<<< I am delighted that Rob Fitzpatrick from Confluence has agreed to write a guest blog on personality disorder. Confluence has extensive experience in mental health and criminal justice and have worked with many UK police forces and NPIA over the last few years.
I am sure many police officers will find this article useful, as it’s a term we hear a lot – often as the reason why something in the mental health world can’t be done – and a greater understanding is undoubtedly due. >>>
In this contribution to the Mental Health Cop blog I would like to raise the theme of personality disorder and explore some of the challenges that people who ‘have’ this condition can present for multi-agency practice. I will also outline some ‘low-tech’ ways in which the police and partner agencies can work together to make a difference for this group. I am not writing this as a Police officer, but rather from the perspective of someone who has worked closely with the Police, firstly on the ground within the voluntary sector and housing, and now as a consultant, specialising in research and service development in the joined fields of mental health, social care and criminal justice.
In these roles I have come to appreciate the significant challenges which personality disordered individuals can present for inter-agency communications and working. I argue that developing a stronger understanding of the thinking and experiences of people who ‘have’ personality disorder can help to make sense of a lot of challenging behaviours at the front-line of service delivery, and that some simple techniques can help to point the way to more effective strategies for multi-agency management, and also to more effective and humane service provision.
DEFINITIONS
While ‘personality’ can be broadly defined as patterns of thinking, feeling and behaving which makes each of us who we are, the term ‘personality disorder’ (or PD) describes a combination of emotional, interpersonal and behavioural traits which result in inflexible or maladaptive responses to everyday situations. Somebody who ‘has’ a personality disorder displays deeply ingrained personality traits which can result in profound difficulties in sustaining fulfilling lives and relationships. For the individual concerned this can lead to profound personal distress, while for the people and agencies who come into contact with them their behaviour can be experienced as deeply challenging.
In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), ten types of personality disorder are identified which are organised into three clusters. The “suspicious” cluster consists of paranoid, schizoid, schizotypal and anti-social personality disorder; the “emotional and impulsive” cluster, borderline, histrionic and narcissistic; and, the “anxious” cluster, avoidant, dependent and obsessive-compulsive PD. Contrary to widespread popular association with violence, risk of violence is not a universal characteristic of PD while in fact many people who have this condition being at risk of self-neglect, self-harm, harm from others or suicide.
While the prevalence of personality disorder has been estimated to be around 5% of the general population, the level could be as high as 66% for prisoners, with similar figures for offenders in the community under the supervision of probation, 70% among homeless people and 61% among substance misusers. This means that many groups with a high likelihood of coming into contact with the police and other emergency or front-line agencies have a high incidence of having this mental health condition.
There is consensus among mental health experts that personality disorder originates in experiences from early years and childhood of trauma, neglect and abuse which become embedded within patterns of thinking, forming relationships and behaving. It has therefore been described as being a form of ‘compounded post-traumatic stress disorder’ where a succession of traumatic events serve to define the way in which an individual’s personality functions. A characteristic of PD is a profound difficulty or inability to bear thoughts which can repeat or re-enact earlier painful experiences – the ‘dissociation’ or profound reaction to personal triggers which can find expression in a range of disturbed or disturbing behaviour which according to the individual can comprise of threatening, coercive, self harming or suicidal behaviour.
Partly because of their challenging behaviour, some individuals who have a personality disorder can experience serial unsatisfactory engagement with a range of different agencies, including mental health services, housing, homelessness, substance misuse, and of course the police and emergency services. Further, although people with PD clearly experience distress, many front-line workers can struggle to or fail to empathise and dismiss their behaviour as ‘attention seeking’. Similarly, due to its deep seated characteristics, some clinicians describe PD as an ‘untreatable’ condition. Both assertions are incorrect and in fact, it has been a principle of mental health policy in England and Wales for some years now for PD should not be a ‘diagnosis for exclusion’. Further, forms of psychotherapy and cognitive behavioural therapy have been proven to be effective treatments.
From a different perspective, the term personality disorder is unpopular with some practitioners and users of services as it is considered to be overly stigmatising and judgemental. While it is clear that the attitudes described above reflect dismissive and careless attitudes to people experiencing distress and in need of support, I nevertheless argue that the term remains valid. For example an understanding of the origins of personality disorder can help inform a progressive exploration of the relationship between childhood poverty, trauma and poor mental health.
CHALLENGES FOR COMMUNICATIONS BETWEEN AGENCIES
Front-line agencies can experience significant challenges around delivering and coordinating effective responses for people with a personality disorder. Because of the highly personally and emotionally challenging behaviour they can present, combined with widespread perceptions around ‘untreatability’ people identified as having a personality disorder be deeply unpopular with practitioners in a range of different services. This can be particularly the case for those who are assessed as having needs which do not reach the threshold for receiving support from statutory agencies or supervision under Multi Agency Public Protection Arrangements and who therefore can effectively become ‘hot potatoes’ between agencies.
‘Stand-offs’ can frequently occur between mental health, substance misuse homelessness, criminal justice and other agencies around which service should take a lead role for case management of individuals with personality disorder and complex needs. The resulting gap in provision may result in an individual more frequently coming into contact with the police and other emergency services on account of repeat offending, personal crises and medical ‘emergencies’. In instances such as this, the challenges faced by a range of agencies in relation to an individual can feel intractable, case files can heave under the weight of paperwork, and despite lots of heated meetings focusing on legal and technical minutiae concerning the remit of services, the individual service user themselves can appear to make no progress. Another consequence for unsupported staff of working with such people can be to create highly defensive, inflexible, ‘tribal’ and at times macho approaches to contact both with an individual service user and with other agencies with an interest in their care or support.
However, if we step back from the seemingly intractable problems which service users with Personality Disorder can present for agencies and staff and consider how they might actually experience both their contact with services and their personal lives, we can start to develop a clearer sense of how agencies might start to move forwards together. Writing about working with personality disordered individuals in contact with homelessness services and the staff who support them, the psychotherapist John Adlam characterises such people as having ‘unhoused’ states of mind. This is a state in which experiences of ‘not belonging’ in earlier life find expression not just in becoming homeless but also in the way in which somebody engages with or accepts services.
“They lead liminal lives, the doorstep, the threshold, the borderline is in a sense their only true home.”
Adlam argues that a clear problem for agencies working with someone with an ‘unhoused’ mind is that that whatever services try to do to house and support, coordinate responses to, or indeed police such people, they can refuse to voluntarily comply on account of their identification with life at the margins. Further, any externally ‘imposed’ solution, however well meaning may be perceived as persecutory and therefore rejected. To illustrate this, how often have we come across cases in our own work where somebody calssified has having PD is offered the support we know they need only to reject it and end up from our perspective in a more impoverished situation? The implication for multi-agency practice is that in order to engage more effectively with service users with personality disorders, a more thoughtful approach is required which can accommodate not just agencies’ own perceptions of an individual’s need, but also an awareness of how they might in fact respond to interventions.
POSSIBLE WAYS FORWARD
So how can agencies start to work better together to improve responses to challenging service users with personality disorders? While there are no clear cut answers, many specialists in this field advocate ‘low tech’ responses which can enable incremental improvements to practice. Here are four recommendations:
- Reflecting upon the actual/lived experiences of service users – developing mindfulness of what life might be like for a service user can help to develop appropriate strategies, either as part of multi-agency meetings, supervision or personal reflection.
- Taking effective joint action while avoiding punitive or counter-productive approaches – As we have explored, a danger when working with personality disordered individuals can be to impose ‘solutions’ which make practitioners feel better but which for service users re-create originating patterns of neglect or abuse and thus perpetuate challenging behaviour and issues for interagency management.
- Doing things differently – Sometimes, it can help for multi-agency groups to think differently, explore different approaches, or take managed risks in order to secure a breakthrough with a personality disordered service user.
- Drawing upon the strength of the Police to offer leadership – due to their practical and solution-focused approach, the Police can be ideal partners for offering leadership or problem solving around Liaison and Diversion, Integrated Offender Management, MAPPA and other multi-agency forums involving mental health. In offering leadership, the Police can start to move from being the ‘social service of last resort’ to becoming a more effective equal partner promoting better multi-agency practice.
Links to further information about personality disorder ·
- Mind’s website:
- Rethink’s website:
- Homeless Link’s website – A short paper by John Adlam outlining the the ‘unhoused mind’ and implications for services:
- DH / NOMS resource which focuses on severe personality disorder.
You can contact Rob Fitzpatrick or Lorna Thorne from Confluence:
Email: rob@confluence-partnerships.co.uk | Twitter: @ConfluenceRob | Website: http://www.confluence-partnerships.co.uk
Winner of the President’s Medal,
the Royal College of Psychiatrists.
Winner of the Mind Digital Media Award
All views expressed are my own – they do not represent the views of any organisation.
(c) Michael Brown, 2012
I try to keep this blog up to date, but inevitably over time, amendments to the law as well as court rulings and other findings from inquests and complaints processes mean it is difficult to ensure all the articles and pages remain current. Please ensure you check all legal issues in particular and take appropriate professional advice where necessary.
Government legislation website – www.legislation.gov.uk
Mental Health Cop 
First and foremost, I’d like to say thank you for explaining the origins of personality disorder compassionately and relating to the terrible distress (gosh ‘distress’ seems inadequate!) individuals suffer.
As someone who has in the past been misdiagnosed as having personality disorder I know firsthand what this diagnosis can mean for sufferers in terms of treatment by services, and perhaps a little insight into how it feels as I have severe depression caused by long-term traumtic situations.
There are three things I’d like to add:
1) People with a diagnosis of PD are DEFINITELY treated with a lack of understanding, compassion, and even basic humanity by MH services. This is because services often institutionally discriminate against this group, and individual practitioners may have an old-fashioned, uncaring ‘you’re incurable’ attitude as well as entrenched ‘compassion fatigue’ (to be honest it’s time to find a new job then!). For someone with these trauma/neglect induced problems this can echo earlier life experiences and be a ‘re-truamatisation’.
2) People are often misdiagnosed as having personality disorder, specifically ‘borderline personality disorder’. Things like self-injuring or having an abusive past can lead to a snap judgement diagnosis which is all but impossible to retract later on. This is worsened by ‘confirmation bias’ by professionals, ie. noticing things that appear to support their diagnosis and neglecting other information. (See the Rosenhan Experiment).
When suicidal or severely depressed, someone with a PD may well be ignored because ‘they always feel like that’ (!), or it is interpreted as attention-seeking (tick a box!). If they question the diagnosis, or try to explain why they need help, they can be labelled ‘manipulative’ (tick another box!). If they are upset or angry about how they’ve been treated – perhaps you told them they were a waste of time, or stitched their self-harm wounds with no anaesthetic – you can call it ‘innapropriate anger’ (tick another box!). Do they have unsual dress sense or anything else you can shoehorn in to a diagnosis? (tick boxes all over at random and justify them later! – in fact you probably won’t have to. It’s not your life this is going to affect.)
I would hope that the expansion of PD services means less of this sort of misdiagnosis, as labelling someone ‘PD’ will no longer mean you can get rid of them. However, with cuts to services all over the NHS we shall see… (note to governemnt: IT’S CHEAPER IN THE LONG RUN TO TREAT THEM!!)
3) Regarding “some individuals who have a personality disorder can experience serial unsatisfactory engagement with a range of different agencies”. I think when the above is taken into account, one can see why!
Aside from this, there seem to be other issues though, encountered by the vast majority of PD service users (mainly BPD) that I have come into contact with. One issue is that psychiatrists seem to want to medicate people up to the eyeballs, often with drugs that have strong sedative effects. This does nothing to help someone with a PD in the long run, but perhaps makes it easier for the professionals, to ‘keep them quiet’, in the meantime? Often these drugs have other undesirbale side-effects which overall make life worse for the patient – yet refusal to take them gets a label of ‘non-compliance’ and threats of exclusion from services altogether.
I have never spoken to someone diagnosed as PD who isn’t willing to get APPROPRIATE help. The problem is that there often isn’t any appropriate help – long-term therapy – and where there is, waiting lists are incredibly long. It is also quite possible to be excluded for not being ‘stable’ enough for therapy – something someone with a PD obviously really struggles with.
Also, services often claim to be ‘involved with’ or ‘supporting’ a patient, but in reality this isn’t very much help at all. It might mean they have a care co-ordinator they can contact by phone every third tuesday morning on a full moon during months that have an ‘r’ in. My personal favourite is ‘support from the crisis team’ which means a phoneline that is often unanswered. When it is answered, the crisis team never visit but love to call the cops for a ‘welfare check’, whereupon one is forced to go to the hospital, perhaps under s136, then must wait in A&E for HOURS until the crisis team show up to asses, before sending the person home saying ‘ring us if you need support’…!
Even having ‘input from services’ such as a CPN visiting once a week, isn’t actually treatment, so they probably won’t get any better. Services then drop them but can claim to have tried.
Apologies for the long post, but it breaks my heart.
Betty
Your comments reinforce the fact that although official health policy states that PD should not be “a diagnosis for exclusion” the reality on the ground can be very different. I am sorry that you have had such a bad experience in your contact with services and hope that things are better for you now.
Rob
I didn’t think this post was very clear, and its four recommendations have nothing in particular to do with personality disorders. Indeed, the first of them is impossible in practice for service users with any kind of severe mental illness.
In mental health, “personality disorder” is completely useless as a diagnostic label, because it refers to such a wide class of conditions. A specific diagnosis like “narcissistic personality disorder” is useful because it tells you something about how the person responds to other people. A specific diagnosis like “borderline personality disorder” (BPD) is less useful, partly because the nature of that illness is emotional instability, and partly because BPD is often misdiagnosed or bandied about without any formal diagnosis at all. The term “personality disorder” on its own may sometimes be a way of saying “BPD without formal diagnosis”. It doesn’t convey any reliable or useful information about the patient.
I’d agree with the explanation in terms of profound reaction to personal triggers, although it applies to all mental illnesses, not just personality disorders. The trouble is, you can’t tell what the triggers are, even supposing you know the correct diagnosis. It’s also true that personality disorders, just like other mental illnesses, can lead to challenging behaviour that includes threats, coercion, self harm and suicide. But in terms of working with mentally ill people there’s a silver lining to that dark cloud, and it’s that their irrationality can make them very suggestible. Challenging behaviour sometimes vanishes if you seem unconcerned and friendly. Sometimes, anyway.
It’s disappointing that the post doesn’t look into why personality disorder is so often “the reason why something in the mental health world can’t be done”. In specific cases of that I’d want to question whether national guidelines for diagnosis and treatment had been followed by the mental health trust.
All views welcome – I’m certainly always learning and your comment helps.
CB Tish
Thanks for your feedback. To clarify, my post focuses on some of the challenges for multi-agency practice of engaging with people who ‘have’ a personality disorder and possible responses, and is not intended as a comprehensive review of this condition. I’m certainly not arguing for the validity of PD as a diagnostic category, but rather that the wider understanding of subjective experiences of individuals with this label can help to free up the thinking space to start to address seemingly intractable multi-agency problems. Further, the solution-focussed approach and leadership of police officers within multi-agency work can achieve a major impact for this group (and for people with other diagnostic labels).
Rob
Apparently borderline personality disorder is not a mental health problem, according to……a DBT therapist in a police statement read out in court. That was at a magistrates court. The therapist worked for the NHS.
Mental health cop please comment professionally about the above.
Patient was on two antidepressants and quetiapine as augmentation, had a history of multiple hospital admissions, totalling one year, recurrent major depression, clinical anxiety and panic attacks and borderline personality disorder.
Doesn’t do much for public confidence.
I understand that certain people with a personality disorder relentlessly persecute others including making a string of false complaints to the Police = harassment by proxy. Indications of a personality disorder for me as a lay person have been – over-friendliness while at the same time logging complaints about a neighbour; self-centred lifestyle – dogs never taken out so bark, howl and whine when left; cats rarely let in due to aggressive dogs; child never dressed except for school; never has friends to play nor does she have friends to visit; is rarely taken out except to the shops; is taken out after 11 p.m. to collect the mother from work; is abnormally passive; allowed to run into the road without restraint; visitors rarely allowed in (she deals with them from the landing window with dogs barking frantically; interferes with tradesmen working for neighbour; briefs against neighbour to these and to other neighbours; family members also harass by means of vehicle nuisance, obstruction, gestures and shouted abuse; tells outrageous lies to the Police but carefully links these to an incident where she was the aggressor/harasser; increased nuisance in order to provoke a response & then record ‘evidence’ to support her lies; ignores the covenants for the development; misleads Police about this; plays the ‘child card’ claiming threatening abusive behaviour towards the child; contrives ‘incidents’ to justify further complaints about the frail, elderly neighbour next door – with camera ready for the carefully planned and acted incident; is personable and flirtatious and adept at turning on tears to play the victim.
Possible indicators for the Police = multiple frivolous, unjustified complaints about attempts to negotiate with her and then a letter explaining the problems; 46 logs in first 14 months; 76 hours of Police time spent responding to her calls by one year later i.e. over 26 months; no action recommended after investigation each time, including after a voluntary interview with the vulnerable neighbour (the first time that the Police had spoken to her); concerns raised by the elderly neighbour about the abnormal lifestyle and welfare of child and animals.
I understand that almost 50% of prisoners have been diagnosed with Antisocial Personality Disorder but what is being done about the criminals conducting hate campaigns in their neighbourhoods. The above is just one example from a ‘Neighbours from Hell’ support site = http://www.nfh.org.uk.
Any advice would be helpful to a large number of people whose lives are blighted by this type of person.