Nice to hear from Dr Giles; even nicer that Sysyphus want to talk to me. My comments were addressed to the utility of the diagnosis of personality disorder in this patient, with some suggestions about why we should be careful about making such "diagnoses". Marsha Linehan and I would agree, and I'm not sure why you would think otherwise. The fact that Marsha doesn't see the diagnosis of "borderline" as hopeless has little bearing on the possible effects of labelling Gary as having a paranoid personality disorder. A label of borderline would mean a suggested programme of several sessions of treatment per week for a year, with negligible clinical change anticipated, possibly a reduciton in attempted suicide and emergency room attendance. Interestingly, there are also data suggesting much briefer cognitive behavioural interventions getting at least as good results. BUT: that's not Gary. My basic question; Why make this diagnosis with this person remains unanswered. It is incidental that your arguments concerning the diagnosis of personality disorders do not deal with the issues I raise. What some choose to call personality disorder undoubtedly exists; I'm not clear why you think I'm denying that. I'm merely suggesting that a good psychological formulation is worth much, much more than such a diagnosis. Lets not mention the reliability and validity of such personality diagnoses; we know they are poor. Lets assume that some therapists will not be biased about the label of personality disorder even when accurately (?) applied. Lets just consider my other point about the scientific basis and predictive validity of the (i) the concept of paranoid personality disorder and (ii) the evidence on treatment outcomes when treatment is focussed on treating this disorder. Are these rhetorical questions, perhaps? Although I don't direct a 550 bed inpatient maximum security psychiatric prison hospital, I have visited such institutions and seen what staff attitudes to personality disordered patients are. I'm relieved to know that your unit does not hold with such attitudes. However, consider this; do you think that the concept of borderline personality disorder explains why they learn to tolerate the distress of prison by swallowing razors and cutting? Or is it better to examine the pattern of past and present problems and abuse, the meaning of confinement, their relationships with the people around them and outside the institution, then try to help them make sense of why they show persistent problematic and distressing reactions, then try to help them find ways of changing their specific and idiosyncratic patterns of belief and behaviour? And so on. You say there are many on their treatment teams who treat them without judgement or negative bias; do you think the concept of personality disorder helps them do this? I agree with you, of course, about the abandonment of biases by clinicians. I imagine we both know the data on labelling; what I don't know, and look forward to your explaining to me, is how the use of a label (which few of us reading this list would ourselves regard as a positive one) can reduce bias. My alternative suggestion is a simple one: try to understand the person (Gary in this instance) from their own perspective, with the use of empathy and the cognitive perspective, not labelling.
The labelling is useful in so far as it represents an operational definition of characteristic problems, but it would be a mistake to assume even then that DSM IV carves nature at the joints. Remember, it's a development of Spitzer's Research Diagnostic Critera.
Sysyphus, there is no evidence at all that training in long term psychotherapy helps here. The little evidence there is suggests that those who train psychodynamically have major problems doing CBT. Sadly, the evidence is that CBT is effective. You can draw your own conclusions about psychdynamic therapy (c.g. What works for whom, edited by the Anna Freud Professor of Psychoanalysis, concluding that there is no evidence for the effectiveness of psychoanalysis). You make the points I made above to Dr Giles beautifully. You say: "These people rarely, if ever, display this initially. It invariably comes out later as the client becomes more trusting of their therapist." Now, lets think, do we think the diagnosis of personality disorder might lead to biased expectations?
Finally, I'd like to just remind you both of the data on axisI/II comorbidity. The outcome research shows that an extremely high proportion of such cases change in axis II diagnosis with brief (sometimes very brief) treatment of their axis I problem. The most notable example of this is social phobia/avoidant personality disorder. This type of observation led Gavin Andrews to suggest that CBT is much better at modifying personality than long term psychotherapy. Lets think about Gary as an upset person with a particular pattern of problems. Going back to where this started; maybe he's not paranoid; maybe there is some evidence that some people are out to get him at least some of the time.......