More on Specialist Therapies More articles by KDB Harvard citation for this article: Dent-Brown K. (1999) Working with personality disorder in community mental health, Dialogue -part of the Virtual Institute for Severe Personality Disorder. Issue 2, Autumn 1999, p5. Working with personality disorder in community mental health This article describes a development based in Hull which may offer a model of how a small, inexpensive team can provide both a useful service to clients and staff as well as a seed from which further development may grow. In 1995 two practitioners in Hull, a nurse and a clinical psychologist, identi-fied a group of clients whom existing mental health services seemed to be bypassing. These were clients who had long psychiatric careers, often multiple diagnoses, a long series of key workers, a whole list of different treatments (none of them successful) and who seemed to generate debate or even conflict in teams. Their use often started with an overdose or other self-harm. Typically what followed was admission to casualty, transfer to psychiatric unit, discharge due to no mental illness", transfer to community key worker, lack of clear or achievable goals and, sooner or later, another overdose. Traditional psychiatric diagnoses and treatment did not actually seem to be of much help. The two practitioners proposed that a relationship based model, informed by the principles of psycho-therapy, might offer a better way of understanding what was happening. Local managers supported the idea and there is now a team of six practitioners (all part-time, with other jobs in the Trust or elsewhere) who comprise the Specialist Therapies Service (STS). The basic premise of the Service is that they offer a detailed assessment followed by a written formulation presented to client and key worker, rather than becoming involved in long term therapy. The six team members all have a basic health profession - two mental health nurses, one learning disability nurse, two clinical psychologists and one occupational therapist Most have further training in some form of psychotherapy -Transactional Analysis, Cognitive Analytic Therapy, Integrative Psychotherapy, Dramatherapy, Psychodynamic Psychotherapy. The team takes referrals from mental health workers in the Hull area. The client is seen for four assessment sessions. A detailed history is taken from the client not only to establish facts but to elicit feelings - particularly about relationships and early life experiences. Other parts of the assessment include a standardised self-report questionnaire, the Millon Clinical Multi-Axial Inventory (MCMI) and a projective test known as the 6-Part Story Method (6PSM). These two very different assessments triangulate with the interview to try and give a range of perspectives on the client. Once the assessment is done, the STS team member takes time to try and make sense of it and prepare a written formulation. An important part of the formulation is often the identification of reciprocal roles - repeating patterns of interpersonal behaviour which seem to crop up again and again. For example, these reciprocal roles might be seen:
	ADULT DERIVED ROLE........ Give "perfect", infantilising care........ Be abandoning, rejecting........	........CHILD DERIVED ROLE ........Be sick, ill, needy and idealising  ........Be angry, denigrating, complaining
	This helps explain the client's repeat-ing behaviour, but also puts it into the context of the way the mental health services respond - sometimes with admissions because clients are felt not to be responsible for themselves, sometimes with discharges because they do not fit the acceptable client profile. The 6PSM plays an important part in the writing of the formulation because it often gives a stunningly economical and eloquent metaphor for the whole situation. Once the formulation is finished it is shown to the client first for their approval and correction. Only then is it shared with the key worker and its recommendations turned into a practical care plan. This rarely, if ever, recommends psychotherapy. The recommendations are restricted to what it is reasonable to expect a front-line mental health worker to provide. This usually means that they are about the maintenance of the client-worker relation-ship, trying to walk a tightrope between infantilising the client with "perfect" care on one hand or rejecting and abandoning them on the other. Having handed over the formulation, the STS team member steps away, although they are available for supervision at any later time. The service is highly valued by clients and key workers, and received 85 referrals in the last 12 months. As well as formulation, the STS offers training to mental health staff on adopting a relationship based model of understanding personality disorder. These workshops have run for the last four years and a large proportion of Trust staff have now undertaken them. The STS provides very little ongoing therapy for clients, apart from one ongoing group, because this would silt up their time and lead to far fewer formulations being produced. This model lent itself to a small beginning, expanding from just one locality to now cover all six in the Trust. The STS is now a well established nucleus on which it is hoped that a service actually providing psychotherapy may form. There are also plans well advanced to conduct research into the effectiveness of the service and some of its components, though the rate of increase of referrals alone indicates that it is meeting a need. It is not known if there are any similar services in the UK. If there are the STS would like to make contact! If you would like to get in touch we are at: Specialist Therapies Service Miranda House Gladstone Street HULL HU3 2RT Phone +44 (0) 1482 617503, fax +44 (0) 1482 617504 Kim Dent-Brown, Dramatherapist

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