AMHPersonality: Disordered?
By John Mitchell
I’m an AMHP who detains few people, and who tries to persuade others to use detention less too. Since the very identity of the AMHP seems to be that of a detainer this is quite a challenge. How far should you resist detention? What are the arts involved in doing so? How do you learn or teach them? Who do you become as this negative capability increases?
For me, clarity of purpose, openness to experience, and understanding of personality are all crucial. We need to question the necessity of intervention, weighing the harms of detention against this. To be authentically present, flexible about the way we assess, as well as hearing from people outside of the MHA process. To understand the person in front of us. How many alleged ‘symptoms’ and ‘risks’ are related more to who this person is, or to our way of seeing them, than to a disorder likely to respond to treatment in hospital? What prejudices, anxieties, and habits, professional and personal, am I bringing to this assessment?
As an AMHP I am known, if at all, for avoiding the detention of people who suffer the injustices of ‘personality disorder’, even when my refusal may itself feel like an injustice to the person being assessed. I attempt to train AMHPs in an approach where, comfortable with both suicidality and uncertainty, we interview better because we feel less fear and so cause less fear. My own experiences of being detained make me listen, at least sometimes, as one of ‘us’, not as one of ‘them’. (How I wish that all my work was touched by this!) Mostly I present evidence, try to model a compassionate scepticism, promote a ‘less is more’ approach that reduces harm but cannot avoid pain for all involved. Many AMHPs respond to that message because it answers something deep in their experience. Fewer, however, find the courage needed to follow this path very far, and AMHP services may struggle to support such a journey.
Professionals are trained to sift through distress for signs of mental disorder, and to medicalize abnormality whenever alloyed with risk. We often medicalize normality if we can find enough risk. (When detention is at stake diagnosis plays a role more ‘political’ than clinical). We tend to ignore personality unless dysfunctional enough to label as personality disorder. Even then, we have the patience for a few brands only. “Already tagged with ‘EUPD’? Ah good: well, we should try not to admit you…”. “You have ‘PTSD’, ‘ASD’ and ‘ADHD’ as well? And schizoaffective too… Mmm, more disorder. What do we do now?”
A person is no more or less complex with five diagnoses than with one. Or none. But assessors and assessed alike may be infected by dangerous expectations in imposing these concepts. We often need to investigate an overdose of psychiatry. “But I’m an AMHP. I have a social model….”. Precisely: we are allied to psychiatry and are parasitical on it unless we are continually redefining the relationship. In resisting detention, it helps to know at least some of the better psychiatry, (Paris, 2020; Tyrer and Mulder, 2022), whilst listening more closely to service users (Barker, 2017; Blakely et al 2021) and not expecting unanimity of view.
The concept of ‘personality disorder’, with its stigmatizing baggage, is a challenge. Retaining the term, for now, within ironic inverted commas (Ramsden et al, 2020), can only be justified by the need to respond helpfully to identifiable patterns of distress. Unfortunately, ‘personality disorder’ has something of a history as a damaging response. “You do not have the kind of problem that responds well to medication, or to psychiatry, but if you refuse to go away you may get both anyway, together with a large dose of professional frustration and anxiety which we will blame on you”.
Changing terminology does not, of itself, solve the problem. Neither does an exclusive focus on trauma. But if we imagine that we can observe people through the distorting lens of ‘personality disorder’ with no questions raised about ourselves, we misunderstand everything. Only through skilled use of our own personality can we properly assess anyone. We must be prepared to feel at least some of the weight of traumatic experience, of silent emptiness: “When they left, it felt like they had taken ‘me’ with them, and I was left floundering, not knowing who I was. I was who they had made me in that instant. I existed because they defined me. Without their definition I was incredibly lost, and I relied on the next interaction to recreate another ‘me’“ (Tracy Barker, 2017, p15).
Yet kindness alone cannot bear very much reality. Pure empathy also has its dangers. An MHA assessment is not therapy, even when those involved have therapeutic skills. Attending repeat sessions here is a sign of institutional malaise, of services more disordered than the person they should serve. Recognising past errors and evasions will not deliver us from the temptation of more detention today: to resolve everyone’s pain, especially our own. Of course, we can project the addictive behaviours involved onto those who have made us so uneasy: “these people shouldn’t be detained, but when they behave in this way what else can you do?” Such thoughts will be the more powerful for being unspoken, inwardly unacknowledged.
“But what can we do with this mumbled suicidality? I mean, there are no adequate alternatives. Crisis team, is that it? They don’t want her and she knows it. She’s refusing everything anyway, and we’ve been through this twice this week already….”.
Sometimes we must find the best way of doing less, of insisting on no more than proportionate support, of letting go of control while still leaving a door open for tomorrow. Your door. Your tomorrow. Demanding that you make reassuring noises to us now, before we will allow you to leave, mirrors maladaptive behaviour. Less intervention requires more presence, more patience, the bravery to tolerate uncertainty, persuasiveness. It needs AMHPersonality.
Mental health services were not designed with personality in mind. We see this from the notes of those pictured only in silhouette throughout years of ‘care’. We see how the problems of ‘personality disorder’ often preoccupy specialist rather than mainstream services. The real business of mental health is the application of medication to disorder. The real business of the MHA is to restore medication to those who ‘lack insight’: those who have ‘disengaged’, are ‘non-concordant’, and so have ‘relapsed’. (NB: it is always patients who ‘disengage’, not services). Personality is marginal, time consuming, and can largely be ignored if you can find illness.
But psychiatry tends to turn personality into illness whenever we are worried about risk, particularly a perceived high risk of suicide. For if there is something that we fear more than disordered personality it is suicide. Few are prepared to teach us that, since we can neither predict nor prevent individual suicides, we had better focus on what we might do well: achieve the best assessment and care. Assessment itself might be only care that this person will receive, for now at least.
Would you ‘guarantee your own safety’ if anxious professionals were looking to you for their security because their organisations felt so unsupportive? If someone believes that “you’re only interested in me when I’m suicidal” then we can expect more expressed suicidality, even when that expression is no more than a hooded murmur. Silence is not manipulative because professionals feel manipulated. It is easy for us all to become habituated to detention and evade responsibility for our own recovery.
Personality disorder is about far more than suicidality, but where the two meet in acute care it can seem so personal for all involved. Feeling powerless, we reach for the only powers that we imagine we have and miss our true potential.
What though is that potential? To forever send young women into the rain with, at best, 2 mg of human diazepam, at worst, a rebuke for being suicidally alive? Withholding detention can seem powerfully rejecting if you only feel safe on a ward. Somehow, we must communicate a fundamental acceptance: demonstrate that we believe in you more than we do in detention.
Just be with me. Yourself have the courage to go on when nothing is working. Encourage today, without trying to take away the option of suicide; suicidality may be helping me to survive, may be a key part of who I am. The fact that I am still alive should communicate something to you. Don’t pretend you are saving me from suicide, or that, yet again, I will ‘benefit from an assessment’. Allow yourself a little more angst than that.
Marsha Linehan, the originator of DBT, herself someone with a history of ‘personality disorder’ and detention, was in seclusion for months, and furious when this was ended. “I had been in an environment where no-one could effectively help me, so the only thing I could do was to get them to try harder. It wasn’t a conscious strategy on my part […] but I now suspect that my suicidal behaviour was being reinforced by increased efforts to help me” (Linehan 2020).
In the end, whatever the strength of the evidence, best practice must be shown. We need an inclusive practice leadership that ‘gets it’. I write this piece because of the service users and professionals who have inspired me and are too modest to claim these lessons as their own.
“That’s it? John, I thought you were going to avoid a clichéd focus on ‘EUPD’, with all its gendered oppressions, concerning which, forgive me, you are not the most persuasive critic?”
Yes, you’re right, I was.
“Surely you were promising us a wider view of other ‘high risk’ situations where personality predominates, and where we may be tempted to detain anyone we don’t understand?”
That’s true. Sorry. I lost my way. Much as I did when running through the darkness, emotions too raw to name, from what was never a place of safety for me.
I’ll (probably) be back. You can reassess me then. And yourself.
References;
Tracy Barker (2017): A Sad and Sorry State of Disorder: A Journey into Borderline Personality Disorder (and out the other side). London: Jessica Kingsley.
Louise Blakley, Carolyn Asher, Angela Etherington, Joanna Maher, Emma Wadey, Valerie Walsh & Sandra Walker (2022) ‘Waiting for the verdict’: the experience of being assessed under the Mental Health Act, Journal of Mental Health, 31:2, 212-219, DOI: 10.1080/09638237.2021.1922624
Marsha Linehan (2020): Building A Life Worth Living. New York: Random House
Joel Paris (2020): Treatment of Borderline Personality Disorder. New York: Guilford.
Jo Ramsden, Sharon Prince and Julia Blazdell (2020): Working Effectively With ‘Personality Disorder’. Shoreham: Pavilion Publishing.
Peter Tyrer and Roger Mulder (2022): Personality Disorder: From Evidence To Understanding. Royal College of Psychiatrists. Cambridge University Press.