Not may people realise how big this is...

This week I received an interesting email, in my role as moderating clinical messages on the National PD website (www.personalitydisorder.org.uk)  from somebody whose son has finally found a specialist service for what is probably diagnosable as Emotionally Unstable Personality Disorder. This is after agonies of  being passed from one service to another, nobody being able to help, and no honesty about the likely diagnosis.

It is so encouraging to hear from somebody who can see the size of the problem here – I so often feel that I’m ranting on about something that nobody is interested in. And the response from ‘the system’ is so corporate, anodyne or cautious to render it meaningless: “so much is being done to improve community care”, “the government’s first priority is public protection” and “all the European metrics show how well we are doing” are all things I have heard recently, and the last was from the government’s director of mental health in a very uncomfortable personal conversation I had with him. 


With the growing despair that the world of mental health is going the wrong way, several of us who are ‘medical psychotherapists’ met John Alderdice in the Lords last week (he is a retired medical psychotherapist himself).  His advice was to get local and make a fuss (as there is no central control anymore beyond awfully empty and arid things like ‘No Health without Mental Health’)  – but to focus on good MH stories where it is being done well. Personally – since reading Paul Mason’s ‘Why It’s Kicking Off Everywhere’ – I have been trying to send a daily tweet and a weekly blog about it all (hence you reading this!). I know it takes a while to get these things going, so I will persevere for a few months yet - or until I am 'silenced'!

I started medical life as a GP – but, being most interested in the ‘soft psychiatry’ that they were very good at teaching us as part of the GP training in Cornwall in the 1980s, decided to return to Oxford to train as a psychiatrist – but was sorely disappointed with what I found. Although I remember thinking how much more opportunity there was to do psychosocial practice better in primary care, and being sorely tempted to go back to being a GP, I remember my trainer’s wife – a feisty Bodmin magistrate – saying, as her parting shot to me, ‘at least go and do something about PD, Rex!’.


Since then, I think I have had a fair stab at that – although usually in the teeth of opposition to my determinedly ‘biopsychosocial’ approach. But I did get a reasonably lucky break for my consultant job, when in 1994 I was appointed to develop a ‘therapeutic community’ as part of a regional psychotherapy service in Berkshire – then another when I was invited onto the DH working party to help write the government’s PD policy guide ‘No Longer a Diagnosis of Exclusion’. It was only when I had to diagnose our service users for Royal College of Psychiatrist student examinations in about 1998 that I realised that all our 'patients' had Borderline Personality Disorder!  In the DH working party, I ended up causing quite a stir by gathering a gang of about twenty very unhappy – and generally rejected – service users from across England and setting up focus groups with them and fairly senior civil servants. Suddenly, somebody realised that there might be a problem here.

That was in 2002, and over the last decade many flowers of excellent service have been blooming – but there are still many areas of desert. That is as true geographically (88% of England has no ‘tier 3’ PD services) as it is professionally (unfortunately, the inherent conservatism of my own profession either sees the psychosocial approaches as ‘not real medicine’ or are frightened of the challenge to their authority that it might imply. 


Furthermore, what little hope that there was for further development of community services for PD has been largely dashed by the recent ending of the national programme – and effectively insisting that IAPT is “the only show in town” (see last week's blog entry). 


One glimmer of hope that we are holding onto is that the time is indeed very opportune to ‘do it locally’. If we could organise a good campaign to educate and inform the CCGs before they come into operation next April – which means me and like-minded colleagues (in our ‘spare’ time), and three days a week of Fiona (a passionate and energetic graduate of a proper PD treatment programme). 


Our fear is that the message will be lost in the clamour for ‘really important’ NHS services – and that people who are ‘attention seeking’, ‘manipulative’ and  ‘their own worst enemy’ don’t deserve public money.


Our hope is that three things will  get recognised (1) good treatment is now available – and GPs and psychiatrists no longer need to tear their hair out with these ‘difficult patients’ (3) the burden of suffering – patients, families and friends – is immense and (3) good treatmet availability will save far more money than it costs.