The Trouble with Personality Disorder

1. The Trouble with Personality Disorder Rex Haigh Consultant Psychiatrist in Psychotherapy, Berkshire Wessex Psychotherapy Society, 21 September 2005

2. Outline • Modernity is the enemy of therapy • PD is an ideological battlefield: • Traditionalism is little supported • The dominant discourse is modernism • Postmodernism offers therapeutic hope • 7 provocateurs and provocations

3. Ivan Illich PROVOCATION: • Clinical, social and structural iatrogenesis is exactly what happens in PD • i.e. Medicalising PD makes people worse

4. Ivan Illich, Limits to Medicine. Medical Nemesis: The Expropriation of Health (1975) Harmondsworth, Penguin “An advanced industrial society is sick-making because it disables people from coping with their environment and, when they break down, it substitutes a clinical prosthesis for the broken relationships. People would rebel against such an environment if medicine did not explain their biological disorientation as a defect in their health, rather than as a defect in the way of life which is imposed on them or which they impose upon themselves”

5. Michel Foucault PROVOCATION • The diagnosis of PD is an exercise of power, sanctioning those labelled deviant to be treated differently to “normal” people. • i.e. the power dynamic is never absent in clinical work with PD

6. Michel Foucault, The Archaeology of Knowledge (1972): London, Tavistock • We must conduct an ascending analysis of power, starting from its infinitessimal mechanisms, which each have their own history, their own trajectory, their own techniques and tactics, and then see how these mechanisms of power have been -and continue to be- invested, colonised, utilised, involuted, transformed, displaced, extended etc by ever more general mechanisms and by forms of global domination. • We need to eliminate “the fascism in our heads” by exploring and building upon the open qualities of human discourse, and thereby “intervene in the way knowledge is built up and believed in, at the particular sites where a localised power discourse prevails”.

7. S H Foulkes PROVOCATION • Individuals’ identity - and pathology - can only be defined by consideration of their place in their social environment • i.e. individualism throws out the baby with the bathwater

8. S H Foulkes, Therapeutic Group Analysis (1964): London, Allen & Unwin "Each individual - itself an artificial, though plausible, abstraction - is centrally and basically determined, inevitably, by the world in which he lives, by the community, the group, of which he forms a part. The old juxtaposition of an inside and outside world, constitution and environment, individual and society, phantasy and reality, body and mind and so on, are untenable. They can at no stage be separated from each other, except by artificial isolation."

9. R D Laing PROVOCATION • If we call only upon objective expertise and measurable skills, we lose the power to be effective with others. • i.e. expert-driven answers are not enough

10. R D Laing, The Divided Self (1968) Harmondsworth: Penguin "The greatest psychopathologist has been Freud. Freud was a hero. He descended to the 'Underworld' and there met stark terrors. He carried with him his theory as a Medusa's head which turned these terrors to stone. We who follow Freud have the benefit of the knowledge he brought back with him and conveyed to us. He survived. We must now see if we can survive without using a theory that is in some measure an instrument of defence."

11. Nick Manning PROVOCATION • The scientific and professional communities (as actor networks) have elaborated PD on their terms • i.e. they have made a “PD industry” to live off. (We are part of it!)

12. Manning, N. (2000) "Psychiatric diagnosis under conditions of uncertainty: personality disorder, science and professional legitimacy", Sociology of Health and Illness, vol. 22, no. 5, pp. 621-639. The development of a new type enabled a heterogeneous group of patients that did not fit elsewhere (neither schizoid nor affective) to be simplified into a new category, which was juxtaposed with a theoretical explanation (childhood trauma), articulated with alternate theories (no evidence for heritability), and became inverted - from a statement about difficult patients, to the discovery of an already pre-existing and coherent type: the "borderline".

13. Gerhard Wilke PROVOCATION • BPD is a rational response to the consequences of modernity, such as fragmentation • i.e. society is “borderlinogenic”

14. Wilke, G. 2000, "Holding and Fragmentation", AUC Journal, vol. 1, no. 1, pp. 2-8. Modernity by definition means a crisis of identity - self harm, the disembowelment of secure identities is normal. The way out of this crisis is not a return to a paradisical vision of a true and integrated self, a holding and motherly organisational environment - but the acceptance that fragmentation is the core experience of modernity, that there is no depth to experience, all is presentation of aspects of self in a variety of social contexts. In this view,the people we label as borderliners are the truest expression of existential reality. In other words, the problem we have posed here and are trying to work through don’t really need solving. They need to be lived with and tolerated.

15. Zygmunt Bauman PROVOCATION • Postmodernism can give dignity to human and irrational passions that have been silenced and suffocated under modernity • i.e. it is time for “re-enchantment”

16. Zygmunt Bauman Postmodern Ethics. Chapter 12 in: The New Social Theory Reader. (Eds.Seidman S, Alexander J C). London: Routledge, 2001; 138-146. The mistrust of human spontaneity, of drives, impulses and inclinations resistant to prediction and rational justification, has been all but replaced by the mistrust of unemotional, calculating reason. Dignity has been returned to emotions; legitimacy to the 'inexplicable', nay irrational, sympathies and loyalties which cannot 'explain themselves' in terms of their usefulness and purpose. We accept that not all actions, and particularly not all among the most important of actions, need to justify and explain themselves to be worthy of our esteem.

17. How can PD work be done when Seeing as illness makes people worse So does the power imbalance Social context is just as important Using theory is defensive We’re in it for ourselves It’s pointless to resist in a fragmented world The health system is relentlessly modernistic ? Answer (partial maybe) A different sort of relationship based on needs we all have So… here’s the problem

18. Necessary developmental experience • Attachment - belonging • Bowlby, Balint, M Main, Trevarthen, Stern, Holmes, AAI work • Containment - safety • Winnicott, Bion, Meltzer, Bollas, some Kleinians • Communication – openness • T Main, Whiteley, much general psychodynamic theory • Inclusion – place amongst others • Elias, Foulkes, Systems-based therapies, Maxwell Jones • Agency – personal effectiveness • Stack-Sullivan, Jung, Humanistic and Integrative Psychotherapies

19. Clinical strategies • Open theoretical framework • That applies to us all • Staff not exempt from same developmental needs: support, training, supervision, groups • Informality & therapeutic ordinariness: being with > doing to • Prepare to be swimming against the tide • Form networks of people doing similar things