Subspecialist psychiatrists are sometimes selective about whom they will treat

EDITOR—The article by Kisely (on which one of us (AJP) wrote a commentary)1 and the responses to it show the difficulties that people with severe personality disorders present to health policymakers and the different views among mental health professionals who work with these patients. Haigh's letter2 and the longer electronic version of it3 provide an insight into how a psychiatrist working in a narrow subspecialty can lose sight of the realities of psychiatric practice Haigh has taken offence at the description in the commentary of a patient who deliberately harmed herself (her behaviour led to over 100 operations) and who caused distress and dismay among social workers, the police, the legal profession, and all health workers who tried to help her. The vignette had to be brief to preserve anonymity, but it was entirely factual.

Haigh accuses one of us (and, by implication, the multidisciplinary team) of being unprofessional and is critical of our inability to form a therapeutic relationship with this patient. In the three years before the patient came into our ward numerous mental health professionals considered her to be psychiatrically untreatable. Because her life was in danger, our multidisciplinary team on a general psychiatric ward opted to attempt to treat her under the terms of the Mental Health (Scotland) Act. We were able to carry out a comprehensive assessment and reduce her self harm and exposure to general anaesthetics. We could not, however, successfully change her behaviour despite our best efforts over 14 months. Her local health board said that it would underwrite any extracontractual referral, but none of the specialist units for the treatment of personality disorder would accept her. After discharge she embarked on an orgy of self mutilation until a general psychiatric unit in London began a programme of treatment under the Mental Health Act.

Haigh seems proud of his therapeutic community for day patients with personality disorders, where “selection and drop out is often part of the clinical process.”3 We suspect that he can effectively limit his distress and dismay in dealing with patients because he can decline difficult referrals to his specialist unit. Is it not, in fact, unprofessional for Haigh to deny the emotional burden on colleagues who are prepared to try to help deeply disturbed patients?

This exchange between Haigh and ourselves will, we hope, give general readers some understanding of this topsy turvy part of British psychiatry Those who claim to have the greatest skills in dealing with personality disorders do not accept severely affected patients. This leaves general psychiatric teams to do their best to help these patients, often in the most difficult circumstances. Policymakers who are desperate for a solution to the inadequacies of services for severe personality disorders should bear these issues in mind when subspecialist psychiatrists from centres of excellence ask for additional funding.