Personality Disorder: Temperament or Trauma?

The title is rather misleading: this is not a book that discusses or makes any headway on the subject of the aetiology or nosology of personality disorder (PD). It is a report of a survey, conducted in the Colchester area of England, of the experiences and opinions of people with PD in relation to the care they have received from health care professionals. In many countries, the assumption that in order to provide a 'service' one should consult the 'market' has been transposed wholesale from the business world into health care. While accruing marks for political correctness, it is hard to understand how this can include people with PD without losing faith in the outcomes; after all, untrustworthiness, manipulativeness, and self-interestedness, are part and parcel of the DSM-IV criteria for PDs. Nevertheless, maybe it would be possible to distinguish the honest, insightful and useful observations and opinions of people with PD from their lies, distortions and contradictions; if we can make this distinction, they may have something important to say about themselves and the response of the system to their disorder. However, this study makes no obvious effort at such distinctions, and appears to accept the contribution of people with PD entirely at face value. The study uses no checks on trustworthiness, consistency, reliability or validity, and does not even discuss such issues. Neither does it discuss the study's methodology or the research design, and it says nothing about the theoretical framework from which the data is interpreted, although it is unrelentingly critical of mental health services and professionals. All but 3 of the 50 participants in the study were contacted by networking via the advocacy group in which the author is a manager, but there is no account of exactly how participants were located and enrolled in the study, or of the problems that such a sampling method entails. There are many similar problems that could be listed here: all participants had a borderline or dissocial PD, but this was based entirely on self-reported diagnosis, for example, and there is no effort to conduct anything more sophisticated than a simple % and pie-chart analysis of the data.

As a piece of formal research, it is poorly designed and poorly articulated, and it would not have been approved by any of the committees with which I have been involved, either in the university or health sector. It is significant that the researchers sought approval only at the suggestion of an academic advisor, and that occurred after 14 interviews had already been completed. I can only conclude that, when it comes to research, political correctness -- in this case canvassing the thoughts of service users -- is more important that matters of research design and scholarly rigor. There are also numerous minor but glaring errors in the text, so the French alienist Morel becomes "Monel", Lombroso is "Lambroso", and Erving Goffman is "Irvine Goffman". JKP has a high standard to maintain in the forensic field, and its editorial staff really ought to have picked these up.

 The author is a mental health advocate, and her work displays all the virtues that brings – passion, sensitivity, non-technical language and a readable style - but it also displays the shortcomings of non-professional authorship on technical subjects: a brevity which sometimes borders on the telegraphic; a simplicity which fails to recognise the myriad subtleties in the arguments, and overlooks the implications of the claims being made; and, a general lack of respect for alternative interpretations, existing research and empirical evidence.

Yes, it is certainly an unusual book, and it does purport to offer an insight into the self-perceived needs of service users with a PD. One must admire Heather Castillo's eagerness to understand people with PD, to represent their interests, and to discover better ways of managing them in health service settings; many people have spent a lifetime trying to do exactly that. However, a close collaboration with an experienced researcher was needed to shape this into a believeable and significant study. At the time of writing, it had been presented 18 times at local, regional and national venues, and it has led to several publications in professional journals. I believe that's where it should have ended.

If you decide to dip into Castillo's book, the recent text by Len Bowers' Dangerous and Severe Personality Disorder: Response and Role of the Psychiatric Team (2002), which reports a study of the attitudes and practices of mental health staff toward people with severe and dangerous PD in an English high security hospital, makes fascinating complementary reading!

© 2003 Colin A. Holmes

Dr Colin A Holmes, School of Nursing Sciences, James Cook University, Townsville, Queensland, AUSTRALIA