Treating Personality Disorder: Creating Robust Services for People With Complex Mental Health Needs

Have you wished you could learn the condensed, practical wisdom of the most seasoned psychiatric nurse in your institution regarding the treatment of patients with personality disorders? Now you can.

In Treating Personality Disorder, forensic psychologist Murphy and psychiatric nurse McVey bring considerable clinical experience and expertise to bear in this eminently readable and pragmatic volume. They draw from settings—prisons and hospitals—where “containment or management” has been the accepted strategy, and they challenge mental health professionals to do better. Plus they show us the path for doing so.

Beginning with a description of character pathology that is hopeful but not sugarcoated, they outline how a number of systems issues collude to result in routinely poor patient care. They observe that training is inadequate and that nurses often resort to a medical model, even when faced with evidence of its ineffectiveness. Huge investments in brief cognitive-behavioral treatments are unlikely to be effective, yet they are emerging as the standard of psychotherapy. Because physician and nursing staff alike often lack a psychological understanding of personality, patients' bids to get needs met are sometimes interpreted with hostility.

The authors take a sober look at the personal qualities required to be successful with this population, suggesting that many staff are likely ill suited for the work. Effective staff members bring a desire to work with patients with personality disorders, as well as good emotion-regulation skills, a capacity for self-reflection, robust self-esteem, the ability to set and hold limits, and the ability to perceive vulnerability of the patient, among other qualities.

Chapter 4 meanders through questions of etiology, including trauma, and at one point suggests prioritization of an etiological focus, but by chapter 5, the book is fully back on track, presenting a number of very solid treatment strategies that could be useful for any mental health provider working with patients with personality disorders. Specifically, they advocate a primary relationship focus with appropriate emotional intimacy, built carefully by focusing on affect and identification of behavioral obstacles to tolerating emotions.

A patient with a history of polysubstance dependence, eating-disordered behavior, self-injury, and angry outbursts once asked me, “Do all people have feelings?” These authors would answer yes to that question, and they advocate a stance of ongoing interest in the affective experience of the patient through systemically identifying and challenging barriers to emotional experiencing. One such barrier is the gap between the logical worlds of patient and clinician; for example, providers might assume that the kinds of relationships and ways of relating that make themselves feel safe and comfortable work as effectively with their patients.

After two chapters on interdisciplinary work, the remainder of the book considers the roles of nursing, occupational therapy, prison officers, psychiatrists, and psychologists in working with patients with personality disorders. These chapters are worthwhile, although they contain less authentic wisdom than the chapters primarily written by Murphy and McVey.

Despite its Britain-specific examples and occasional meandering, this volume is a welcome addition to the psychiatric services literature. It would be especially useful to treatment teams that provide care for patients with personality disorders.