Personality disorder: no longer a diagnosis of exclusion? Law, policy and practice in Scotland

Abstract

Personality disorder has been and continues to be a contested diagnosis. Those who attract this form of diagnosis have been particularly vulnerable to the effects of stigma and have tended to be excluded from service provision. This thesis provides an examination of how recent developments in law, policy and practice have impacted upon the status of personality disorder as a diagnosis of exclusion in Scotland. The theoretical framework that provides this thesis with its structure is derived from the post-empiricist approach proposed by Derek Layder. This approach seeks to contextualise emergent inductive findings within a broader historical and contemporary analysis. In the case of this research the broader context consists of the interplay between mental health law, policy and practice in the field of mental health and the diagnosis of personality disorder more specifically. The empirical enquiry at the core of this thesis is based upon an analysis of the views, beliefs and expectations of front-line staff (psychiatrists and social workers qualified as mental health officers) involved in the process of assessment and service provision. In addition to front-line staff (n = 27) a range of key informants who were in a position to shed light on the strategic imperatives underpinning recent developments in law and policy were also interviewed. This analysis is contextualised within a review of key developments in law and policy that have particular significance for anyone who may attract a diagnosis of personality disorder.

Despite the ostensibly inclusive approach towards those who may attract a diagnosis of personality disorder evident within the Mental Health (Care and Treatment) (Scotland) Act 2003, the reality is a highly selective and very limited inclusion of those who attract this form of diagnosis. The effective inclusion of those who may attract a diagnosis of personality disorder has been obstructed by several key impediments: 1: an insufficiently robust policy framework to drive forward the process of inclusion; 2: residual ambivalence towards the legitimacy of the diagnosis of personality disorder itself and the legitimacy of the claims made upon services by those who may attract a diagnosis of personality disorder; 3: insufficient and inadequately focused resources; 4: service structures that have not been redesigned sufficiently to engage successfully with service users who may attract a diagnosis of personality disorder. As a consequence of these impediments to inclusion, the majority of those who may attract a diagnosis of personality disorder in Scotland are likely to continue to face high levels of marginalisation and exclusion.