Clinical Topics in Personality Disorder

Simon McArdle (Department of Family Care and Mental Health, School of Health and Social Care, University of Greenwich, London, UK.)

Therapeutic Communities: The International Journal of Therapeutic Communities

ISSN: 0964-1866

Article publication date: 5 April 2013

43

Citation

McArdle, S. (2013), "Clinical Topics in Personality Disorder", Therapeutic Communities: The International Journal of Therapeutic Communities, Vol. 34 No. 1, pp. 53-54. https://doi.org/10.1108/09641861311330509

Publisher

:

Emerald Group Publishing Limited

Copyright © 2013, Emerald Group Publishing Limited


This book is called, Clinical Topics, and is very much written for the practitioner. The book is divided into three very appropriate and readable sections: the nature of the problem, the management and general treatment approaches, and specific treatment approaches. This text has Gwen Adshead as one of two joint editors and, as one would expect with such an editor, is a first class resource for all practitioners working in the field of personality disorder. However, that said, I want to preface my detailed discussion of the content with a general point of disagreement. Although the book is published by the Royal College of Psychiatrists and therefore, as one would expect, there is regular reference to it being suitable for psychiatric trainees, I do not see any mileage in perpetuating this myth that there is a body of specialist knowledge in the personality disorder field which only one profession can embrace, as this book appears to do at various points. It is the one general point made by these editors with which I disagree. Gwen Adshead advocates here, as elsewhere, for the necessity of the medical psychotherapist. I believe that the successful worker in this field is one with the appropriate personality, regardless of professional background. I thought when reading the first part of this book about the nature of the problem of personality disorder, that this concern about a medicalization of the work is not unrelated to the concern with the non‐specific aspects of treatments in this field, which is particularly difficult for colleagues coming from the more positivist perspectives to accept.

Despite this general psychiatric bias underpinning this text, it is argued in a number of places, not least in the Forward by Nick Benefield, that a psychologically informed approach is essential to working with personality disorder. Indeed, this perspective is evidenced throughout. In fact, the editors themselves, in the first part of the book, specifically discuss the primacy of using the psychological theory of attachment as an approach to an understanding of personality disorder. I would say, however, that I do not agree with them that borderline personality is associated with preoccupied insecure attachment. I would view borderline pathology as very much associated with disorganised attachment. However, more generally, there is a real sense in which this entire book owes a great deal to the work of the Canadian Psychologist, John Livesley. This is clear, for example, in the chapters from the East Midlands forensic experience of working with people with personality disorder, where both Conor Duggan and Rebecca Lawday acknowledge the importance of Livesley's work to informing their own thinking. Certainly, from my own experience of designing and delivering a programme of teaching in personality disorder for generic mental health nurses, I have found Livesley's work essential. If I have one reservation about Conor Duggan's thinking in terms of developing Livesley's thoughts about the diagnosis and classification of personality disorder, I do wonder whether or not the addition of a further layer of classification, with the four “As” of personality, is not an unnecessary addition; particularly given that one of the most important characteristics of Livesley's work is the parsimony of his approach.

I hope my last point gives a good indication of the rich nature of the material in this book, written as it is by such outstanding colleagues in the field and with such fascinating insights. For example, in the second part of this book, Gwen Adshead follows on from the sophistication of the chapter by Sarkar and Duggan, with a fascinating philosophical – as well as medical – reflection on the treatment and treatability of personality disorder. I found that this high quality of material continued throughout the remaining third part of the book, with a range of chapters from expert authors on particular treatments, from the likes of Sue Evershed, sharing the wealth of her experience in a chapter on skills‐based approaches, to Kerry Beckley and Neil Gordan discussing their excellent innovative work on insight‐orientated approached, to our own Rex Haigh again preaching the importance of the therapeutic community (TC) as a major player in providing complex treatment for complex needs. Having said that, from the perspective of the TC world – and the general world of psychiatry for which this text is as much intended – Rex is not alone, for once, in this book in recognising the contribution the TC brings to this field. For me, this is what makes this book extraordinary. While Nick Benefield writes in the Forward that social therapies, in particular the TC, has been one of the few areas for optimism in the field of personality disorder, Bateman and Tyrer are very clear in the third part of the book dealing with treatments, that TCs do provide NHS Level 1 evidence of effectiveness, and that TC must be part of the personality disorder treatment and research landscape. I was struck by how different a perspective this is from the one that we could have seen just a few years ago. I was also struck by just how much of this shift in the opinion of psychiatric colleagues, and with it the written acknowledgement of the evidence‐base of TCs, is due to the work of Rex Haigh in doing so much to spread the word within the contemporary field of psychiatry.

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