It’s not often that you read something and find that you immediately need to go and share your thoughts about it with the world. The most recent one for me was Hope in the Dark by Rebecca Solent (Highly recommended!) until Friday afternoon when I found myself on a long train journey with some time to kill. I’d just finished a week of Dialectical Behaviour Therapy training for those diagnosed with Borderline Personality Disorder and while I knew I should have been reading more about that, my mind skipped onto thinking about what was written in the world of Occupational Therapy and “Personality Disorder”. I know that the answer is ‘very little’ so I decided to throw myself into “Understanding Persons with Personality Disorders: Intervention in Occupational Therapy” by Ann Nott. You’ll find it in Occupational Therapy in Psychiatry and Mental Health (2014) Edited by Rosemary Crouch and Vivyan Alers.
Keir is an Lead Therapist in an NHS Specialist Service and provides training, sconsultation and therapy around complex mental health problems through beamconsultancy.co.uk
The chapter got off to a bad start for me by giving one of the Key Learning Points as “Clinical handling of behaviours such as manipulation, lying and deceit”. Lets take a deep breath and see what else we’ve got…
It opens by sensibly defining personality and what might then describe a personality disorder. Given that ‘personality disorder’ covers such a spectrum of presentations it then makes some incredible generalisations such as “No feelings of anxiety about his/her behaviour…blame is put upon others…they believe their behaviour is right, ignore or refuse psychiatric help”. Now I have not conducted a randomised control trial, but I have met many people with this diagnosis who are crippled with anxiety about their actions and choices, they believe they are always, always wrong, they blame themselves to the extent that they have to punish themselves and they cannot get psychiatric help regardless of their levels of distress.
We are told that long term progress can be poor which is not the case for what gets described as Borderline Personality Disorder. We are also told that some can have a “good prognosis with excellent work histories, supportive networks and willingness for therapy”. While I suspect that’s true it reads as “people who have difficulties that don’t particularly affect their lives tend to do ok in life”.
The chapter goes on to describe the ICD -10 and DSM-5 ways of categorising personality disorder. Sadly these are presented in a fairly factual way with no critique as to their value. While personality disorder is one of the most contested psychiatric diagnoses, you would not know this from reading this chapter. There is equally no comment on the stigma that the diagnosis can bring or the flaws inherent in diagnostic system. Now this isn’t unique to this chapter and as OTs we need to be more critical about this and challenge our medical colleagues a bit.
We are invited to consider 4 different theoretical frameworks for the development of personality disorder but the chapter skims over these, leaning most on biological explanations. There is the interesting statement that for cluster B & C clients (including people diagnosed with borderline personality disorder) “psychoeducation is contraindicated as there is already a distortion of thinking present which would be counter effective in any therapy”. Ummm, so no therapy then? Obviously you then have to wonder if this is the one client group in psychiatry with disordered think and whether psycho-education and therapy needs to be withdrawn as an intervention for all. You can balance this with the widely held view that psychological therapy is the primary intervention for this client group.
The chapter gets a bit Freudian at this point and while it spouts about ego and unconscious processes, it points out the “defence mechanisms used by the person with personality disorder”. What it neglects to say is that assuming all the splitting and projection stuff is accurate – these are things that are identified as being used by everyone in the world. Dividing the world into good and bad is by no means unique to people given the label of personality disorder and if you’re being mean, you might point out that saying this is the case is an example of projection. Also, it states that “Parasuicide is often seen in persons with borderline personality disorder, and although it is attention seeking behaviour, it should always be seen as a cry for help”. It doesn’t link these attention seeking cries for help with the fact that one in 10 people with this diagnosis will die by suicide, risking people in distress being dismissed.
Models of Treatment
We begin with “treatment normally takes place in a psychiatric unit” which I’m not sure is the case at all. “The person with a personality disorder settles quicker within the contained environment of the hospital” doesn’t fit with my experience whatsoever and while I’m very supportive of admission where it’s helpful, too often I associate it with people who have lived through abuse being restrained for things that would pass unnoticed in the community. Anyway….
I heartily agree that the team should have a unified approach and shared frame of reference but the absence of a focus on a collaborative approach is striking. We are told “family involvement….(is) essential for success” but we are not advised to seek permission or consent to do this or consider the extent to which events and behaviours within the family have impacted on the difficulties these individuals experience.
Some different approaches are outlined. We hear about behavioural approaches and how OT interventions such as relaxation and assertiveness training fit. We may have trouble telling the rest of the mental health world these interventions belong to OT.
DBT is outlined where there “may be positive validation” rather that it being the most important aspect of DBT. There’s no mention of how OT can fit within this which I think is odd as my version of Occupational Therapy mirrors much of DBT.
CBT comes next and there’s little for OTs to do other than know that assertiveness skills are useful for those with avoidant personalities.
The therapeutic community model is described and while I normally love this approach, unusually there isn’t an emphasis on collaboration, consensus and shared power described here. This could reflect that therapeutic communities are different things in different places but might also reflect a common attitude that people should be ‘done to’ rather than ‘done with’.
We learn that people with personality disorders “take poly-pharmaceutical medicines in a desperate attempt to cope” with no mention that you can only get prescribed these by a doctor (who may well be prescribing them in a desperate attempt to cope). Despite there being no recommended medication for ‘personality disorder’ the chapter then describes how different medications can be used. We might be starting to see how these poly-pharmacy issues come about…
Into the meat of the chapter! What can OTs do for this client group? Initially it is quite sensible but in my opinion it starts to meander a bit. We are given some principles to work on such as…
“Focus on behaviour and not an explanation of behaviour” – I believe if you cannot think about why people do what they do you are likely to be directive, judgemental and often wrong. Always work out why behaviour makes sense. If you don’t know what drives it, you will never stop it.
“Confront and not interpret defence mechanisms” – I’m going to suggest this language is really unhelpful. Be curious and wonder rather than confrontative.
“Allow for participation in groups and helping others” – this makes sense but I’m not sure which clients in other areas should be banned from groups or helping others.
But OTs should NOT:
“Listen to repetitious complaints” – Turn your back on people? Fingers in ears? See the above about seeking to understand why people do what they do.
“Insist on a contract” – Now I’m not too aware of insisting on a contract being a huge issue but this chapter also contains the advice “the client is…encouraged to take responsibility for behaviour by signing contracts”, “It is imperative in all therapeutic processes that there is contracting”, “The occupational therapist needs to contract in therapy” and “It is useful to get group members…to sign a group contract”. It isn’t massively consistent.
“Save face if fooled and resort to blame and punitive acts” – I’m 100% behind avoiding blame and punishment, but I wonder how helpful the idea that people are out to trick you is?
“Lie or present conflicting non verbal messages” – Again, I wonder about the wording of this. Who is the client group it is useful to lie to?
For the next part we go through the different clusters of personality disorders and how to be helpful.
For cluster A the author points out that group work isn’t recommended but can be beneficial. If we need to exclude people it should be because of their specific difficulties rather than their diagnosis.
For B it’s suggested we manage conflict with confrontation (best way I know to get the ward alarms ringing). We are warned (and hold your breath here) “students due to inexperience may not cope with the highly demanding, manipulative and undermining characteristics that may emerge in therapeutic intervention”. This client group is not safe for students? Wow. “The ‘gentle, do good approach’ is not beneficial and the occupational therapist will need to delineate his/her own boundaries…so the process of therapy…(is) not sabotaged.”
For working with people diagnosed with borderline personality disorder “take care that there are no physically harmful tools lying around” rather than collaboratively managing risk.
“The pharmacological approach has been to include both mood stabilisers and antipsychotics” – 3 paragraphs back you were blaming them for their poly-pharmacy!!!
After some discussion on cluster C we then get to look at intervention methods
I’ve got no problem at all with this section. I have a minor quibble about group therapy being optimal rather than a mix of group and individual, but most of the rest of it makes sense. The chapter is explicit that OTs could be delivering aspects of DBT which I heartily agree with. We get given two case studies that have fairly unbelievable changes in functioning and I question the outcome measure of angry drawings becoming happy drawings indicating success. Aside from that I’m content with this section.
So as a whole I seriously disliked this chapter. It makes no mention of the stigma clients with this diagnosis face, which is an incredible omission for me given the focus OTs have on the social environment. The likely explanation for not talking about stigma could be that the attention seeking, sabotaging, manipulative, lying, deceitful, blaming, help refusing, unable to hear information about their diagnosis, think in ways that would counter any therapy, inappropriately medication seeking, demanding, sabotaging and undermining people who are not safe for students deserve everything they get. I would say that OTs should try and get all the above language out of their practice and out of the environments they work in. The words we use shape our environment and we should be making it a place where people understand rather than judge.
Take all of the ways of describing people listed above. If you walk into work thinking that about people it is going to be impossible for you to develop an empathic relationship. If the people we work with read this chapter and believe this is not only what practitioners think but that it has enough validity to be published in a textbook – how can they possibly trust us to help them?
I shudder at the idea that this is the first thing that OT students might read about this diagnosis. I wouldn’t want it pulled from the shelves but I think as a profession we need to distance ourselves from this total acceptance of the diagnostic system and the judgemental language described. In the UK the RCOT professional standards state:
11.1 Your language and communication style demonstrate respect to those with whom you are working
Now this is opinion rather than fact, but if you are using the language above I don’t think its possible for you to be working within your professional standards.
Now having read though all the above I have a mix of feelings. I know that I’ve taken somebody’s work and eviscerated it. I’d hate it if it happened to me. Further, I reckon 15 years ago if I’d been asked to write this chapter I’d have written similar things. We learn the things we do from our experiences which are shaped by people who know more than us. I’ve been lucky to be exposed to people who would not let me continue to think like this and not everyone gets that opportunity. Equally in the UK we have had a few publications that have sought to identify and reduce the stigma around this diagnosis. They may not be known in other countries however, in a book with international reach (and a publisher based in the UK) I’d expect those publications to be evident in the narrative. I know that another OT textbook is currently seeking the views of service users to comment on chapters. I think this chapter would look a lot different if views had been sought, discussed and understood rather than confronted. I did ask Facebook and Twitter how influential this book was and unfortunately someone told me it had really influenced them, the personality disorder chapter in particular. It was then that putting a different view into the world became more important than upsetting someone.
If you work in education please, please let your students know there are other views on this subject. I say nothing of the quality of –
Harding K (2016) Working with people with personality disorder. In: J Clewes & R Kirkwood (eds) Diverse Roles for Occupational Therapists. Cumbria: M&K Publishing (p237-250).
– but it is certainly different.
- I was lucky enough to be able to bounce these ideas off a respected lecturer in Occupational Therapy. Given that there are many unbalanced aspects to this review and the author they didn’t want to be identified. Regardless their approval and guidance was much appreciated and needs to be acknowledged. I’m going to contact Wiley to ask them to update this chapter asap and regardless of what you think of my criticism, feel free to make your views known to them.
Keir is an Lead Therapist in an NHS Specialist Service and provides training, consultation and therapy around complex mental health problems through beamconsultancy.co.uk