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Editor - The article by Kisely1 and the several recent responses
demonstrate the difficulties which people with severe personality
disorders present to health policy makers and the splitting that occurs
amongst mental health professionals who work with these patients. The
published letter from Dr Haigh2 and its longer electronic version3 provide
an insight into how a psychiatrist working within a narrow subspecialty
can lose sight of the realities of psychiatric practice. He has taken
offence at the description of a patient who deliberately harmed herself
leading to over 100 surgical operations and who caused distress and dismay
amongst social workers, the police, the legal profession and all health
workers who tried to help her. This vignette had to be brief to preserve
anonymity but it was entirely factual.
Haigh accuses one of us (and, by implication, the multidisciplinary
team) of being unprofessional and inhumane and he is critical of our
inability to form a therapeutic relationship with this patient. In the
three years before the patient came into our ward numerous mental health
professionals considered her to be psychiatrically untreatable. As her
life was in danger, our multidisciplinary team on a general psychiatric
ward opted to attempt to treat her under the terms of the Mental Health
(Scotland) Act. We were able to carry out a comprehensive assessment and
reduce her appalling and degrading self-harm and exposure to general
anaesthetics. However, we could not successfully change her behaviour
despite our best efforts over a period of 14 months. The patient's local
Health Board made it clear they would underwrite any extra-contractual
referral. However, none of the specialist units for the treatment of
personality disorder would accept this patient. After discharge she
embarked on an orgy of self-mutilation throughout the country until
another general psychiatric unit in London began a programme of treatment
with the assistance of the Mental Health Act.
Haigh appears to be very proud of his therapeutic community for day
patients with personality disorders where "selection and drop out is often
part of the clinical process".3 We suspect he can effectively limit his
distress and dismay in dealing with patients because he has the luxury of
being able to decline difficult referrals to his specialist unit. Is it
not, in fact, inhumane and unprofessional for Haigh to deny the emotional
burden on colleagues who are prepared at least to try to help deeply
disturbed patients?
This exchange between Haigh and ourselves will, we hope, give general
readers of the BMJ some understanding of this topsy-turvy part of British
psychiatry. Those who claim to have the greatest skills in dealing with
personality disorders do not accept severely affected patients. This
leaves general psychiatric teams to do their best to assist these
patients, often in the most difficult circumstances. Policy makers who
are desperate for a solution to the inadequacies of services for severe
personality disorders should bear these issues in mind when subspecialist
psychiatrists from "centres of excellence" come to ask for additional
funding.
Anthony J Pelosi Consultant Psychiatrist
Irene McKee
Clinical Nurse Specialist
Department of Psychiatry,
Hairmyres Hospital,
East Kilbride G75 8RG
1 Kisely S. Psychotherapy for severe personality disorder: exploring
the limits of evidence based purchasing [with commentary by AJ Pelosi].
BMJ 1999;318:1410-1412.
2 Haigh R. Psychotherapy for severe personality disorder. Evolution is
part of the therapeutic process of therapeutic communities. BMJ
1999;319:709.
Response
Editor - The article by Kisely1 and the several recent responses
demonstrate the difficulties which people with severe personality
disorders present to health policy makers and the splitting that occurs
amongst mental health professionals who work with these patients. The
published letter from Dr Haigh2 and its longer electronic version3 provide
an insight into how a psychiatrist working within a narrow subspecialty
can lose sight of the realities of psychiatric practice. He has taken
offence at the description of a patient who deliberately harmed herself
leading to over 100 surgical operations and who caused distress and dismay
amongst social workers, the police, the legal profession and all health
workers who tried to help her. This vignette had to be brief to preserve
anonymity but it was entirely factual.
Haigh accuses one of us (and, by implication, the multidisciplinary
team) of being unprofessional and inhumane and he is critical of our
inability to form a therapeutic relationship with this patient. In the
three years before the patient came into our ward numerous mental health
professionals considered her to be psychiatrically untreatable. As her
life was in danger, our multidisciplinary team on a general psychiatric
ward opted to attempt to treat her under the terms of the Mental Health
(Scotland) Act. We were able to carry out a comprehensive assessment and
reduce her appalling and degrading self-harm and exposure to general
anaesthetics. However, we could not successfully change her behaviour
despite our best efforts over a period of 14 months. The patient's local
Health Board made it clear they would underwrite any extra-contractual
referral. However, none of the specialist units for the treatment of
personality disorder would accept this patient. After discharge she
embarked on an orgy of self-mutilation throughout the country until
another general psychiatric unit in London began a programme of treatment
with the assistance of the Mental Health Act.
Haigh appears to be very proud of his therapeutic community for day
patients with personality disorders where "selection and drop out is often
part of the clinical process".3 We suspect he can effectively limit his
distress and dismay in dealing with patients because he has the luxury of
being able to decline difficult referrals to his specialist unit. Is it
not, in fact, inhumane and unprofessional for Haigh to deny the emotional
burden on colleagues who are prepared at least to try to help deeply
disturbed patients?
This exchange between Haigh and ourselves will, we hope, give general
readers of the BMJ some understanding of this topsy-turvy part of British
psychiatry. Those who claim to have the greatest skills in dealing with
personality disorders do not accept severely affected patients. This
leaves general psychiatric teams to do their best to assist these
patients, often in the most difficult circumstances. Policy makers who
are desperate for a solution to the inadequacies of services for severe
personality disorders should bear these issues in mind when subspecialist
psychiatrists from "centres of excellence" come to ask for additional
funding.
Anthony J Pelosi
Consultant Psychiatrist
Irene McKee
Clinical Nurse Specialist
Department of Psychiatry,
Hairmyres Hospital,
East Kilbride G75 8RG
1 Kisely S. Psychotherapy for severe personality disorder: exploring
the limits of evidence based purchasing [with commentary by AJ Pelosi].
BMJ 1999;318:1410-1412.
2 Haigh R. Psychotherapy for severe personality disorder. Evolution is
part of the therapeutic process of therapeutic communities. BMJ
1999;319:709.
3 Haigh R. Therapeutic communities. BMJ 1999;
www.bmj.com/cgi/eletters/318/7195/1410
Competing interests: No competing interests