This is a fairly bold statement, and it is based on my (potentially unfair) summary of Misdiagnosed, mismanaged, mistreated: personality disorders and the Mental Health Act, an article published this year in the BJPsych Bulletin.
To be clear from the outset: I agree with the authors on a great deal of what they say. My concern is not with the critique of coercion, risk-driven care, or defensive psychiatry. It is with the conclusion, which I worry is too unilateral and too driven by diagnosis and labelling, rather than by clinical reasoning and individual presentation.
Where I agree with the authors
The authors make very valid points about how the new Mental Health Bill is unlikely to bring meaningful change for people diagnosed with BPD/EUPD. I share very similar worries (and have written about this before. Services continue to mistake restriction and coercion for care, prioritising the anxieties of risk‑averse organisations over the wellbeing of patients.
Given the millions of pounds spent on detaining people, and the devastating costs to their lives and wellbeing, most of us want change here. Where the authors and I differ is in what that change should look like.
The article frames personality disorder through a relational lens, acknowledging the impact of early adversity and disrupted attachment. It recognises that a Mental Health Act assessment — a process where two doctors and an Approved Mental Health Professional decide whether someone should receive treatment against their will — is itself a relational encounter.
That process can replay early trauma. Someone may be forced to do something against their will, echoing experiences of coercion and control, or they may be rejected and abandoned. Either way, there is a risk of re‑enactment.
The authors also highlight how repeated crisis presentations, focused narrowly on risk, can worsen relationships with services and paradoxically increase suicide risk. They are right to point out that for many people, being locked in hospital ‘to keep them safe’ is both the beginning and the end of acute inpatient treatment.
Alongside others in this field — Joel Paris among them — they note that acute wards rarely offer evidence‑based treatment for “personality disorder”, and that people who have been forced to do things throughout their lives often react badly to being forced to do things in hospital.
None of this feels controversial. We should remember what has happened to people. We should acknowledge that inpatient environments harm some people. And we should not detain people in environments that make them worse.
The part of the Mental Health Act that keeps people trapped (the bit that matters most)
Where I think the article misses something important is in its analysis of why people with a personality disorder diagnosis remain detained for so long.
At present, people can only be discharged from involuntary detention if it is not the case that:
they are suffering from a mental disorder of a nature or degree which makes it appropriate for them to be detained for medical treatment; or
detention is necessary for their health or safety, or for the protection of others; or
appropriate medical treatment is available; or
if released, they would be likely to act in a manner dangerous to themselves or others.
This is where things unravel.
There is no medical treatment for ‘personality disorder’ in the way the Act imagines. In practice, ‘medical treatment’ becomes stretched to mean forcing someone to be safe. When coercion itself is framed as the treatment, it becomes self‑justifying: if restraint and locked doors are what keep someone alive, then restraint and locked doors are always necessary for their health and safety.
The absence of therapy — or the fact that any therapy offered is delivered under coercion and thus often worthless— no longer matters. The silver bullet that blocks discharge is the clause about likely dangerous behaviour. For people whose coping strategies involve doing dangerous things to themselves, this can mean indefinite detention.
Taken to its logical conclusion, the standard becomes absurd. Someone like Frank Bruno wanting to leave hospital to go to a boxing match would not be allowed as he’d be acting in a manner dangerous to himself.
This is the part of the Mental Health Act that traps people — and it is largely absent from the article’s analysis.
Where law and ethics really collide
The authors argue that compulsory detention of people with a personality disorder is ethically questionable because many retain decision‑making capacity, even during crises. I agree with the spirit of this, but I think the reality is messier.
The decision about when to stop someone acting on suicidal impulses is relatively straightforward when someone is cutting themselves — behaviour that may have been present for years. It is much harder when someone is standing on the wrong side of a bridge safety rail. We can take comfort in the idea that ‘they have lived a life of self‑harm’, while forgetting that ‘they do not dangle off a bridge every night’.
The article compares this with addiction, noting that we do not use the Mental Health Act to intervene when people take life‑threatening quantities of recreational drugs. That is true, but the acuity of a lifetime of addiction is not the same as the acuity of a single, imminent, potentially irreversible act.
The authors are also right — and brave — to say that suicides will happen. There are limits to how much we can control the actions and thoughts of others. This stance is practical and honest. It can also be read, by some, as a licence to give up on people.
Diagnosis-based exclusion is not person-centred care
The article concludes that compulsory detention undermines the principle of seeing the person as an individual, because it is risk‑focused and fragments identity. This is where I most strongly disagree.
There is nothing that robs people of their individuality more than responding to a diagnosis rather than to their unique presentation.
The authors argue that the Mental Health Bill should actively limit compulsory inpatient detention for people with a personality disorder diagnosis. They acknowledge that brief, informal crisis admissions to structured, personality‑disorder‑informed settings may be helpful, but argue that repeated Section 2 detentions for people with well‑established diagnoses should be legally restricted.
It is not clear how such restrictions would work. Three Section 2s in a lifetime? One per year?
They also suggest adding a clause stating that detention should be unlikely to worsen the person’s mental disorder. As written, this undermines their own argument. More broadly, I worry about the ethics of warning against admission purely on the basis of diagnosis rather than individual history and response.
Some of the people we work with are far more likely to die in hospital than in the community. We actively warn systems about this and encourage avoidance of admission at all costs. But that advice is based on a very individual understanding of someone’s history — not on a label.
Equally, we work with people for whom hospital can be helpful. I would not want them excluded from admission purely because of a diagnosis that may have been applied briefly, superficially, or in a stigmatising way.
The risk of a dog whistle
What worries me most is how easily the position ‘we don’t admit people with personality disorder’ could become a dog whistle for exclusion.
Given how casually and inconsistently the diagnosis can be applied, I would not want a ten‑minute encounter with a locum doctor — who did not enquire about trauma history — to become the basis for never protecting someone at times when they cannot protect themselves.
I also would not want two people dangling from a bridge, one taken to hospital because they are depressed, and the other left there because they have a personality disorder diagnosis.
Guidance that already exists
The article overlooks protections that are already in place.
NICE guidance for BPD is clear that home treatment and alternatives to admission should be used first, that the length and purpose of any admission should be agreed in advance, and that clinicians should consider the likely harm of admission. These are not part of the Mental Health Act, but they are clear professional standards that support clinicians who do not want to admit.
NICE also states that people with borderline personality disorder should not be excluded from any health or social care service because of their diagnosis or because they have self‑harmed.
The Royal College of Psychiatrists is similarly explicit: patients with personality disorder should not be denied mainstream services on the basis of diagnosis alone, and Tier 4 services should include both detained and informal patients.
Arguing that people with a personality disorder diagnosis should never be detained sits uneasily with what both NICE and the RCPsych describe as good practice.
What needs to change instead
Changing the Mental Health Act to exclude people diagnosed with a personality disorder diagnosis from compulsory treatment is not the answer for me.
The Act already contains the mechanisms that keep people detained — particularly the conflation of coercion with treatment and the vague, self‑perpetuating use of ‘risk’. That is where reform is needed.
The article also overlooks the impact of the privatisation of inpatient care for those with this diagnosis. Much inpatient provision for this group is now delivered by self‑declared ‘specialist’ hospitals that are financially rewarded for providing coercion. This creates a system where people are brutalised in the name of safety, with very little scrutiny of outcomes.
We need political and legal change that allows people who have learned to destroy themselves to survive to access help without being further harmed. We need services to feel confident not to detain people when we know detention increases their risk of death. That will require explicit legislation, and clear leadership from coroners, professional bodies, and politicians.
In closing
There is a huge need to improve the care we offer to survivors of abuse, whether or not we insist their personalities are disordered.
That improvement will not come from blanket exclusions.
Featured article -Misdiagnosed, mismanaged, mistreated: personality disorders and the Mental Health Act