Can I just say how much we at Mental Nurse like Seaneen’s blog? Funnily enough, I met Seaneen several years ago, before I’d ever even applied to study mental health nursing. We met up one sunny afternoon in London and went for a pizza and a wander round the National Portrait Gallery. Then she ran around Trafalgar Square referring to Nelson’s Column as “Nelson’s Willy” and jumped fully-clothed into the fountains. Now we seem to have had a reunion of sorts via the blogosphere - myself blogging as a mental health nurse, her as a mental health patient. Life does has a funny sort of irony.
But anyway, musings aside, I’d just like to reply to Seaneen’s list of the Six Worst Psychiatric Labels, of which number 2 is “Any personality disorder”. As she (probably rightly) points out, a PD diagnosis “implies that the sufferer is at fault.”
Just to illustrate this point, a mental health nurse once made the following comment to me:
I can forgive being assaulted by any patient who does it because of their mental illness, because it’s the illness that assaulted me, not the person. I can’t forgive an assault that was the result of a personality disorder, because that was the person that did it and not the illness.
Unfair and judgemental?
My first instincts are to say that it is unfair and judgemental, but then when I look back on my own practice, it’s harder for me to cast the first stone. Consider two patients I’ve worked with recently.
James is in the grip of a paranoid delusion. He’s convinced that anyone who comes near him is liable to hurt him. I casually walk past him in the corridor. As I do so, he gives out a little scream and lashes out at me. I manage to dodge it, but it was a shock.
John has a personality disorder. He regularly chooses members of staff to target for a while, until he gets bored and moves on to a different member of staff. A nurse and I enter his room to give him an injection. It suddenly becomes apparent that he’s just decided I’m his new object of hate. He starts glowering at me and muttering, “I’m gonna hit him.” The nurse notices this and quickly takes over the procedure from me, but not before he tries to throw a punch in my direction.
Two assaults, one the result of a mental illness, the other the result of a personality disorder. Much as I’d like to repeat the mantra about “non-judgemental attitudes”, the brutal truth is that I find it much easier to forgive James (”He’s psychotic, he’s scared, he didn’t know what he was doing”) for assaulting me than John (”He’s just a nasty little cunt who likes to hurt people”).
There’s an additional piece of irony here. James is a large, strong man and when he hits you he can do damage. On the other hand, John has had several decades of substance misuse and repeated kickings, and as a result has the fighting ability of a wet paper bag. I might find it easier to forgive James than John, but James is far more likely to actually injure me.
Like it or not, there is a pejorative aura that surrounds personality disorders. Even some of the diagnostic titles sound pejorative - “narcissistic”, “antisocial”, “histrionic”.
Here’s an interesting mental exercise. Every time you hear the words “personality disorder” being bandied around at ward rounds, handovers etc, try mentally replacing it with the word “arsehole” and see how it scans.
For example, these words, spoken by a staff nurse at handover…
“There’s something slightly odd about the way he presents on the ward. I can’t quite put my finger on it. I think there might be a personality disorder at work here.”
…become….
“There’s something slightly odd about the way he presents on the ward. I can’t quite put my finger on it. I think he might be an arsehole.”
Try it. See what happens.
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47 Comments
“I can forgive being assaulted by any patient who does it because of their mental illness, because it’s the illness that assaulted me, not the person. I can’t forgive an assault that was the result of a personality disorder, because that was the person that did it and not the illness.”
Perfectly fair. People with personality disorder are not ill; they have to learn to control and moderate their own behaviour.
Although I’m not sure that psychosis is really any excuse either. I recently changed psychiatrist and am pleased to report that the referral letter confirmed “no history of aggression towards others”.
And it is sad that has to be specifically mentioned instead of assumed.
I was once told I had a personality disorder (borderline) and in the past I have done things I am not proud of, but I haven’t blamed my disorder for this and I have never been violent to anyone else. I do blame my PD for the violence I used to inflict on myself however… Apparently women with BPD tend to turn it inwards, whereas men turn it outwards. I don’t know what the answer is, but I suppose it is human nature to feel more sympathy for some people than others. At the Therapeutic Community, people with eating disorders where almost idolised by residents and staff alike, yet anyone even thinking about self harm was shunned.
In the teaching world, I find it easier to understand a child being unruly when he/she has some kind of reason (diagnosed things or home issues), rather than is just a nuisance.
*salutes* Thanks very much!
I’ve never been diagnosed with a personality disorder, but I have been diagnosed as having “borderline traits”. This doesn’t surprise me: I am young woman who self-harms and who has a dead alcoholic father. BPD is a stock diagnosis for any female self-harmer and I’m surprised I escaped the chop of the entire diagnosis.
My borderline traits were clarified as, “self-harming, difficult relationship (refering to my relationship with my father) and impulsive behaviour such as binge drinking”. Nothing too serious there. I escaped full diagnosis because the speed of my mood swings, which were at first attributed to maybe being BPD, were in the end attributed to having ultra-rapid cycling bipolar disorder 1, rather than just yer classic cyclical, sometimes okay, bipolar disorder. I also have a very even temper and a history of extremely stable, uneventful personal relationships, which the exception of one which was conducted almost entirely in a manic phase. My reasoning involves many grey areas, not the classic black and white.
I escaped also because the “stress induced psychosis” of BPD is just “manic/depressive psychosis” in my case and all my psychotic episodes have lasted weeks or months.
I really hate the implications of BPD. What I hate more is the overlap with bipolar disorder. It can be confusing, yet bipolar and borderline patients are regarded completely differently by the psychiatric community. One of them is ill, the other is a brat. I think the key is lack of causation in mood instability. Bipolar moods tend to come out of nowhere and (usually) last at least a few days, whereas borderline mood swings are far more rapid, don’t last more than a day or so, and are caused by external circumstances.
Using the idea of replacing PD with “arsehole”. I do believe a ward I was on used PD to sound more politically correct and less derogatory than actually saying “arsehole” when that is what they meant.
People who are challenging without other MH labels on them to explain it, are banded (by nursing staff) as having a personality disorder.
I think I should go to bed, I am far too cynical this evening!
PD is a dustbin diagnosis. If the person doesn’t fit any of the other boxes, then they’ll fit into the PD one for sure. This has unfortunate consequences for many people, not least of which is the notion that they are completely in control of everything they do ergo they are culpable for everything they do. How well I remember a man on a neighbouring ward hanging himself (and dying as a result) because the staff nurse encouraged everyone to ignore his pleas for help as he was “only a PD”.
I suspect that at some point in the future, that either there’ll be a genetic/neurobiological explanation for PD and we’ll have to reframe some of our assumptions about people with them and/or generic psychiatry will jettison them entirely to a third service, combining therapy and detention.
I think it’s clear from the personality changes displayed by some people with Parkinsons Disease, dementia, acquired brain injury etc make it obvious that at least some PDs do have a neurobiological explanation. That makes it less defensible to describe someone with a PD as being “not ill”.
Oh, and hi Seaneen. I agree with you that borderline PD can be a bit of a stock diagnosis. The thing about “borderline traits” does sound like a bit of an exercise in ticking boxes….”She self-harms (tick)…difficult relationship with her father (tick)…sometimes gets pissed (tick)…Oh wait, that’s about it, so let’s call it borderline traits.”
zarathustra: How would you have reacted to James if, instead of being in the grip of a paranoid delusion, terrified that you were going to hurt him, he was in the grip of a grandiose delusion that he had been specially chosen by God to enforce God’s laws and fix society- and lashed out at you because he felt you were getting in his way?
Would you feel as sympathetic to him then?
I postulate that it is easier to empathise with someone who lashes out because of fear than someone who lashes out in anger.
Then she ran around Trafalgar Square referring to Nelson’s Column as “Nelson’s Willy” and jumped fully-clothed into the fountains.
How unsurprising was my diagnosis of bipolar 1, eh!
A little bit of a surprise. If you had stripped naked and then jumped into the fountain then it would be certain
I wasn’t wearing pants that day if you recall!
That would have just increased the certainty of diagnosis !
(”He’s just a nasty little cunt who likes to hurt people”)
Question: Why?
Answer:
Because when he was little he was hurt a lot. Like most patients - whatever false name is given to their “symptoms” i.e. coping behaviours.
People are not born bad. They learn to be that way. They LEARN it in the social circumstances they grow in. Unless they are lucky enough to escape such negative circumstances and fall on their feet they will keep on dancing the dances they were taught as a child day in day out.
Seaneen
“I wasn’t wearing pants that day if you recall!”
Yes you were. I saw them when you climbed out of the fountain.
Aaaah. Foggy memory! I knew you saw something!
(It was another time I went to Trafalger Square. Was not wearing pants and was with a tall Mancunian!)
Ariel said: “Perfectly fair. People with personality disorder are not ill; they have to learn to control and moderate their own behaviour.”
Ariel, I read your post some time a few days ago and was unfortunately unable to respond because of problems logging in (not because of my head rotating like something out of the Exorcist and spitting bile from between my gritted teeth).
However, as someone who has been diagnosed with a Personality Disorder, this is one of the most ignorant, insulting and offensive comments I’ve read in a long time. Worse still, you have made this comment when you obviously suffer from mental health problems yourself. Way to go.
P.S. Can I advise you to write to a) my consultant psychiatrist b) my therapist and/or c) The Diagnostic and Statistical Manual of Mental Disorders. I’m sure they’ll all be delighted to hear that I’m not really ill, BPD doesn’t exist as an illness and we can all go home and eat bourbon biscuits until we explode (how very Borderline).
Lou,
just because someone takes a different point of view to you does not imply that their opinion is necessarily based on ignorance.
The following link is to a paper from the Institute of Psychiatry, King’s College London, entitled ‘Should Psychiatrists Treat Personalitly Disorders?. (The case against is a fair representation of my views).
http://www.iop.kcl.ac.uk/departments/?locator=600
Ariel,
Thanks for the link, which I read with interest. However, it seems that Moran, despite his distaste for the “diagnosis” and the lament for the lack of specific treatments to “contain” this “difficult group of people” (cheers Paul) he actually concludes that psychiatry is in a position to help “these people” with their “deviant behaviour.”
“Psychiatry is in a position to help.”
So, if Moran’s case is a fair representation of your views, it may be fair to assume that you think that however inconvenient the diagnosis may be, it is still appropriate to chuck all these deviants into the mental health system and watch them all foam at the mouth while they settle into a 12 month waiting list.
And, if it is treatable by Psychiatrists, rather than the electric chair (as stated by Moran), surely it is then reasonable to view it as a mental illness?
Lou,
The paper presents two opposing cases. I specifically supported the case against, so no, I categorically do not agree that it is appropriate to treat people with personality disorder in the mental health system.
Ariel,
Yes, a paper will usually present an opposing view. This is called an argument. However, as the paper is written by Moran, I think it’s reasonable to assume that you agree with his conclusion. Which is that people with Borderline Personality Disorder should be treated in a mental health system.
Where do you think people with a personality should be treated?
oops. Spot the Freudian slip.
Although, I would argue that Personality Disorder must be treated by a Psychiatrist who has a personality.
Seems to me that the whole trouble with people with PD and the psychiatric system is one of resources. If you’ve spent, say, 18 years of your life developing and maturing a nice little personality disorder, it’s not going to be fixed in the span of time allocated to your average psych patient in out-patients or on in-patient wards. However, psych services are expected by society and by the government to ‘fix’ these people. The failure of services to fix people with PD gets transmogrified into a failure of people with PD to be fixed, if you get my gist, hence the stigma directed towards them.
Beakie Wrote: “If you’ve spent, say, 18 years of your life developing and maturing a nice little personality disorder, it’s not going to be fixed in the span of time allocated to your average psych patient in out-patients or on in-patient wards.”
Agreed. It takes time to develop a personality disorder so it’s reasonable to take a bit of time trying to repair the damage caused by a lifetime of crappy coping mechanisms.
A therapeutic relationship doesn’t establish itself overnight and the last thing the patient/therapist needs is pressure to “just fucking fix it” and decrease the never ending waiting lists.
it’s It’s like Simon Cowell yelling at a tuneless granny because she can’t sing.
I’ve been in treatment for nearly seven years and I’m only starting to “deal” with my problems.
P.S. I’m not unfixible - just emotionally challenged.
Beakie,
I think the reason for stigma (I would call it legitimate disapproval) against people with personality disorder is much more fundamental than you suggest. It is based on what you previously described as “the notion that they are completely in control of everything they do ergo they are culpable for everything they do”
Or, as Gwen Adshead (consultant psychotherapist at Broadmoor Hospital) puts it:
“Formalised diagnostic criteria, such as the DSM or ICD, have tended to equate symptoms with negatively evaluated behaviours, such as deliberate self-harm or violence to others. This causes conceptual problems because usual accounts of illness, and illness behaviour, define ‘symptoms’ as actions or experiences that are not willed, desired or chosen by the patient. However, negatively evaluated behaviour is so evaluated precisely because it is perceived to be chosen or willed by the patient, and behaviours or experiences that are willed or chosen are not symptoms.”
A number of doctors appear to take the same view (see link below)
Psychiatrists criticise colleagues who describe self harming patients as wilfully immature.htm
Hi Ariel,
I can’t help the feeling that you’re generalising. Surely every person with a personality disorder should be viewed as an individual rather than “they”? What type of personality disorder are you referring to?
Not everyone has an axe to grind and gets an en suite room in Broadmoor.
Most people are just just sad, depressed and make unhelpful choices that may be based on years of continued emotiona/physical or sexual abuse.
They don’t need your disapproval, “legitimate” or not.
Beakie wrote:
“If you’ve spent, say, 18 years of your life developing and maturing a nice little personality disorder”
Nicely put.
Whilst elsewhere (climbing on a high horse) he scribed the following:
“For all you know, there might be people out there reading this site who have serious mental health problems and will be frightened off from seeking help by endless scary tales of dreadful nurses and doctors.”
So what about the people out there with Personality Disorder (that you a/ don’t understand b/ don’t know the pathology of and c/ don’t know how to treat) who read that lovely little patronising line of yours and decide to jump out of the window because of the misunderstandings they can no longer bear because of people like you?
Oh sorry I forgot. You are a Mental Health Professional. It’s OK for you to be patronising eh? All part of the “containment game”, I suppose!
lou .. im in full agreement with every word you have written in this thread.
I’d also like to appologise for flaming back at you in the other thread. I don’t like being called an arse and I wasn’t being one. I was having a discussion about power and politics.
If I decide to jump out the window, I’d be making a choice. I’d also be making that choice as a result of a mental illness.
Hopefully it would be a ground floor one though.
M. Scott Peck, acclaimed author and psychiatrist, said in his widely acclaimed book “The Road Less Travelled” that:
“99 per cent of the population have no idea why they are doing what they are doing 99 per cent of the time.”
He’s a brighter, more qualified and more respected authority than any of us. And what he has written above makes the nonsense below plain:
Ariel wrote: … “I think the reason for stigma (I would call it legitimate disapproval) against people with personality disorder is much more fundamental than you suggest. It is based on what you previously described as “the notion that they are completely in control of everything they do ergo they are culpable for everything they do” … “
Hi IB,
Thanks for your apology. I’m sorry for calling you an arse.
Ariel,
I’d be genuinely interested to hear how you think Borderline Personality Disorder should be treated.
Personally, I fancy one of those Californian Spa Ranches but I can’t see the NHS stretching the budget to therapeutic horse whisperers and 4 ply linen sheets.
Lou … you might appreciate this:
In 1979, Elvita Adams jumped from the 86th floor of the empire state building in an attempt to commit suicide. There was a strong wind blowing that day and Elvita’s attempt was foiled as she was blown back onto the 85th floor ledge and knocked unconscious. Half an hour later she awoke and banged on the window until someone came to her aid. She escaped with only a broken hip and decided that it wasn’t her day to die after all. Once the Hip was fixed she got on with her life which somehow made more sense to her than ever it did before.
… so you could go for the ground floor … yes I would actually. I think the circumstances abpve are unlikely to occur frequently.
but while looking for the details of that ^^^ I found this:
http://www.snopes.com/horrors/freakish/opus.asp
Possibly one of the saddest/funniest tales I ever encountered.
(although untrue)
Which also proves that no one is”completely in control of everything they do.”
Although I think Elvita Adams must have been a size zero.
When I was diagnosed as having a Personality Disorder I was made to wait 2 years for therapy to “prove I wanted it”.
Then they realised (after I pointed it out) that I didn’t have a personality disorder at all but that I suffered Chronic PTSD, and later it was recognised that I suffer DID. Now the NHS is paying £25,000 a year for some very specialised and beneficial therapy from an independent provider.
How much spa treatment would that run to? Actually if I booked into a spa for a year they’d probably do it for that .. and Id have 24/7 pampering as opposed to 2 hrs a week of chatter.
Lou I might look into this
Interestingly whilst under the diagnosis of personality disorder I was “responsible for all my actions”. Now I am not, apparantly, though actually the truth is I am, only some of those actions don’t come from the same ‘personality’ as others. Some of them come from a little child in me who stopped growing age seven … some from younger personalities.
Say someone pins me up against a wall and threatens me. That triggers a different personality who is very socially undeveloped and unaware but very self-defensive. I kill them in rage triggered by what they are doing to me.
Which personality would you hold responsible Ariel? And given that my condition is recognised as meaning that at certain times I can be triggered into a personality with a mental age and development of a child, can I be held criminally responsible for my actions in such a state? Should I be?
No, of course not. The responsible persons are: the abusers who left me in this state; the mental health system which took years to recognise my condition - because it chose to ignore the abuse history and therefore failed to intervene at the earliest opportunity; and, the fool who pinned me up against a wall without knowing what I was capable of.
Yet .. whilst I had that label of “Personality Disorder” pinned over me I would have been banged up for life and labelled as having not learned “to control and moderate (my) own behaviour”.
Of course I didn’t. My body and mind were violently ripped away from me throughout childhood: I never learned to control my own behaviour because I was taught from very early on that my body and mind were not mine to control.
Hence the diagnosis Dissociative Identity Disorder: NOT my body NOT my mind. And this is actually the disorder that most people diagnosed PD probably have, according to Valerie Sinason, one of the leading practitioners in this field and with possibly a greater knowledge of the subject than anyone else in the UK.
The theory is their violent outbursts and other symptoms are not “knowing acts” but the repressed personalities trying to break out, through the control of one overwhelming personality that embodies and enshrines their final teenage response to their childhood as a “nasty c**t”
My Personality Disorder only took me about 4 years to “cultivate” and about 2 to beat. I’m lucky.
I went to a Therapeutic Community for 3 of the 12 months one would normally spend there. It worked by putting my behaviour up to my face in the form of 15 or so other patients. I soon realised how much I didn’t want to be like them and haven’t looked back since.
IB
Just wondered if you were finding therapy helpful. Is it CBT?
I see a CBT therapist weekly. Until then, I wasn’t aware that the choices I made were often based on negative voices from my childhood. I was/still am mentally ill, but now I am beginning to challenge these voices and make choices that help me to live as a happier, healthier adult.
Now, even if I’m in the middle of making an unhelpful choice (say, self-harming) I am more able to analyse the reasons behind it and how I can take steps to seek out alternative methods of coping. It doesn’t always work but as I’ve already mentioned, it takes time and perserverence from both patient and therapist.
I am obviously one of the lucky ones.
IB - see you in the Jacuzzi. Champagne cocktails on me.
Elliecat,
It’s great to hear your story. You should be really proud of yourself and it proves that Borderline Personality Disorder IS treatable and recovery IS possible.
Great to hear your comments.
L x
Lou
No not CBT. it’s Psychoanalytic based Psychotherapy but with a very highly trained therapist specialising in issues such as mine. It’s very non confrontational and I feel like its my space for me to heal. I also have the chance to undertake other approached through the clinic and with their help.
They see themselves as facilitating my recovery and not as “treating” me “confining” me or anything else.
I am not expected to lay on a couch with the therapist behind me - something the Tavistock tried to force on me when they treated my non-existent “Personality Disorder”. Can you imagine a therapeutic recipe worse for a survivor of prolongued ritualised abuse than expectinmg them to relate to a disembodied voice behind them? lol I can’t and I’ve tried a few things.
The clinic also offer me telephone support whenever I need it and help pay for complimentary therapies.
If I am not up to travelling on public transport they pay for a cab to be sure I can go.
I would like to add some CBT in to the mix soon but that is to address some specific issues. It is good to hear how effective it has been for you.
And yes, as long as its all in moderation you can buy the champagne cocktails - I’ll bring the rubber duck
Matthew
IB
Yes, my therapist uses the collaborative approach too. It’s empowering, no?
Initially I found the CBT really challenging but I’m getting the hang of it now.
Look forward to meeting the duck
IB - are you going to stalk me round this site picking apart everything I write from hereonin? Just let me know if you are, so I’ll know what to expect.
beakie wrote:
“IB - are you going to stalk me round this site picking apart everything I write from hereonin? Just let me know if you are, so I’ll know what to expect.”
No way mate … not my style … actually last night I was contemplating our previous spat: I came to the conclusion that you are probably a little marxist in your politics and meta-analysis of the human situation and that that lead in large part to the confusions between us: We were working and speaking from different meta-paradigms. I was contemplating that we might both learn something if we explored that more. In particular I thought it might be something that could inform us both through a more private dialogue as in comment threads it becomes too confused with the input of others.
But where I see absolute bunkum, contradictory statements or poorly argued thinking I reserve the right to argue with it to my hearts content.
Regards to what I wrote above I am not picking you apart - you simply can’t have it both ways.
You told me off in no uncertain terms for potentially making a visit to this site unpleasant. If the idea that visiting this site is not to be a negative experience for people in trouble is as important to you as you say, then be more careful about what you say:
““If you’ve spent, say, 18 years of your life developing and maturing a nice little personality disorder”
I find that to be insulting, belittling and to show a total lack of understanding and a deep lack of compassion. I am worried that people with personality disorders looking for information may come accross what you have written and end up feeling that little bit worse about themselves than they already did.
Might be the straw that breaks the camels back. As a MH professional and trainer I really would expect a greater awareness of the subtlety of such issues than you seem to exhibit. Especially as you made such a point out of this yourself.
Be consistent and support what you say with logical statements. Live by the edicts you pronounce others must live by. And stop trying to have the last word when what you say is plainly unsupportable.
I’m sure we’ll have every possibility of ending up best of friends at the end of the day, because I know I am not a bad person and I have no reason to suspect you are either.
This comment is an ironic joke with historical references - Just in case anyone doesn’t get that.
I think people with Personality Disorders should be treated by the “ducking stool”.
As they are responsible for everything they do, should they chose to live when under the water, that will prove they had a really messy Personality Disorder. We are therefore better off without them so at that point they could be thrown back in tied to rocks or given a chemical cosh to control their unruly behaviour.
Should they die it will prove they weren’t responsible for everything they did and had an “organic mental illness” after all. Then we can give them a half decent burial and save quite a lot of money on unproven treatments.
This would be a great crowd puller and Mental Health Trusts could boost their ailing finances with the ticket revenues and TV sponsorship for the ducking events. Then people with “real” mental illnesses could get all the help they so rightly deserve.
You told me off in no uncertain terms for potentially making a visit to this site unpleasant.
No I didn’t. I pointed out how aversive constant tales of horrible health professionals might be for casual visitors to this blog. That was not directed at you, and I’m sorry if you felt it was.
My comment about “nice little personality disorder” was not meant in anything but a flip way, and it’s interesting that the one person I’m aware of who was actually diagnosed with a PD had no problem with it.
Again, I would thank you not to cast aspersions on my abilities to do my job based on my contributions here. It’s unnecessary, offensive and bullying.
So this wasn’t directed at me?
beakie wrote:
IB - as I understand it, this is a moderated site … blah etc …
I shall cast no more aspersions nor make snide remarks. You are a jerk mate. You don’t even remember what you said a day ago half the time.
And you are the bully: the passive aggressive tone in your posts makes me feel physically sick.
Beakie: Go on - have the last word, I know you can’t resist it.
^^ passive aggressive bullying at work.
(and you don’t know me that well - I am quite happy to let that thread stand exactly as is)
Beakie Said: “My comment about “nice little personality disorder” was not meant in anything but a flip way, and it’s interesting that the one person I’m aware of who was actually diagnosed with a PD had no problem with it.”
*shrugs* I didn’t have a problem with it.
IB - just an observation (not a criticism). This is obviously a discussion between Beakie and yourself BUT
I do feel that you see this site in very black and white terms - “Service Users” on one side and professional mental health staff on the other.
I’m just wondering if this is helpful for you or anyone else.