Saturday, February 11, 2012

Our Guest Blogger Writes About Personality Disorder

It's guest blogger day!

Today Kerry's entry touches on a subject that we have recently become interested in learning about, due to some association with people diagnosed with the topic at hand.

We've done one blog post so far, discussing Personality Disorders (Personality vs Dissociative Disorders, illustrating the difference between the disorders as best as we could.

You might also want to read Treating and Healing Dissociative Identity Disorder

We're happy to get Kerry's view on the topic. While we may not agree, or be sold, on the positive side of PD, we completely respect her 
professional and personal view on it; maybe we're jaded from what we know to be a limited (mainly borderline), and negative, experience with people who have these disorders. It's not really our place to have a negative opinion of anybody with a mental illness, if they are working towards getting the help they need. So we're just going to shut our mouth...for now.

We'd like to talk about the range of personality disorders at some point, which have three main classifications:
• Suspicious • Emotional and impulsive• Anxious
   paranoid    borderline  avoidant
   schizoid    histrionic  dependent
   schizotypal    narcissistic  obsessive compulsive
...but today is not the day.

We'd love to have you weigh in on your thoughts and opinions in the comments section following this entry. Just for fun.

And now, guest blogger, writer, mental health nurse, and groovy lady (yep, we said groovy, bite us)...Kerry Stott.
Personality Disorder, what is it and why do I like it?

I work with people who have a diagnosis of Personality Disorder (PD). These people tend to be chaotic in their presentation and resource intensive. By this I mean multiple presentations at A and E (ER for my American friends), possibly police involvement, numerous unplanned admissions to hospital and, generally a stressed out and frazzled mental health worker who co-ordinates their care. These patients can very easily burn out professionals and quite a few on my caseload have had several care co-ordinators prior to coming to me. They are often referred to as heart sink patients, because the mere mention of their name causes professionals to groan. Or at least that is the polite sanitised version.

So 2 questions, what is a personality disorder and why do I like working with people that can burn me out and cause so much stress? Throughout this blog I will repeatedly refer to people who have a diagnosis of PD. This means that they are very much struggling with life and being able to function, and not just a reference to people who are flaky and a pain in the bum. Also, it has a biased towards Borderline/Emotionally Unstable PD as this is the most common group that I work with.

For years I have been trying to find a definitive, snappy answer as to why I enjoy working with PD. Some of my colleagues say that’s because I have one myself, but then so does everyone to a certain degree. I like a challenge and these patients are certainly challenging. However, just because someone likes a challenge, doesn’t mean that they are any good at their job. There may be issues to do with my up bringing that cause me to relate well to people with a diagnosis of PD. Being British I might value the under dog and want to help them. Possibly I may want to ‘rescue’ people. I actually don’t like rescuing patients, I like assisting people to find their own feet and give them the tools to help themselves. Often this means not getting nervous or over anxious/excited if someone says that they want to kill themselves or have taken an overdose. Most of the time it is about being calm and consistent in my demeanour and behaviour towards them, as well as listening and being respectful.

From an emotional perspective I feel that I can connect to people with this diagnosis and it gives me great satisfaction and pleasure seeing them psychologically grow, and being part of that growth process. Watching them become more accepting of themselves and develop a greater independence from their more chaotic behaviour. Working with people who have PD is not about freeing them from it, rather finding some common ground where they can feel more in control of their behaviours and emotions. It’s not all about drugs and medicating people, although medication can play a role. It has a lot to do with interaction with the therapist/care co-ordinator/mental health nurse and the patient, role modelling, therapy, working with each other rather than the professional knowing best. Ultimately it is this team work that I love, the interaction and being able to hear other people’s stories about their lives and to help them see that they have the power and strength to change the ending. It need not be inevitable.

So what is PD? For clarification Frankie does not have PD, she has a dissociative condition, please read ‘D in DID’ for more info.

Personality is what makes us who we are, it make us individuals, separate from each other, psychologically identifiable from each other. I often describe personality as being like facets of a diamond, we all have different sides to our personality: funny, flirty, sarcastic, cruel, mournful and so on. We act and react to each other, usually within the cultural and social norms of our society. We bounce off each other. For example if I wanted to go and have a laugh because I felt funny I would choose a friend who could meet that need. If I wanted to have some sympathy I would go to someone I know who will be likely to give me the response I wanted. It works the other way around too. People frequently come to me because I get things done, or if you want to hear it straight rather than pussy footing around a topic – I’m your woman. However, we work within social conventions too. If I lived in the Middle East I would not be able to do the type of work that I do, wear the clothes I do (jeans and a jumper [sweater] at the moment before you ask), I would not be able to be as outspoken as I am. I live in the UK and I am (at times) actively encouraged to be outspoken, there are forums that promote this such as Facebook and Twitter, as well as my friends and work colleagues.

The key factor is how feelings can dictate our behaviour and they frequently do. As human beings we do things to bring about desired feelings to stop undesirable feelings. I love going on scary rides at the fair ground because I like the feelings that it induces. When I am feeling sad I will often eat crap or drink alcohol. The eating is in connection to trying to replicate the nice feeling that I associate with that food, biscuits (dark chocolate digestives [cookies]) were a treat when I was little and thus when I eat them I still feel like I am treating myself. The drinking alcohol is about dampening down and dulling the emotional pain. As you can see, form these examples how our feelings can force us to behave in a certain way. It is interesting that the two examples of self comforting stemming from different psychological places, as the lay person might think that they were done for the same reason. One way is to dampen down and avoid the uncomfortable feeling, the other to elicit happy memories from my early life. Neither of which work in the long run for clarification, there are most definitely short term coping strategies, but they get me through the moment.

It is these interactions between emotions and behaviours, and social interactions and cultural norms, which help define and mould our personalities. A psychologist once joked that there are no personality disorders on a dessert island. This is true but the one with obsessive compulsive PD will be out there lining up the coconuts and leaves. Livesley (2003) stated that the function of personality is to solve problems or life tasks fundamental to effective adjustment, to develop an adaptive sense of self and to be able to have a capacity to function in close relationships. Thus a personality disorder is the failure to solve basic life tasks. A failure to establish an adaptive self system; unable to develop a capacity to function adaptably in interpersonal and societal relationships. This is about as snappy a definition for PD gets!

In non psychologist speak this means that a person with PD is unable to have the complete range of ‘self’. I work predominantly with Borderline PD aka Emotionally Unstable PD (depending on which diagnostic criteria you use, USA or World Health Organisation) and frequently find people with this type PD are malleable and will be markedly different with different people. Not dissimilar to when I was a girl dating boys and would say, ‘Well he’s lovely when he’s on his own, but horrible when he is with his mates’ but a more extreme and pervasive version. People with a diagnosis of PD will often polarise people, with half loving them or wanting to protect and rescue them and the other half loathing them. Please note that this is not a conscious thing, rather a subconscious strategy that has been successful in keeping them safe through what is an often turbulent childhood. In addition to this what patient’s frequently report is an inability to feel emotionally stable. These emotions are overwhelming, uncontrollable and uncomfortable. I see them dating and falling in love, and falling hard; or feeling sad and suicidal with little in between these two extremes. The vast majority of my time, initially when working with Borderline patients, is being able to weather the storm of this tsunami of emotion. It is this that can cause professionals to become burnt out or cynical. I would place myself in the sceptical category not cynical just yet.

Knowing who you are is essential, how you will react to people and situations. This is the interpersonal and societal relationships that Livesley (2003) talks about. Not being able to maintain personal relationships, and not being able to work out why, is a lonely place to be. It is, therefore, unsurprising that people with a diagnosis of PD tries to get away from it, by any means possible. Thus there is a higher prevalence of drug and alcohol issues as well as self harm and suicidal behaviour.

Being able to work out why people behave and react enables me, and other professionals to offer help and guidance and the appropriate therapy. It really is like trying to work out a jigsaw puzzle. Sometimes (if I am very lucky) I am able to see most of the pieces of the puzzle. However, sometimes I don’t have all the pieces, some may be missing. Occasionally it feels like I only have a few pieces of the puzzle, that they are upside down with no picture to work out where they came from, and that I am in a room with the light off – tough work! Spending time at this point, working out why people do what they do not only enhances the therapeutic relationship because, quite often, these type of patients have not been given the chance to tell the story of their life to a health care professional.

Without a robust therapeutic relationship, nothing will happen and the patients will not get better. Indeed it may make things worse for both the patient and the professional, with increased likelihood of suicide and burnout. It is at this point in the relationship that I will discuss boundaries and rules in which we can work together as a team. What they want from me, what I want from them, what to do if things start to go wrong, who to call and appropriate systems.

‘Appropriate systems’ may seem an odd choice of phrase but it enables patients to have a clear understanding of how to access help and the appropriate way to go about it. For example anyone who is distressed will seek help but if they do not feel that they are being listened to, like a rather snotty receptionist at the doctors, they will try more urgently. It is this behaviour pattern that can cause an unwanted reaction in professionals from the patients’ perspective. This is what I hear a lot of ‘It’s just behaviour’ when I am working with PD. However, that’s the thing, it may be ‘just behaviour’ but it is behaviour at not having their needs met, at not being listened to, at not being able to control their emotional state, at not being able to conform to social norms.

I help people, it’s what I do. Helping people who consistently get themselves in an emotional mess and don’t know how to get out of it is just as valid as helping with any ‘illness’. In a nut shell, that is why I do it and it is why I love working with this client group. I hope that this post (if you ever got to the end of it) gives you some insight into why I do what I do….it has taken 6 months to be able to decant and condense what is a very complex and difficult topic, so thank you for reading.

Kerry x

Livsey, J. (2003). Practical Management of Personality Disorder. New York, Guilford Press.

More guest entries written by Kerry Stott @kerrystott
and visit her websites at


  1. I'd love to hear your thoughts on DBT as a treatment for PD. Many of the multiplesey I've known over the last dozen years or so (including myself) displayed BPD symptoms so severe, it took years to get to the DID. I was lucky to have a therapist who helped me navigate the PD issues so the vast majority of my treatment focused on DID recovery.
    From what I've read of DBT, it's similar to the approach used with me before it had a fancy name.
    Also, do you see attitudes towards PD patients/clients to be improving as it is better understood? In my day, such a diagnosis meant little more than "attention whore" and best ignored. I believe the invalidating nature of such professional attitudes made it worse for those seeking help in the 80s and 90s. I hope it is better now.

  2. People using phrases such as attention seeking, manipulating behaviour, acting out, and 'cry for help' (fortunately I haven't heard the phrase attention whore professionally otherwise I think I may have gone NUCLEAR!). To me, these are just indicators of someone's internal state, what emotions they are feeling inside. If a child was that distressed you would have to be a cold hearted bastard to walk away, so why would I do that to an adult?
    DBT (dialectical behavioural therapy) is a frame work, like any other therapeutic model, it has it's uses and limitations. Being able to understand yourself and why you think/feel/behave/react how you do is essential to everyone and in particular people who are in need of my help/treatment. Using a robust framework can help, with the support of a suitably qualified therapist (if you like them it always helps!)it is systematic, which whilst potentially making it too prescriptive, means that people in a mercurial distressed state can work through things in a sequential manner.
    Ultimately, finding a therapist that you can trust is always the key. It is that therapeutic alliance that can allow you to set yourself free, rather than be a prisoner to a mental health professional.
    Hope this helps
    Kerry x

  3. EEEEEeepppp I am shockingly upbeat about PD and people with that diagnosis. This is because in my experience it is not hopeless nor a waste of time. People, regardless of diagnosis, are not a waste of time. Possibly because it is my speciality or because I see people recovering from whatever hell they have been in - this makes me hopeful and upbeat and glad that I do my job! :D

  4. Thanks so much for your response. :)