarding controllability and intentionality. When an individual’s suffering or behavioral crisis is perceived as uncontrollable (e.g., an involuntary symptom of biological disease or severe trauma), observers typically experience empathy, pity, and a pro-social motivation to assist. Conversely, when the adverse behavior (e.g., severe interpersonal aggression, sudden self-injury) is perceived as controllable and deliberately chosen, the observer attributes personal responsibility, triggering feelings of anger, resentment, and punitive behavioral reactions. In the context of the BPS Attitude Scale, the “Assumption of Manipulative Tendencies” and “BPD-Negative Emotions” subscales directly reflect this attributional shift: viewing self-injury or crisis displays as intentional acts of interpersonal manipulation triggers moral condemnation, anger, and administrative withdrawal.

Corrigan’s Social-Cognitive Model of Mental Illness Stigma

Patrick Corrigan’s public stigma model differentiates between stereotypes (cognitive beliefs and knowledge structures), prejudice (emotional evaluations and agreement with stereotypes), and discrimination (behavioral manifestations, such as withholding care or imposing social distance). The BPS Attitude Scale operationalizes this progressive pathway within the institutional hierarchy of psychiatric hospitals:

• Stereotypic Cognition: Conceptualized in the scale as fixed beliefs regarding treatment impossibility and universal manipulative intent (“BPD Treatment Difficulties” and “Assumption of Manipulative Tendencies”).
• Prejudicial Emotion: Measured through the “BPD-Negative Emotions” subscale, reflecting clinician anger, irritation, and dread.
• Discriminatory Action: Captured behaviorally through the validated construct of social distance, wherein staff isolate patients, minimize contact hours, or advocate for institutional exclusion.

Psychodynamic Countertransference and Biosocial Models

The theoretical conceptualization of the scale also incorporates insights from clinical psychoanalysis (Kernberg, 1975) and the Biosocial Theory of Dialectical Behavior Therapy (Linehan, 1993). Kernberg emphasized that borderline personality organization inevitably induces intense objective countertransference reactions in clinicians, frequently splitting staff into punitive or over-involved factions. Linehan observed that the profound emotional vulnerability and pervasive invalidation experienced by BPD patients create an escalatory transactional dynamic: intense emotional arousal in the patient triggers invalidating, protective, or frustrated responses from clinicians, reinforcing the patient’s dysregulation. The BPS Attitude Scale translates these clinical dynamics into quantifiable psychometric items, capturing the precise points where the clinician’s cognitive and affective defense mechanisms emerge during psychiatric care.

Validity

The psychometric validation of the BPS Attitude Scale was established by Schäfer et al. (2023) through comprehensive criterion-related, convergent, and construct validity analyses within a heterogeneous sample of German psychiatric healthcare professionals, including psychiatrists, clinical psychologists, and psychiatric nurses.

Criterion and Convergent Validity

Criterion-related validity was rigorously assessed by examining the empirical associations between the BPS Attitude Scale (total score and subscales) and the German adaptation of the Social Distance Scale (Angermeyer & Matschinger, 1997), an internationally recognized measure of discriminatory behavioral intention and social rejection toward psychiatric populations. The findings established distinct patterns of association:

• Total Scale Criterion Validity: A substantial, statistically significant positive correlation was observed between the composite BPS Attitude Scale score and the Social Distance Scale ($p < .001$), confirming that higher overall stigmatizing attitudes predict a heightened desire to maintain behavioral and interpersonal distance from BPD patients.
• BPD Treatment Difficulties: Exhibited a statistically significant, robust positive relationship with social distance ($p < .001$), demonstrating that clinicians who perceive BPD treatment as inherently exhausting and futile are significantly more likely to endorse institutional and personal avoidance behaviors.
• BPD Assumption of Manipulative Tendencies: Demonstrated a large, statistically significant positive association with social distance ($p < .001$). This subscale showed the strongest correlation with social rejection, supporting the theoretical premise that viewing patient behavior as deliberately deceptive directly fuels exclusionary clinical practices.
• BPD-Negative Emotions: Showed a small but statistically significant positive parametric correlation with social distance ($p < .001$). When analyzed via non-parametric testing to account for distributional skewness, Spearman’s rank correlation yielded $rho = -.20$ ($p = .056$), indicating complex interactions between conscious emotional acknowledgment, social desirability, and behavioral distance.
• BPD Assessment of Suicide Risk: The correlation between the assessment of suicide risk subscale and social distance did not reach statistical significance ($p = .067$). This divergence confirms the construct validity of this specific subscale, demonstrating that objective risk assessment operates independently of personal social rejection and moralizing stigma.

Content and Translation Validity

The scale’s content validity was safeguarded through a translation methodology adhering to the European Social Survey Translation Guidelines (European Social Survey, 2018). A panel of bilingual psychometricians, clinical psychologists, and psychiatric researchers translated the original 44 BPD-CAT items and 20 BPD-EA items developed by Bodner et al. (2011). Three items from the BPD-CAT were eliminated during preliminary expert review due to irreconcilable cross-linguistic and cultural ambiguities. Subsequent item-level relevance analysis reduced the pool to 26 cognitive items and 17 emotional items, ensuring that only items exhibiting high face validity, clinical relevance, and linguistic clarity were preserved for structural analysis.

Reliability

The BPS Attitude Scale displays high internal consistency across its full scale and individual subscales, establishing its precision as an empirical research and clinical audit tool.

Internal Consistency Metrics

In the primary validation study by Schäfer et al. (2023), internal consistency was calculated using Cronbach’s alpha across the multidisciplinary sample of mental health professionals:

• Full Composite Scale (22 items): $\alpha = .90$, reflecting exceptional overall internal consistency and confirming that the combined cognitive and affective items consistently measure provider stigma toward BPD.
• BPD Treatment Difficulties Subscale: $\alpha = .90$, demonstrating outstanding measurement reliability for items quantifying therapeutic nihilism and operational strain.
• BPD Assessment of Suicide Risk Subscale: $\alpha = .82$, indicating high reliability in assessing clinician evaluations of parasuicidal and suicidal threat severity.
• BPD-Negative Emotions Subscale: $\alpha = .84$, evidencing strong internal consistency across items capturing clinician anger, apprehension, and emotional burden.
• BPD Assumption of Manipulative Tendencies Subscale: $\alpha = .72$, reflecting acceptable to good internal reliability, appropriately balanced for an abbreviated subscale targeting specific attributions of manipulative intent.

Measurement Precision and Standard Error

The high composite reliability ($ge .90$) indicates that the scale contains minimal measurement error variance, satisfying the classical test theory benchmark for group-level comparative research and institutional benchmarking. The narrow confidence intervals around subscale scores allow researchers to detect subtle shifts in clinician attitudes following educational interventions or systemic institutional reforms.

Factor Analysis

The structural dimensionality of the BPS Attitude Scale was empirically established using Principal Component Analysis (PCA). The analytic pipeline moved from an initial item pool to a refined 22-item factor solution.

Dimensional Reduction Pipeline

The item selection and reduction sequence followed three methodological stages:

1. Initial Item Synthesis: The translated item pool began with 64 items (44 BPD-CAT items assessing cognitive appraisals and 20 BPD-EA items assessing emotional reactions).
2. Qualitative and Semantic Screening: Three items from the BPD-CAT were removed due to translation ambiguities, yielding 61 items. Next, an expert panel of psychiatric clinicians evaluated the items for clinical relevance and clarity within modern German inpatient and outpatient frameworks, retaining 26 items from BPD-CAT and 17 items from BPD-EA (total 43 candidate items).
3. Extraction and Refinement: The candidate pool was subjected to iterative extraction based on Kaiser-Guttman eigenvalues ($lambda > 1.0$), scree plot inspection, component interpretability, and cross-loading minimization. Items exhibiting low primary component loadings ($< .40$) or significant secondary cross-loadings ($> .30$) were systematically removed.

Final Four-Component Model

The final Principal Component Analysis yielded an unambiguous four-component structure comprising 22 items:

• Total Explained Variance: The four retained principal components collectively account for 63.60% of the total cumulative variance, exceeding standard psychometric criteria for exploratory questionnaire development in the social sciences.
• Component 1 (BPD Treatment Difficulties): Captures therapeutic burden, perceived intractability, and treatment delivery strain.
• Component 2 (BPD Assessment of Suicide Risk): Loads uniquely on items measuring professional assessment, skepticism, and forensic anxiety regarding parasuicidal acts and acute suicidality.
• Component 3 (BPD Assumption of Manipulative Tendencies): Comprises items reflecting causal attributions of conscious interpersonal calculation, splitting, and manipulative intent.
• Component 4 (BPD-Negative Emotions): Encompasses visceral affective reactions, including anger, frustration, and countertransferential distress experienced during clinical contact.

Inter-component correlations ranged from small to large, demonstrating that while these dimensions are related manifestations of staff stigma, each captures distinct variance, supporting separate subscale scoring.

Instrument / Measurement Tool

• Test Type: Standardized self-report inventory / psychometric attitude rating scale.
• Format: Paper-and-pencil or secure computer-assisted web interview (CAWI).
• Item Count: 22 items distributed across four distinct subscales.
• Response Scale: Five-point Likert scale, ranging from “1 = decline” to “5 = agree” (German: 1 = ablehnen bis 5 = zustimmen).
• Subscales:
  • BPD Treatment Difficulties (Cronbach’s $lpha = .90$)
  • BPD Assessment of Suicide Risk (Cronbach’s $lpha = .82$)
  • BPD Assumption of Manipulative Tendencies (Cronbach’s $lpha = .72$)
  • BPD-Negative Emotions (Cronbach’s $lpha = .84$)
• Target Population: Multidisciplinary psychiatric healthcare personnel, including adult psychiatrists, child and adolescent psychiatrists, clinical psychologists, psychiatric nurses, social workers, and occupational therapists working in inpatient, day-clinic, or outpatient mental health facilities.
• Administration Time: Approximately 5 to 8 minutes for complete self-administration.
• Scoring Procedures: Subscale scores are derived by calculating the mean or sum score of the corresponding items, with higher aggregate values indicating elevated levels of stigmatizing attitudes, perceived manipulation, therapeutic nihilism, or negative emotional countertransference. A global stigma score may be generated by averaging all 22 items.

Permissions & Fee and Test Year

• Test Year: 2023.
• Original Authors: Marvin Schäfer, Claudia Luck-Sikorski, Regine Hochrein, Georg Schomerus, and Sabine Gollek.
• Copyright & Permissions: The instrument was published academically in Psychiatrische Praxis (Georg Thieme Verlag KG). For academic, non-commercial research and institutional quality evaluation, permissions should be requested directly from the corresponding author, Marvin Schäfer (Email: [email protected]), or through the COPE Research Group at SRH Hochschule für Gesundheit.
• Commercial Availability: Non-commercial instrument. No licensing fees are required for independent academic or clinical research, subject to proper formal citation and author authorization.

References

• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing. https://doi.org/10.1176/appi.books.9780890425596
• Angermeyer, M. C., & Matschinger, H. (1997). Social distance towards the mentally ill: Results of representative surveys in the Federal Republic of Germany. Psychological Medicine, 27(1), 131–141. https://doi.org/10.1017/s0033291797005510
• Bodner, E., Cohen-Fridel, E., & Iancu, I. (2011). Staff attitudes toward patients with borderline personality disorder: The development of two new measurement tools. Journal of Psychiatric Research, 45(10), 1342–1349. https://doi.org/10.1016/j.jpsychires.2011.05.010
• Corrigan, P. W. (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625. https://doi.org/10.1037/0003-066X.59.7.614
• European Social Survey. (2018). European Social Survey translation guidelines. ESS ERIC Headquarters, City, University of London. https://www.europeansocialsurvey.org/methodology/ess-methodology/translation
• Kernberg, O. F. (1975). Borderline conditions and pathological narcissism. Jason Aronson.
• Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. Guilford Press.
• Schäfer, M., Luck-Sikorski, C., Hochrein, R., Schomerus, G., & Gollek, S. (2023). Entwicklung eines Selbstauskunftsfragebogens zur Erfassung stigmatisierender Einstellungen des psychiatrischen Personals gegenüber Patienten mit Borderline-Persönlichkeitsstörung [Development of a self-report questionnaire for the measurement of stigmatizing attitudes of the psychiatric staff towards patients with borderline personality disorder]. Psychiatrische Praxis, 50(8), 424–430. https://doi.org/10.1055/a-2088-3629
• Weiner, B. (1985). An attributional theory of achievement motivation and emotion. Psychological Review, 92(4), 548–573. https://doi.org/10.1037/0033-295X.92.4.548

Items of the Scale