Suitable cases for treatment?

As clinical director of a residential 'therapeutic community' for people with severe personality disorders, I can produce a file full of similar letters from public health consultants rationalising their decisions not to fund extra-contractual referrals for this client group. Yet our experience, and an increasing volume of research on outcomes for this group, confound these prejudices, and suggest that treatment can be effective in the majority of cases, and may even lead to long-term savings by way of reduced demand for health services.

'Personality disorder' is an area of psychiatry clouded by confusion. Indeed, many of us would prefer not to use the term, with its negative connotations that patients are undeserving and untreatable.

Francis Dixon Lodge is part of Leicestershire Mental Health Services trust and has 16 beds, day facilities for patients towards the end of treatment, and outpatient follow-up groups. It serves adults of both sexes (usually aged 17-45 years) with profound problems of living and relating, usually referred because of their destructive ways of expressing distress. Clients stay voluntarily, but are encouraged to remain for about 12 months, and there is no use of seclusion or sedation.

Most suffer what clinicians would describe as borderline personality disorder. As many as 75 per cent are referred by general psychiatrists, 50 per cent have been detained in the past under the Mental Health Act, 10 per cent have been in prison, and 85 per cent have acted in a violent, high-risk, life-endangering manner at some point in their history. Much of the deliberate self-harm is more bloody and shocking than the usual casualty overdose case, and two of our residents were heroin addicts by the age of 11.

Almost all of this group come from grossly abusive and neglectful families - occasionally of the 'public school, holidays in Barbados' variety, but increasingly from a poverty-stricken, social underclass with parents who are prostitutes, drug addicts, or alcoholics, in and out of prison, who left their children to survive a variety of foster parents and institutions. Two-thirds have been grossly sexually or physically abused, some by foster parents and key workers as well as by the original perpetrator.

Clients desperately need psychotherapy, but the risk of them doing harm to themselves or others is far too high for them to be seen as outpatients. Most psychiatrists are reluctant to see them individually because of the intense feelings of love, hatred, rage, envy and disappointment that can arise when their 'prototype' of close, supposedly caring relationships has been so disastrous.

We therefore have no individual therapy, but bring everything into a group of about 20 residents and staff, which is hopefully big, strong and safe enough to contain the intense feelings that can arise.

A typical day starts with a community meeting at 9am, chaired by one of the residents, who also has a large part in setting the agenda. It is followed at 11am by a psychotherapy group, and the formal structure of the day ends with another community meeting at 5pm. Activity sessions and assessments also occur.

Potential residents are assessed by a panel of two staff and three residents, and all residents have three-monthly assessments. Occasionally, if no consensus is reached, the whole community will vote on whether a resident should stay. Crisis meetings can be called at any hour of the day or night.

The highly structured day and the availability of staff and residents around the clock encourages individuals to feel safe enough to explore feelings that might otherwise overwhelm or destroy them completely. Of course, uncontrolled and destructive behaviour, or 'acting out', continues, and residents may cut themselves, overdose or inflict other self-harm when they first come in. However, peer pressure, often from more experienced residents, for them to take responsibility for their actions, and focus on their underlying distress and the effects of their actions on the group, often has a positive effect.

The concept of putting a group of dangerous, disturbed people together to create something relatively safe and therapeutic is perhaps the most important principle underlining the therapeutic community movement, and from it the concept of flattened hierarchies, democracy and open communication to empower our patients, prevent institutionalisation and lessen unhelpful dependency on professionals.

The other cornerstone of our work can be summed up as a 'culture of inquiry': the constant attempt by all to make sense of what is happening, to draw links - for example, between feelings and conflicts in individuals and the behaviour of the group, or how conflicts in the staff team, or between clinicians and managers, get acted out by particularly vulnerable patients. Staff constantly have to get sucked in, enough to develop a feel for the types of emotions and conflicts residents are struggling with, while at the same time stepping back to make sense of it.

Much of our work is about predicting disasters and crises which may arise and trying to pre-empt or avoid them. Ideally, we try to identify key problems in the past and predict how these may be enacted during treatment.

There is a constant tension between permissiveness on the one hand, and keeping boundaries on the other, between containing anxiety and taking control, and, for myself, between medical accountability and encouraging residents to take responsibility for themselves. The constant discussion and struggle to understand why the line is being drawn at a particular point at a particular time is an important and creative part of treatment.

Because of clients' extremely low self-esteem and feelings of worthlessness, they find it difficult to ask for help. Clients have no basic trust that people in caring positions have their welfare at heart. Key figures in the past have neglected them, not understood, abused positions of authority and power, and often left them humiliated, helpless, raped and even maimed. That they should develop any degree of trust in us becomes an extraordinary achievement, and is a constant focus of therapy.

There is always a certain amount of antagonism towards staff that sometimes reaches frightening levels. As psychotherapists we try to understand and make sense of the intense rage and catastrophic disappointment that follows our seemingly minor insensitivities. But the structure of the therapeutic community means that there is usually someone who residents can turn to, even at the blackest times of regression, when the rest of us have become totally untrustworthy and hateful.

Perhaps the most difficult thing to work with is the 'acting out' - the lack of impulse control, the risk of violence, craziness and suicide. It has been said that the object of our work is to help our clients become both 'thinkers and feelers'. They are referred to us because their feelings are so intense that they either cut off from them completely, or risk being totally overwhelmed. The structure of the community means that overwhelming feelings can be talked about at any time so that, hopefully, a reflective capacity gradually develops, and with it a more consistent, elastic control and comfortable integration of feelings.

This is a long and painful process for everyone. When successful, it involves such a major change in the way people see themselves and relate to significant others that treatment has been likened to major surgery without an anaesthetic. However, when I first heard people with severe personality problems labelled 'patients psychiatrists hate', I complacently assumed I was different in this regard.

Years later, I realise a lot of my experience, training, skill and emotional energy is aimed at containing anger and hatred towards my patients, finding ways of describing and clarifying hateful behaviour without increasing the paranoid spiral, trying to get people to own and explore their destructive feelings, gently easing the lid off years of repressed rage, and trying to survive hatred without being destroyed and rendered impotent by it and resorting to revenge.

Intense love and murderous rage can co-exist very painfully towards the same person and we try to challenge residents' simplistic and polarised worlds. A large and diverse staff team can be very therapeutic in this respect. It is amazing how often when I'm completely at the end of my tether with a patient, someone on the team will have a very different and more positive perspective.

There are times, of course, when we get well and truly stuck. Patients, sectioned and transferred to locked wards, discharged and homeless on the streets, and the ever-dreaded successful suicide, are realities we have to live with, and the support, understanding and challenge we offer each other is perhaps the most important part of our work.

Outcomes are notoriously difficult to measure. But a study at one supra- regional therapeutic community looking at change in service use a year before and after treatment suggested that admission pays for itself within two years.2

At Francis Dixon Lodge, data collected on use of inpatient psychiatric beds both three years before and after admission for 52 consecutive admissions showed a 10-fold reduction for ECR patients.3

Use was also markedly reduced after treatment, although this was less pronounced in the district admissions (77 per cent of the sample compared with 23 per cent for the ECR group). This is possibly because an easily accessible district service may offset some of the costs before they occur, certainly in respect of inpatient psychiatry admissions.

Such research is beginning to quantify the idea that short-term costs can lead to long-term savings and that, untreated, this client group will continue to suck in resources in a reactive, unpredictable and non-productive manner.

One of the problems is the diversity of caring agencies involved. Our future research will attempt to offset the cost of treatment against visits to accident and emergency departments, plastic surgeons, gynaecologists, social workers, probation officers, the police and legal system, time spent in prison, and the cost of suicide and violence on the lives of others.

But it is important that services are not provided on the cheap. Residents' histories show that the potential for making their condition worse is high where staff are inexperienced and supervision is poor.

Although some of our residents do badly and leave prematurely, the majority (75 per cent) who stay for more than six months improve significantly. For some, Francis Dixon Lodge is literally a lifeline, thrown out when suicide seems the only option left, providing them with an intensive living, learning, strengthening, healing experience which puts them back on track, allows them a new beginning, opens the door to loving relationships and gives their lives meaning and purpose.