by Len Bowers
Review by Roy Sugarman, Ph.D. on Apr 22nd 2004
Bowers is a psychiatric nurse, and
the view he expresses is favorably coloured by this perspective, given that in
his environs, it is nursing that must bear the daily brunt of most of the toil
that goes with caring for such 'difficult' customers.
As John Ratey at Yale has noted
across time, it is this group of patients that will most test the persona and
skill of any carer, and also at the same time elicit the most unprofessional behavior
from even the most caring professionals.
Bowers puts a lot of emphasis on a
synergistic interplay between various poles of manipulative behavior, from the instrumental
(objective, conscious, clear cut goals) to the interpersonal (emotional,
unconscious, obscure goals) which define the parameters of manipulation. The
hexagon, as he defines it, or rather the hexagonal model he provides, categorizes
manipulative interactions with the patient as one or many of: Corrupting,
bullying and dividing (the instrumental side), and the other three categories
conditioning, capitalizing, conning (the interpersonal dimension).
Bowers draws on many works in the
general literature, but also heavily on the results of a survey of 651 nurses
who responded to his questionnaire. This all makes for fascinating but
familiar reading. Anyone from the industry would recognize the emotive and
concerned responses from nurses in specialized PD units, as well as those from
general wards, as they ponder their experience of those whom others consider
sad, bad or mad by virtue of their interpersonal, enduring styles.
Most interesting are the
correlations with negative views of PD, mostly confined to those with
inadequate training or understanding, and those who are just too long in the
tooth in the specialized care, and have burned out or been hurt too often, or,
as with so many, have just had enough.
Some of the stress of course is
experienced by contrasting history with presentation, wondering how someone
with this presentation could have done those things. Not only
manipulation, but self injurious behavior is also capable of inducing negative
attribution in observers.
Bowers sets about outlining an
approach to inpatient management and treatment that has some aspects of many
things in it, but draws on the known and desired attributes that carers have
come to value, namely positive regard, structured interaction, clear boundary
management, and loads and loads of training, teamwork, and the always positive
person in a positive structure. Looming over the professional always is the
threat of legislation and litigation, disciplinary committees and consumer
groups, who may not always allow for the necessary 'dignity of risk' approach
that may allow for more leeway in the field, rather than the slavish commitment
to lock up someone at any hint they may die by their own hand or some
misadventure: high mortality is a feature of personality disorder, and also the
cycling mood disorders that some of them strongly resemble. Patients may rot
without their rights, given repeated threats of self or other harm, or rot with
their rights in a community program poorly funded to attend to their needs.
Either way, a standard medical or psychological approach to PD seldom shows
efficacy, and the need for special structure is acknowledged.
What is clear, as always in books
like this, is that we need different approaches to the traditional ones, in
order to protect and serve our clientele with personality disorder.
The use of the nurses' comments
illustrates nicely the consensus of those who work with this spectrum of
disorders, and makes this book unique.
It is a most helpful tome, concise
and readable, useful for both entry-level professionals and also those more
experienced, across the spectrum of those who need to work better within the
hospital setting, anyone in fact in the multidisciplinary team, including the
A great strength of Bowers'
approach is the reiterated stance of explaining and engaging with such clients,
always telling them why.
He makes no mention of the many
problems they may have in processing information, but his interventions would
appear to serendipitously solve such issues by the imposition of such clear
communication of structure as he paints it.
If the neophyte then emerges from
college, and now wishes to engage with such challenging personalities, then a
combination of this work, with John Ratey's neuropsychiatric tome, and Marsh
Linehan's various works in Dialectic Behavior Therapy, should constitute a
thorough grounding for any professional. Making life easier for 'us' and 'them'
as Bowers styles his last chapter, is what it is all about.
This book is highly recommended.
© 2004 Roy Sugarman
PhD, is post of Clinical Director of the Clinical Therapies Programme in Liverpool (Sydney) and Clinical
Associate Professor at the University of New South Wales.