Understanding and caring for people with personality disorders.

“M anipulative”, “difficult” and “attention seeking” are words that have b e e n u s e d b y m a n y health professionals to describe individuals with a diagnosis of personality disorder. Despite examples of good practice and positive attitudes (Castillo, 2003), psychiatric descriptions of personality disorder (American Psychiatric Association, 2000, 2012a, World Health Organisation, 1992) sound like moral, rather than medical, descriptions of behaviour (Gould, 2011). This is one reason why some authors have criticised personality disorder as a diagnostic category and have argued that some health professionals make negative judgments about people so diagnosed, assuming that they are merely “bad”, rather than in need of help (Gould, 2011). In the past, this sometimes resulted in individuals with personality disorders being excluded from health services, partly because of “therapeutic nihilism” (Casey, 2011): a belief that any professional intervention would be of no benefit (Horn et al, 2007). However, research suggests that a variety of approaches reduce distressing symptoms and help some individuals with personality disorder to change behaviours that cause distress to themselves or others (NICE, 2009b). The Department of Health emphasised that personality disorder was “no longer a diagnosis of exclusion” (NIMHE & DH, 2003). Since the publication of this document, there have been an increased number of services for individuals with this diagnosis (Garrett et al, 2011). But research suggests that professionals’ positive attitudes are crucial for the success of interventions (Bowers, 2002). An empathetic understanding of the positive attributes and the difficulties of people with personality disorder is fundamental to all professional work with them. However, empathy can be hard to achieve, given some individuals’ difficulties in trusting professionals and in building and maintaining relationships (Aiyegbusi & Clarke-Moore, 2009). It is easy to see why professionals in general, for example, in accident and emergency departments, may find these distressed individuals difficult to cope with. Without appropriate support, education and clinical supervision, there is a danger of negative responses: “Oh no, it’s her again.” Understanding the nature of personality disorder, and causative factors involved, is crucial to work with individuals with this diagnostic category.