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on the 6PSM
Harvard
citation for this article: TRANSCRIPT OF PAPER TO THE 3RD EUROPEAN CONGRESS ON PERSONALITY DISORDER, SHEFFIELD, JULY 1998 KIM DENT-BROWN This article will describe the use of storymaking in the context of a small team working with personality disordered patients in the NHS. The Specialist Therapies Service (STS) is part of an NHS Community Trust. It has six members, all with a basic mental health qualification (Clinical Psychologist, Nurse, Occupational Therapist) and most with further psychotherapy training (eg Dramatherapist, Cognitive Analytic Therapist, Integrative Psychotherapist) It works as a specialist team to support the community mental health teams, the wards and the learning disability services. Where those teams and services have a "hard-to-help" patient, they will make a referral to the team. The criteria for referral include:
The team usually finds that words such as "manipulative", "attention-seeking" or "behavioural", when they occurring a referral, are as good a criterion as any. The team undertakes a series of assessment sessions (usually about four), to try to get a full picture of what is going on for the patient, relating this current situation particularly to the patient's history. This forms me basis for a detailed written formulation usually covering several pages and including diagrams and text Initially the formulation goes back to the patient themselves. Once they are happy that it is a reasonable description it goes to the key worker so that it can be turned into a care plan to help manage that particular patient's difficulties. The STS provides recommendations for care plans and if necessary follow-up supervision for the mental health team and its key workers to implement that care plan. It also provides support to the worker because these can be among the most difficult patients to work with; patients who are repeatedly self-harming, or pushing the boundaries or employing projective identification on a large scale. The four sessions of assessment involve a number of different elements. A detailed history is taken. Often it is surprisingly rare to find a full history of this kind taken directly from the patient, rather than one which relies on earlier entries in the clinical notes, GP letters and soon. The team will ask the patient about presenting problems, particularly about what repeating cycles. of behaviour such as self-harm might be going on. Such cycles are looked at in terms of reciprocal roles taken by the patient and others, this idea being derived from the practice of cognitive Analytic Therapy (Ryle, 1990). The team uses some published tests to add to the clinical interview. The Object Relations Test (ORT) was tried, and was of some use, but was difficult to interpret consistently. The Millon Clinical Multi-axial Inventory (MCMI) is now used more often, but it has its drawbacks. It is a lengthy questionnaire (175 items) and the results it gives are couched in very medical/psychological terms. The final part of the assessment, which the rest of this paper describes, is the six-part story method (6PSM). THE SIX-PART STORY-MAKING (6PSM) TECHNIQUE Why use an assessment with storymaking at its centre? Why not stick with diagnostic instruments that have proven validity and reliability? As Jung states:
So the diagnosis merely helps the doctor (or therapist) to orient themselves in the field; it is the story that enables them to start to help the patient Perhaps what Jung is saying is that by 'story' he does not just mean the 'history' in the sense of a linear recounting of the events and circumstances of a patient's life. More than this, he means what kind of story are they telling? Is it a tragedy, is it a comedy, is it a farce? What are the roles being played in this story? Are there villains and heroes and princesses to be rescued? Once we can get a sense of what kind of story the patient has constructed for him or herself it is possible to be able to respond appropriately. That is all very well to say, but the story may be difficult to get at for a number of reasons. There may be a lot of shame around telling the story. The patient may be anxious about telling the story, particularly if the story has not been told before. There may be a simple lack of insight; they may not be able to see their story objectively enough in order to tell it There may be defence mechanisms of various sorts; some sort of repression at an unconscious level. Or there may simply be unfamiliarity with psychological thinking; an individual may be used to thinking more concretely and may find it hard to think in abstract psychological terms. That being the case the STS has found the storymaking approach a helpful one. Mooli Lahad, who originated the & Part Story Method, says:
The creation of a story is a way of projecting some kind of meaning. Before anew story is made there is a blank screen. Once the story is projected onto it there exists an extended metaphor that can be used as a tool. The 6?SM was developed at the Community Stress Prevention Centre in northern Israel which works with both Arab and Israeli communities. They are very close to the Golan Heights where there have been high levels of military, paramilitary and terrorist activity for over thirty years, and there is a high level of stress in the region. The 6PSM was initially developed to try to identify coping mechanisms in individuals through the BASICPh analysis (Lahad & Ayalon, 1993). The STS use it slightly differently and this will be described later. The 6PSM is introduced to the patient by saying that much of the assessment so far has concentrated on factual, logical, left-brain issues. The 6PSM is an attempt to let the dreamy, illogical, creative right-brain have its say. It is emphasised that this is a story making exercise) and that a new story is going to emerge, not simply a retelling of an existing story like 'Cinderella' or 'My first day at school'. This is necessary in order that the screen is blank for projections to be seen as clearly as possible. A pre-existing story could be worked with, and the patient's projections into it investigated, but it is felt that would restrict the range of possibilities. The patient is asked to set the story at some distance from their real life - in fact the further into fantasy the better. The reason for this is to achieve some degree of aesthetic distance - one of the five core dramatherapy processes described by Jones (1993). Experience has shown that a patient who is (for example) a teacher and who makes up a story set in a school is unlikely to do much beyond restating the issues they have already highlighted in the more formal interview. Setting the story in a far distant time and place, with characters that are utterly different from the patient and those around them provides a degree of distance. This means that themes and relationships can be seen at a process level, rather than being always dictated by content This distinction between process and content, and the striving to uncover the former from beneath the latter, is a central aim of the formulation. This distance provides a freeing because it is, after all, only a story about a fairy princess, not real life. Because it is not real life everyday defence mechanisms are unnecessary and unconscious processes can be revealed relatively safely. Thus paradoxically, the further from real life the story is set, the greater the degree of revelation is possible. The patient is asked to draw images, pictures and symbols and not to write words, even if they need to illustrate an abstract concept like love or strength. In this case they are asked to find an image or a symbol rather than writing the word down. The reason for this is to open the opportunities for ambiguity and double meaning inherent in images. Of course ambiguity is possible with words too, but images and symbols seem to offer so much more. In addition, this lack of emphasis of the written word makes the 6PSM easier for patients with poor literacy skills particularly prevalent in the patient group the team serves. The 6PSM is well described by Lahad (1992), but will be summarised here. The patient is given blank paper and pens and invited to draw six spaces in which to work. They are encouraged just to take one step at a time and reassured that they will have simple step-by-step instructions. 1) In the first space goes a main character - who need not be human. They could be an animal or a supernatural being or a talking flowerpot but there has to be something with some sort of a life form or will or some sense of being alive. The patient is asked to draw that main character, to show something of what that main charter looks like, and also to show a little of the setting where we first find the main character. 2) The second element of the story is that the main character is faced with some sort of task. There is perhaps a journey to be made, an enemy to be defeated, something to be built, a lost object to be found In the second picture the patient is asked to illustrate or symbolise this. 3) The third element is that there are going to be some factors in the story which oppose the main character. These may be weaknesses or inabilities that the main character possesses; objects, weapons, things found in the environment; or there may be enemies who will positively attack or try. and thwart the main character. 4) The fourth part is the opposite of the third, in that there are going to be some helpful forces in this story, things which will make it more likely the main character' will succeed. Once again these could be internal, externally passive or externally active forces. 5) This is the main action of the story, where the first four parts come together. This is the crucial turning point of the story, the part where we see how and whether the main character achieves their task. An analogy is made here with the penultimate scene of a film or chapter of a book, which usually contains the climax. 6) What next? What happens after the main action? In classic fairy story, what happens next is "and they all lived happily ever after." Is that what happens in this story, or does something else happen? Is this the beginning of another story?
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