Rough sleeping and personality disorders: a dual diagnosis of exclusion?

'Services for people with characteristics of personality disorder need to be shaped in a way that makes them accessible to people who display those characteristics, rather than in a way that suits clinicians or managers'. The former Director of Health & Recovery at homelessness charity St Mungos presents his argument.

‘Personality Disorder: No Longer a Diagnosis of Exclusion’ was published by the Department of Health back in 2001. However, displaying the characteristics of personality disorder remains just as much a diagnosis of exclusion today as it did then: Exclusion from society and from mental health services, including most specialist personality disorder services. Many such people become homeless and/or rough sleepers because there’s nowhere else for them to go.

"Services have to work with a variety of techniques and modalities at a pace the patient can manage, not the pace that the manual prescribes, because a forced pace is reminiscent of abuse and being controlled and risks repeating experiences of early trauma."

When I started working with homeless people and rough sleepers over 25 years ago, one of the frustrations was that many of the people we worked with displayed behaviours and attitudes that suggested deep-seated emotional and psychological difficulties, often compounded by heavy drug or alcohol use and all sorts of ‘challenging behaviours’. If we did get them to a psychiatric service to be diagnosed, they would usually get a diagnosis of ‘personality disorder’, and then be discharged. This was because - according to the NHS at the time - personality disorder was ‘untreatable’.

After ‘Personality Disorder: No Longer a Diagnosis of Exclusion’ was published, personality disorder was deemed treatable after all. Over the next 20 years, treatments proliferated – there was and is transference-focused psychotherapy, dialectical behaviour therapy, mentalization-based therapy and Schema therapy. This complemented psychodynamic psychotherapy (which had provided a theoretical and practical approach to working with personality disorder since Kernberg’s work in the 1980’s). And just for good measure, though there was no evidence to support it, lots of psychiatric drugs were given to people with diagnoses of personality disorder.

Shut out of services

The trouble for me as someone working with rough sleepers and homeless people with characteristics of personality disorder was that virtually none of the services offering these treatments would work with the people homeless services we were working with. Very few would even assess homeless people, and if they did, they would not give them diagnoses. In a piece of research by Clinical Psychologists at a hostel for rough sleepers, just over 80 percent were found to meet the criteria for a diagnosis of personality disorder: just under 8 percent actually had a diagnosis of personality disorder.

Routinely, clients were denied access to treatment because they took drugs and abused alcohol; because they were ambivalent in their commitment to treatment and their attendance at clinics; because they were offensive or aggressive; because they were defensive and withdrawn; because they were emotionally volatile; because they had the characteristics of personality disorder…

Most of the specialised personality disorder services would not work with people who displayed the characteristics of personality disorder that we worked with in homelessness services. It is still the same today – only last week a psychotherapist I supervise was telling me about a homeless client of his who was refused treatment at a specialist personality disorder service in London because he had ‘anger issues’. Oh come on!

Personality disorder remains a diagnosis of exclusion. People with ambivalent care-seeking behaviours, damaged attachment patterns, volatile emotions, distrust-based interactions, and lots of ‘acting out’ – drug and alcohol dependency, self-harm, suicide attempts, aggression, attacks on caregiving – are excluded by the great majority of NHS mental health services, including so-called specialist personality disorder services. Many of them, because of the same behaviours and patterns of interacting, end up homeless or sleeping rough. This in itself becomes a cause for exclusion from mainstream mental health services. Personality disorder remains seriously under-diagnosed in the homeless (and other socially excluded) populations, and NHS personality disorder services continue to systematically fail people with characteristics of personality disorder.

Shaping inclusion

However, this situation is not in any way inevitable, nor is it irreversible. Current mental health services, including specialist personality disorder services, fail people with personality disorder because they simply do not offer them treatments in a way that they can use. Services for people with characteristics of personality disorder need to be shaped in a way that makes them accessible to people who display those characteristics, rather than shaped in a way that suits clinicians or managers, but which further alienates the very people they are supposed to work with and for.

Services for people with characteristics of personality disorder have to work flexibly because people with histories of abuse, neglect and exclusion by caregivers, including institutional caregivers, are ambivalent in their attitude to caregiving. They have to work with people who take drugs and alcohol because people in high levels of distress with an unstable personality structure tend to self-medicate. This sort of object-dependency arises from the same early childhood neglect and abuse that is part of the background to the development of personality disorder.

Services have to work with a variety of techniques and modalities at a pace the patient can manage, not the pace that the manual prescribes, because a forced pace is reminiscent of abuse and being controlled and risks repeating experiences of early trauma. Services have to be accessible, i.e. where excluded people already go, rather than expecting them to make the effort to come to the service. Services must also be patient, allowing the client to develop trust at their own pace. Above all, services have to be genuine, compassionate and really interested in the individual and in the individual history that brought the person there, both to the service and to the mental state we call personality disorder.

Theoretical framework for success

The good news is that some services that work this way do exist, providing psychosocial and psychotherapeutic interventions that enable people with characteristics of personality disorder and a wide range of challenging ‘acting out’ behaviours to embark on a self-developed journey of recovery. They exist in the third sector and in the NHS, and they are based on solid evidence from theory and from practice, and they have a track record of effectiveness. 

Using a focus on work with homeless people and rough sleepers, my new book, Social Exclusion, Compound Trauma and Recovery, outlines the theory behind effective work with people with characteristics of personality disorder, the links with compound trauma, and the psychology of recovery. It includes chapters by a range of Psychologists and Psychotherapists on practical experience of working effectively with this client group. It ends with a consideration of the systemic issues at play in providing effective (or ineffective) services for people with personality disorder-type self-organisation.

Personality Disorders, with all the challenging behaviours typically associated with them, no longer need to be a diagnosis of exclusion. There are inclusive services working effectively with this client group: there is much for mainstream mental health services to learn from their approaches.

Dr Peter Cockersell is a former Director of Health & Recovery at leading homelessness agency St Mungo’s. He is a Psychoanalytic Psychotherapist with over 20 years’ experience in the NHS and third sector working with homeless and other socially excluded groups.