Personality disorder, once the enfant terrible of psychiatry, has now come of age, having agreed diagnostic criteria in both the major glossaries and even possessing its own National Institute for Health and Clinical Excellence treatment guidelines. Adshead and Jacob have collected a series of classic papers focusing on that most destructive aspect of personality disorder – the exquisite talent of an individual who has the disorder in alienating anyone who ventures near and tries to help them.

The book starts with Winnicott's classic study, well summarised in its title ‘Hate in the countertransference’, which describes how patients with personality disorder are adept at eliciting hatred from their therapists, a hitherto unthinkable sentiment for a carer. However, it was Main's work at the Cassel, in his classic 1957 study of psychiatric nurses, ‘The Ailment’, a must-read for both trainees and the trained, which showed the way forward through this therapeutic impasse. Main started a research group which entailed meeting every week with the Cassel nurses, who began to describe their experiences with 12 difficult female patients who would now be considered as having borderline personality disorder. He described how the patients would sometimes single out a nurse, perhaps imbue her with qualities of greater compassion and understanding than her colleagues, and how there would be ‘in-groups’ and ‘out-groups’ of nurses, processes we now recognise as splitting and projection. Uncertain as to whether such information was helpful, Main nevertheless thought he had achieved something and wrote:

Nowadays, staff supervision and staff support forms the cornerstone to the many diverse modern personality disorder treatment programmes offered in the National Health Service. Studies emanating from the Henderson Hospital (now sadly no more) by Kingsley Norton describe how the therapeutic community model of sociotherapy, combined with the use of peer-group reflection, can sometimes help a client achieve a greater degree of personal maturity. This model has been partially incorporated into modern treatment programmes, which are more oriented to day care than the original in-patient model of the Henderson.

There then follows a group of theoretical papers attempting to explain the dysfunctional relationships in terms of animal ethology, attachment theory and classical psychoanalytic theory. All are well written, each more plausible than the next, yet sadly such theorising has done little to alleviate the plight of these patients or offered much in the way of comfort to their carers. Such collections, often accompanied by sterile debates on issues of treatability and non-treatability, form part of an inevitable diet of any compendium on the personality disorders and are likely to remain so until there is some seismic shift in our understanding of these disorders.

The book ends with another short but ‘must-read’ paper, on the issue of professional boundaries and the medico-legal dangers of crossing them. Gabbard and Gutheil carefully review the danger of gifts, touching, self-disclosure by therapists, inappropriate clothing, money and the setting for therapy. The founders of psychoanalysis were not nearly so circumspect in this realm. Freud was the analyst to his own daughter, Anna; Melanie Klein took Clifford Scott on holiday with her and continued his analysis while he reclined on her hotel bed; Winnicott often ended his sessions with coffee and biscuits. Such boundary violations would be unthinkable now, but then 50 years ago patients were much nicer than today and did not sue their therapists.

This book is excellent value for anyone who has had difficulty working with clients who have personality disorder – but then isn't that just about everyone?