<<< 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.
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: email@example.com | Twitter: @ConfluenceRob | Website: http://www.confluence-partnerships.co.uk
The Mental Health Cop blog
– won the ConnectedCOPS ‘Top Cop’ Award for leveraging social media in policing.
– won the Digital Media Award from the UK’s leading mental health charity, Mind
– won a World of Mentalists #TWIMAward for the best in mental health blogs
– was highlighted by the Independent Commission on Policing & Mental Health
– was referenced in the UK Parliamentary debate on Policing & Mental Health
– was commended by the Home Affairs Select Committee of the UK Parliament.