THE SIX PART STORY METHOD (6PSM) as an aid in the assessment of personality disorder

TRANSCRIPT OF PAPER TO THE 3RD EUROPEAN CONGRESS ON PERSONALITY DISORDER, SHEFFIELD, JULY 1998.

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:

• At least one year history of contact with the mental health services

• Self-defeating or self-harming behaviour exhibited

• Feeling of 'stuckness' between patient and key worker

• Diagnostic uncertainty, disagreements about treatment or splits in treatment team.

The team usually finds that words such as "manipulative", "attention-seeking" or "behavioural", when they occur in 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 the 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 so on. 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 story-making at its centre? Why not stick with diagnostic instruments that have proven validity and reliability? As Jung states:

"Clinical diagnoses are important, since they give the doctor a certain orientation; but they do not help the patient. The crucial thing is the story. For it alone shows the human background and the human suffering, and only at that point can the doctor's therapy begin to operate." (Jung, 1993)

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 themselves 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 6-Part Story Method, says:

"Thus our assumption is: in telling a projected story based on the elements of fairytale and myth, we will see the way the self projects itself in organised reality in order to meet the world." (Lahad, 1992)

The creation of a story is a way of projecting some kind of meaning. Before a new 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 6PSM 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, so 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 who 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.

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 character looks like, and also to show a little of the setting where we first find the main character.
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.
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.
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.
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.
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?
PERSONALITY DISORDER - SOME BASIC CONCEPTS
This article assumes a certain familiarity with the concepts of personality disorder. Within the STS the term is being used to try to distinguish between two groups of patients. There are those with an acute mental health problem which is susceptible to treatment and where, from the patient's point of view, discharge from the mental health services is both possible and desirable. There is a second, smaller group for whom discharge never seems to be achieved, or where it may not be desired, and where the relationship with the key worker is not a means to the end of discharge but is in fact an end in itself. This is the group the STS concerns itself with. We do a lot of work to try and counter the belief that personality disorder is untreatable.

There are many ways of classifying personality disorder, and the STS uses a three way division based on the work of Manfield (1992). This is not inconsistent with the classification of the ICD or DSMIV, but reduces the number of personality disorders to three fundamental types -narcissistic, borderline and schizoid.

Each is characterised by at least two basic ways of relating to others, which tend to be mutually exclusive and even contradictory. There is no middle state, and there tends to be flipping between the extreme states which can lead to the bewildering and apparently chaotic changeability reported by key workers of their patients.

The narcissistic disorder has a grandiose, haughty state where everyone else is seen as somehow inferior, and where great efforts are made to prove this. The opposite state is a small, weak, powerless, ridiculed position which is more realistic but infinitely more painful to be in. Hence much of the time is spent trying to maintain or return to the grandiose state.

The borderline state involves a search for "perfect" care from an idealised other, usually obtained at the cost of being ill, sick or needy. When this falls down the person feels abandoned and abused by a hated and denigrated other, and may become "ill" in order to return to the cared-for state.

The schizoid dilemma is one between two equally unsatisfactory positions. Either the person feels devoured, overcome and annihilated by others who are too close, or feels vanishingly distant and non-existent because others are too far away. Life involves a constant shuttling between the two extreme states.

EXAMPLES OF SIX-PART STORIES IN PERSONALITY DISORDER
The following are three genuine 6PSMs which have not been altered. The reader is invited to bear in mind the three basic personality structures described above while reading the stories.

STORY ONE: The main character of this story is Elvis Presley, who is shown clad in his cloak, on a stage, with his guitar. Also seen in the first picture are TV cameras, lights, microphone, and the audience. They are seen just as rows of small heads gazing upwards. Elvis's task is to entertain the audience, who are not only in the theatre but also round the whole world watching on TV. The helping factors are the cameras and a satellite which will beam the signal all over the world. The problems are a bomb threat which might cause the theatre to be evacuated, the wires to all the electrical systems which might explode, or there might be a power strike which would black out the theatre. The main action is that all the problems are overcome and the performance goes ahead; afterwards we see Elvis going home in a stretch limousine, receiving applause from the crowds going home.

In this story there are very clear narcissistic features present. The choice of a main character such as Elvis is characteristic - other narcissistic patients have chosen characters such as St George, Planet Brain or even God. The small size of people in the audience and their rapt attention is also characteristic. Even the threats are grandiose - bombs, strikes, explosions. What is shown in this story is only the grandiose side of the narcissist; the small, weak, self-doubting side is nowhere to be seen. This overshadowing of the true self by the false self is often played out in real life; grandiose individuals tend to produce grandiose stories. In this case it was different. The patient presented as a shy, submissive man. It was only through the six-part story that the narcissistic nature of his personality was revealed. Beneath his submission he was deeply contemptuous of others.

STORY TWO: The main character is the therapist. The therapist's job is to sort out the mess that is in the patient's head. As for the things that will help there is simply another picture of the therapist to show what will help the patient's head to get sorted out. The things that will get in the way are knives and blades and pills. Also, being left alone would get in the way of this successful resolution. The patient did not actually draw anything for the main action but the outcome is that at the end we see the patient and therapist, hand in hand (the patient shown smaller) with everything sorted out.

This story has a very borderline feel to it - a strong rescuer and a helpless, passive person eliciting care from them. The rescuer is idealised and seen as able to provide almost magical care which rescues the recipient but also infantilises them. As with the narcissistic story, we see no evidence of the denigrating, abandoning other or the angry, abused self. This self state might perhaps have been elicited in another story drawn at a different time by the same patient.

STORY THREE: The main character is a sailor who is stranded on a desert island. The island is surrounded by circling sharks. His task is simply to endure, he simply has to exist, to survive. The things which may be able to help him are that the palm drop fronds with which he might be able to make a fire to signal to people, and he has a bucket to collect rainwater to enable him to survive until he is rescued. The things that will hinder are that first of all a ship might not see him at all. If a ship did see him it might not bother to alter course and investigate the smoke. The sharks are also a problem; if he were to try and swim home the sharks would completely devour him. The action is that the ship appears, he lights his fire, and somewhat to his surprise the ship alters course towards him. The final outcome is that once he is on the ship he and the crew start to get suspicious of one another; the crew are asking "Why was this guy marooned - is he bad luck? Was he marooned by a previous crew or is he the survivor of a shipwreck? Maybe we'd better get rid of him." He in turn starts to get suspicious of the crew and wonders if they are going to kill him or do something bad to him, so in the end he is marooned again and the ship sails off without him.

The story elegantly and painfully illustrates both ends of the schizoid dilemma. Being alone on a desert island you might as well not exist, there is nothing to do but wait and long for contact. But getting close to others (whether sharks or humans) is to lay yourself open to being overwhelmed, killed or even devoured. Interestingly, this story shows us not just a snapshot of one stage in the process, as did the previous two stories, but the process in its entirety. We see the vacillation between longing for contact when too distant, then fearing it when too close and seeking greater distance as safety.

INTERPRETING THE 6PSM
There are several ways of interpreting the six-part story. The first is demonstrated above and involves looking at the story as a whole for evidence of processes which resemble those at play in the three personality disorders. The stories above have been presented without any background information about the patients who produced them; of course in the STS this kind of context-free story is never possible - even if it were desirable. The 6PSM arises as part of an in-depth assessment, and influences and is influenced by this. How far a context-free 6PSM can be analysed, and what degree of inter-rater reliability is possible, is the subject of future research.

A second method of analysis is to use a tape recorder or take some contemporaneous notes as the person is talking, and look out for word that might be part of a binary split, or which sensibly has an opposite. So, "Once upon a time there was a little boy" would suggest the words little and boy, with the opposites big and girl. Once this is done exhaustively there will be a list of 20 or 30 pairs which can then usually be collapsed down into two or three basic dichotomies. These frequently contain themes familiar to one or other of the personality processes For example accept-abandon or dependent-independent are classically borderline. Admire-insult and big-little suggest narcissism and near-far, advance-retreat suggests a schizoid dilemma.

A third way is to assemble a grid similar to those used in repertory grid analysis. All the elements in the story are identified - for example in Story Three these might be the sailor, island, sharks, tree and ship with crew. These elements are entered along the top of the grid and down the side, to enable the relationship Of each to the other to be coded by describing what one element does to the other. Thus for example the sailor fears the sharks and avoids them, while they threaten to kill and consume him. By pairing up what the sailor does to the sharks and what they do to him, a reciprocal role pair is produced which may be indicative of roles played out in the patient's life.

SUMMARY
Perhaps the main advantage of using the 6PSM is not diagnostic, in terms of deciding which category does this person fit, but in terms of producing some sort of qualitative feedback to the patient, Because the team places great emphasis on the feeding back of the formulation to the patient, it is very important that they accept it and that they feel it accurately reflects their sense of themselves. By producing a story which has many layers of images with all the possibilities of ambiguity in them, it becomes possible to feed something back to the patient which reflects their experience very accurately. It makes the formulation resonate because the original symbols are very rich, just as poetic language is much more complex than prose. Above all it provides a metaphorical language with which to communicate. It provides an arguably kinder and more human language than the cold, reductionist language of ICD Or DSM diagnoses. Rather than telling the patient that they fulfil the criteria for Schizoid Personality Disorder, it feels better for the therapeutic alliance (as well as conveying more information) to talk about the sailor who both desires and fears rescue.

References:
Dunn, M and Parry, G, (1997), A Formulated Care Plan Approach to Caring for People with a Borderline Personality Disorder in a Community Setting, Clinical Psychology Forum, Volume 104.

Jones., P (1993)., Dramatherapy: Five Core Processes, Dramatherapy, Vol 14, No 1, pp 8-15.

Jung, C.G. (1993), Memories, Dream, Reflections, London. Lahad, M and Ayalon, (1993), Community Stress Prevention Vol II, Kiryat Smhona, Israel: Community Stress Prevention Centre.

Lahad, M (1997), Dramatherapy Theory and Practice, Vol III, Chapter 10, Routledge, London.

Manfield, P (1992) Split Self, Split Object: Understanding and Treating Borderline, Narcissistic and Schizoid Disorders.

Ryle, A (1990), Cognitive-Analytic Therapy: Active Participation in Change, Chichester, John Wiley.

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By Kim Dent-Brown

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