In the prison of severe personality disorder

Abstract

Interpersonal barriers frequently stand in the way of the successful treatment of patients suffering from severe personality disorder (SPD). Often this stems from a failure to distinguish accurately between the patient's surface behavioural manifestations and his or her inner mental states. Misinterpreting the SPD patient's gross behaviour may thus result in unsuccessful clinical encounters because of the absence of empathic contact with the atient and through and beyond their SPD patients' behavioural faGades means that such patients continue to feel marginalized and misunderstood, and that staff become no wiser in understanding their patients as individuals. The SPD patient's strong negative emotion and its interpersonal behavioural concomitants may be erroneously equated with no progress, deterioration, or even ‘badness’ and his or her compliant behaviour may be mistaken for therapeutic progress and psychological change. Clinical decisions regarding the discharge or transfer of SPD patients, based on such grounds, are likely to be unsafe. If staff recognize SPD patients' profound problems in identifying and communication their painful mental states, they are better able to help them to give up the self-defeating and anti-social coping strategies and defences that are erected by patients in order to deal with such states. Via the removal of such barriers, some SPD patients may be freed from a metaphorical ‘prison’, which is only partly of their own making. Clinical material from some of Henderson Hospital's SPD inpatients is presented to exemplify the behavioural camouflage assumed by such patients thereby masking their inner states and the consequent interpersonal difficulties encountered in their treatment. Aspects of the therapeutic community (TC) method of idenufying and analysing the difficulties, in particular the availability and use of the ‘social reality’ of the setting, are discussed. Implications for other, non-TC, inpatient settings are considered so that the ‘social reality’ found therein can be put to greater therapeutic use.