Introduction
“Taming the Beast Within” is Professor Peter Tyrer’s new book on personality disorders [1]. Fool that I am, I have decided to post on social media about it as I read it. So why choose this book?
Why am I writing about Taming the Beast Within?
Firstly, Taming the Beast Within sets out in broad terms the new definitions of personality disorder, which the World Health Organisation will publish in the International Classification of Diseases ICD-11 [2]. As Professor Tyrer chaired the relevant working group, one would expect his book to reflect how the psychiatry profession will treat personality disorders for the foreseeable future. As a psychotherapist, I work in a different way to most psychiatrists. However, my clients will often talk about personality disorders in the same way that their psychiatrists do. I will need to understand this, even if my perspective is different.
Secondly, the book’s subtitle is Shredding the Stereotypes of Personality Disorder. And the publisher’s description includes a topic ‘how mental illness differs from personality disorder’. Together, these suggest the author and his colleagues have re-opened the question of what personality disorders are and how treatment might change. This interests me because I believe a radical re-think of personality disorders is long overdue. I question whether whether ‘personality disorders’ is a useful label and whether they even exist in the way the current definitions suggest.
Some perspectives on personality disorders
Personality disorders and relationships
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, I use the relationship between therapist and client as a vehicle for understanding and change.
Sometimes, in unpicking what a medical professional decides is a “personality disorder”, we see instead that the person concerned is experiencing relationship difficulties, perhaps severe ones. We are then closer to knowing what the issue is and we no longer need to label the person as “disordered”. Maybe we never did! It leaves us a with a question: is a ‘personality disorder’ any more than just a person’s individual basket of overlapping difficulties in relating to themselves and other people?
Taming the Beast Within considers the role of the environment
Another issue is the impact of a person’s circumstances or ‘environment’ on their ability to cope. Sometimes a person is told they have a “personality disorder”, but much of their difficulty disappears when they change environment.
For example, they may find life easier when they swap one learning environment for another. Or when they move away from a stressful home life, or from isolation to a place where support is available. Was there really a personality problem or just 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? Possibly there is a need to 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?
Taming the Beast Within has a chapter on nidotherapy. This means the therapist working with someone to change their environment in ways that improve their mental health. I appreciate the attention to this aspect of therapy as it frames the environment as unhelpful rather than the person as disordered.
Does Taming the Beast Within factor in the role of trauma?
Here is yet another perspective. I have an interest in understanding how trauma in childhood translates into what later manifests as a “personality disorder”. Such difficulties include relating to others, difficulties managing emotions and dissociation. Research shows there is a significant link. If a ‘personality disorder’ can be disaggregated in this way, then maybe it is unproductive, even lazy, to use this label. It is saying: “I am going to label you by the negative impact you are having on other people instead of acknowledging that you are facing some trauma-related difficulties.”
‘Trauma’ does not figure in the book’s index as much as I expected. However, Taming the Beast Within does have a chapter called When is Personality Disorder formed? And that chapter states that, where there is abuse or neglect in childhood, personality disorder is more likely to develop. For me, this is a pivotal importance, as it determines how we go about helping someone with this diagnosis.
The diagnosis of personality disorders
If it sounds like unpicking the origins of a person’s “personality disorder” might be complicated, then yes it can be. So can helping them feel better. 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, that is good. 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”.
Controversy about personality disorders
So, why do I feel that 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 even before it was 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.
Sources
[1] Link to Sheldon Press: Peter Tyrer (2018): Taming the beast within: shredding the stereotypes of personality disorder. Sheldon Press.
[2] World Health Organization (undated). ICD–11 Fact Sheet. Retrieved 03 October 2022.I originally posted this article in May 2018. This update changes the title of the blogpost and contains minor revisions. I have also added a link to the WHO’s factsheet on ICD-11.