Professor Peter Tyrer’s new book on personality disorder was published recently. Fool that I am, I have decided to blog on it, chapter by chapter as I read it. Not because I have any great insight on the issue, but because blogging is my way of continuous learning, updating and re-learning. I try and summarise or distil out what is being said and re-present it back to myself. Why this book? Well, because it sets out the new definitions of personality disorder as will be published by the World Health Organisation in the International Classification of Diseases ICD-11; and Professor Tyrer chaired the relevant working group.
So much of what constitutes personality disorder involves difficulties relating to other people. I am not a psychiatrist. But as a psychotherapist claiming to work in a relational way, nothing could be more relevant. Working in a relational way assumes that some problems people bring to counselling originate in their childhood relationships – and there is plenty of evidence for this. So, if the client allows, we use the relationship between therapist and client as a vehicle for understanding and change.
Sometimes we unpick what has been dubbed a “personality disorder” and what we are left with are relationship difficulties. We are then closer to knowing what to work on; and the person no longer needs to be labelled as “disordered” (and never did). So I am still interested in the question of whether and how personality disorder is sometimes more than just a person’s personal basket of overlapping difficulties in relating to people.
Another issue: sometimes a person is told they have a “personality disorder”, but then much of their difficulty disappears when they change environment, for example swapping one learning environment for another, or moving away from a stressful home life, or moving from isolation to a place where support is available. How much of this was a personality problem and how much an environment in which anyone might get angry or demotivated or depressed? Or if not ‘anyone’, then could this be more about individual resilience than personality? Quite possibly there is a need to both help a person build up resilience and find ways to relate to others better. But if a big chunk of this is the environment, why default to a diagnosis personality disorder?
Yet another perspective: I have an interest in understanding how trauma in childhood translates into those things that often seem to make up “personality disorder”, such as difficulties relating to others, difficulties managing emotions and dissociation. Research shows there is a significant link. Again, if personality disorder can sometime be disaggregated in this way, then is it unproductive, even lazy, to say, “I am going to label you by the negative impact you are having on other people and not acknowledge this as a bunch of trauma-related difficulties you are having for yourself”?
If it sounds like unpicking the origins of a person’s “personality disorder” and finding out how to help might be difficult and complicated, then yes it can be. But why not start with what someone is experiencing and not by labelling a person as somehow defective. As Stephen Fry points out in the foreword to the book, naming can sometimes inhibit understanding.
I am alive to the fact that some people find the diagnosis helpful for all sort of reasons. If a diagnosis gives a person hope, or a much needed sense of feeling known or understood, or a platform from which to move forward, then it is not for me to take away from them what they find supportive. And once again I say, I am genuinely interested in what is left over after all of these difficulties have been identified, that may genuinely constitute something that is currently called “personality disorder”.
So, why do I feel I am walking into a poorly marked minefield? Because I am. There was online debate and controversy about the title and cover of this book before it was even published. I suspect its contents will produce more heated debate. But I don’t feel I can call myself a psychotherapist, if I am not prepared to engage with these issues. Admittedly, “the issues” don’t in themselves constitute public debate. I could do my own thing in isolation. But if Professor’s Tyrer’s generation-long culture change is to happen, this requires collaborative effort and not just between the psychiatrists who run the show, but also the public who place themselves in their hands.
After all, much of the topic is about managing relationships with others, so it would be ironic to duck out and watch such an important issue develop from the side-lines, just because it’s a tricky one. So I shall take one step at a time. And hope that, should it become necessary, there will be at least one reader or co-conspirator kind enough to mark the place where I fall.
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