How the Mental Health System Discriminates Against Girls and Women

Dr Jen Daffin and Dr Carly Jackson advocate a trauma-informed approach to mental health that moves beyond stigma and gender stereotypes

The diagnosis of ‘personality disorder’ is disproportionately given to women. Women are 75% more likely to receive it compared to men and the consequences of receiving this diagnosis have been shown to prevent women from accessing appropriate mental health support and impacts how other public services engage with them.

As long ago as 1988 an article in the British Journal of Psychiatry reported research showing that psychiatrists treated patients with a diagnosis of ‘personality disorder’ as more difficult and less deserving of care compared with other patients. Little has changed since.

But the issue of its use runs deeper. The use of the diagnosis of ‘personality disorder’ causes diagnostic overshadowing of developmental and complex trauma. Its continued use masks a hidden epidemic of child abuse and neglect and prevents people, especially women from receiving appropriate treatment and support.

The recent Health and Social Care Committee Connecting the Dots report said that “the mental health and wellbeing of the population will not improve, and in fact may continue to deteriorate, unless effective action is taken to recognise and address the impact of trauma and tackle inequalities in society.” We also welcome Platfform’s calls for a holistic and social justice approach to mental health. By contrast, this stigmatising diagnosis continues to stand in the way of the Welsh Government achieving its mental health strategy objectives.

Today, it is still used against women. Still many providers of public services will exclude those with a diagnosis of ‘personality disorder’, and the police will often accompany public services to 999 calls when they are flagged as coming from somebody with this diagnosis. We are aware of reports where people feel the diagnosis is used as a threat to manipulate their choice of intervention or as an attempt to control their ‘behaviour’ or belittle their trauma and distress. The diagnosis is experienced by some as manipulation. The diagnosis of ‘personality disorder’ has been found clinically and anecdotally by the people it has been given to, to be highly problematic and have harmful effects.

This kind of coercive practice has been well documented as a global problem within mental health practice. The United Nations Special Rapporteur on the right to health, Dr. Dainius Pūras, said in his 2017 report on mental health that there is an urgent need for a paradigm shift in our approach to mental health and substance use. He called for a ‘revolution’ in mental healthcare and a move away from the biomedical model and ‘excessive use of psychotropic medicines’. He said: ‘We need little short of a revolution in mental health care to end decades of neglect, abuse and violence. Mental health policies and services are in crisis, not a crisis of chemical imbalances, but of power imbalances’.

A diagnosis of ‘personality disorder’ tells the person the problem is within you

We are also concerned at seeing mental health professionals advocate for the use of the personality disorder diagnosis in children and young adults despite its unreliability and we have written to the Deputy Minister for Mental Health to express this

We know poverty is correlated to child abuse and neglect. We also know that childhood abuse and neglect is correlated to ‘mental disorders’ including the diagnosis of ‘personality disorder’ and the diagnosis of ‘schizophrenia’. The experiences associated with the diagnosis of ‘personality disorder’ can instead be viewed as ‘normal’ responses to significant disruptions to cognitive and social development in childhood, our relational and attachment systems, alongside other challenges such as nervous system and emotional regulation. In other words, exposure to trauma in its various forms.

We would be particularly concerned about the impact of this diagnosis’ use on girls and young women who, rather than receiving a pathway for support, would see themselves barred from accessing it – earlier in their lives. This could change how those in their schools, further education, employment, housing providers, or communities treat them as well. We would be concerned that children and young people would feel forced to internalise these social issues and experiences and comply with interventions they don’t want or feel fit with their experience or reality.

Some practitioners argue that diagnosing ‘personality disorder’ can facilitate self-advocacy and promote acceptance of evidence-based treatments. We recognise that diagnosis can be helpful for some people but as highlighted already it is harmful to others. At the same time a diagnosis of ‘personality disorder’ tells the person the problem is within you. It says, “there is something wrong with you” rather than acknowledging context and holding in mind what has happened or happening to you or what did you not get that you needed.

Here, we must also consider the process of childhood development. Specifically, the implications for teenagers and in early adulthood, when brains are still adapting, developing and maturing. We know teenage brains are more vulnerable to stress. Therefore, it would be clinically essential to take this into consideration. The criteria for the diagnosis of ‘personality disorder’ already recognises this in acknowledging that ‘personality’ is not considered ‘stable’ until adulthood (approx. 25 years of age). It would therefore be clinically inappropriate to diagnose a ‘personality disorder’ before this developmental stage.

It would therefore be more appropriate to allow the use of the diagnosis of developmental trauma, attachment difficulties or focusing on developing the ICD diagnosis of complex PTSD and supporting them to access the associated evidence based interventions. The challenge is that not all of these diagnoses are currently recognised. Meaning children who experience early trauma, adversity, injustice or loss are often misdiagnosed and misunderstood by professionals, friends and family who have the best interests of the child at heart, but who don’t yet fully understand the impact of early trauma.

They get labelled as being ‘naughty’, ‘autistic’, ‘ADHD’, as having ‘behavioural problems’ or even emerging ‘Emotionally Unstable Personality Disorder’ (EUPD). These terms lead to adult responses which can hold children back from healing, progressing and reaching their potential. But what are we supposed to do when there isn’t an appropriate diagnostic pathway to provide trauma informed support? These problems don’t get adequate attention in mental health training or services because they don’t have their own category within the DSM or ICD (c5) diagnosis and are then masked by other existing ones. All of this hinders the provision of prudent care.

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This is a grave injustice to those children, young people and their families who then have their needs misunderstood or overlooked all together. Many of the children in our care system and youth justice system are trapped by this lack of appropriate support.

In Wales we have started to call this the ‘missing middle’ and exploring ways to address this gap but in a system organised around diagnostic gatekeeping, mental health services will need to find ways to incorporate trauma informed responses into their existing models or move towards models that can in order to bring about the necessary change needed.

Better recognition and understanding of the impact of the social, commercial, and political determinants for mental health must be at the centre of our thinking moving forward.

It has been suggested that the diagnosis of complex PTSD (ICD c5) could be an alternative in Europe, but this is currently focused on adult experiences that are not organised in a way that accommodates childhood or developmental issues. It would need revising and expanding if it were to meet the needs of these children and better meet the needs of adults too.

This is important because without a pathway there are consequences for how research for interventions and prevention develops.

We, therefore, see that better recognition and understanding of the impact of the social, commercial, and political determinants for mental health must be at the centre of our thinking moving forward.

This approach and perspective would sit comfortably alongside the ambitions set out in the Wellbeing of Future Generations (Wales) Act (2015) and is core to the delivery of the ACEs Hub and Traumatic Stress Wales all-society trauma-informed framework. It should be an important part of the Welsh Government’s new Adverse Childhood Experiences (ACEs) plan and the next iteration of the ‘Together for Mental Health Strategy’.

To achieve these aims long-term we must explore and fund the development of more sophisticated modelling of trauma and mental health to provide better human rights focused solutions to these complex problems. We are not starting from scratch. There are a number of long established and emerging fields to draw on including, for example, relational health research, attachment theory, traumatology, and relational neuroimmunology, alongside models such as the ecobiodevelopmental model.

Addressing this will be paramount to the Welsh Government object of becoming a truly trauma informed and relationally healthy society.