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

Categories: Personality, MentalHealth