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Patients with chronic and severe personality disorders place heavy demands on Health and Social Services. In this paper we present the findings of a research study which evaluated the impact of specialized inpatient psychosocial treatment on patterns of Health Service utilization in patients referred for admission to the Cassel Hospital. The comparison between a pre‐treatment and a post‐treatment sample showed a significant decrease in the use of medical, surgical and psychiatric services in the year following discharge from the hospital. We also found that the post‐treatment group relied less on the use of psychotropic medication, on cigarette and alcohol consumption, while the employment rate was increased. This paper adds to the already substantial scientific literature to show that psychotherapy and psychosocial forms of treatment make economic sense, as well as improving the psychological health of patients.

This paper provides an account of some of the organizational and dynamics issuesThe organization and the staff group Grendon Underwood is 230~bed high ecurity pri o n n ear Ayle bury which was ope n ed in 196 2, afte r co n iderable debate abo ut what to do with 'psych opath' in pri on . It consi t of five di crete therapeutic communities of 40 o r so re idents each and an a es ment~preparation unit ~ r 25. Therapeutic communities are thought to h ave originated in the re idential treat ment of sh e ll -sh ocked soldi ers by psychodyn amic psychiatri ts in th Sec nd World War. ritically, a group ana lytic experience add a odal dimen ion to Freud' or ig in a l p ychoanalytic m ode l, a nd a therapeutic co mmunity adds a li v ing/l ea rnin g experience (Kennard, 199 8 ) . Grendon' therap e utic com munity reg im e co n si ts of a group eve ry mo rning; three Jays a we e k, res id ents atte nd a sma ll gr up, a nd twice a week a l a rge~gro up 'c mmunity meeting'. Within the constraint impo ed by the need for ecurity, the activitie of daily li v ing are ca rri ed ut by the co mmunit y m e mb r , and are a potent focu for debate within the community. A far a p s ible, d dsion about the community and t he reque t of individual res ident are devolved t the community, a lthough the staff group retain a right of veto.Each staff group consi ts of 12 pri on office r, a probation offi er, a p ychol~ og isl a nd a co mmunit y therap i t. Broadly, the co mmunity function in a simila r way to an o ld -tyle psychiatric h o pital ward, with the nursing role

Three situations are described where a junior doctor is required by his consultant to do something that he thinks is not in the patient's best interests. The dilemma is explored from the perspective of patients' interests being the doctor's first concern; of the importance of respect for medical teachers, and of the implications of an apprenticeship model of postgraduate medical training.