Friday, 30 March 2018

Piantine italiane per crescere?

Quick train from Cardiff to Heathrow terminal 4, a bit bog-eyed from late-night BIGSPD scheming, to learn that the three of us (Jan, Laura and myself) had been booked on AlItalia’s ‘minimum economy’ to Rome and business class for the return. Minimum economy means no bags, and we had one each: £117 lighter, we got to our hotel to find only one room available for the three of us. Thank goodness we had Laura with us as our translator – and I think after a bit of female sharing, everything was OK for the second and third nights.

This was the LegaCoop annual meeting of several different groups of visiting projects – the principle of which is ultimately derived from the Italian modifications of the RCPsych ‘Community of Communities’ – and we are the link between the two, and called ‘supervisors’. It is always a tutti Italian mixture of talks, heavy duty numbers, and celebrations with jolly team photos.

But this time we learned some interesting new things about the latest developments. First is the difference between the ways it is being done in Northern Italy with Mito e Realta (the national Italian TC organisation) – where it is much more like the British CofC membership, which any organisation can join for the visits, events and general collaboration. In contrast, the Sicilian network is much more like the British TC Accreditation process – where great trouble is taken by TCs and the auditors to ensure that the quality standards are precisely met: they have now been doing it for six years, and there is a great deal of detail in the exact process. I suspect, though did not directly ask, that the communities who were here in Rome for the day are closer to the Sicilian model – but either in the first or second year of it. But their hard work was recognised at the afternoon awards ceremony as all the certificates were awarded, amidst applause and many photos – thankfully not too many selfies!

The second interesting revelation was about the link to LegaCoop – which is the longstanding socialist organisation that promotes cooperative across Italy. Some of the organisation’s leaders were there, welcoming the work, and (now we have perfect translation!) it was explained to us how they are planning to use the principles outside the mental health field. They are particularly interested in Enabling Environments – as they can see the use of it in any setting. I slightly fear that, in Italy, these ideas might have just the sort of backing they needs to grow – that we don’t have in the UK. One to watch…

And business class home was quite a revelation – metal cutlery, china plates and real glasses of grappa behind the green curtain!

Monday, 26 March 2018

What we're all up against (part 2)

The Critical Psychiatry Network always surprises me for the firepower it has, and yet how it always seems to be in curmudgeonly despair about the state of mental health services, and the way the world has inevitably made it like that. And this conference did much the same – an extremely lucid and persuasive set of arguments from five speakers all of whom came from different angles on the same central proposition: we’re going to hell in a handcart. And the only thing we can do about it is to argue p-values, point out loopholes in pharmaceutical regulation, or bask in the comfort of seeing how Foucault said it all years ago. No, I’m sorry, that’s a cheap jibe – these were serious academic contributions to a major modern critique of our current system.

Maybe what I’m fed up with is how little impact ‘serious academic contributions’ have in the world’s current – deplorable and frightening – state of epistemology and ontology. I read about it from ‘real intellectuals’ in the London Review of Books, I hear it from our group members’ fight to have their profound disabilities recognised by the ‘welfare state’, I learn all about it from my wife in how her job, managing the operating theatres in a large teaching hospital trust, attempts at humanity are constantly undermined by ‘the machine’, I see it in the mechanistic way young doctors are now taught their skills and knowledge, and I feel it impinging everywhere around us. And others describe far better than I how the two major political events of the west, in 2016, are now playing it out…

But here’s a quick roundup of what I was excited by at the annual gathering of the Critical Psychiatry Network:
  •  Phil Thomas opened the batting by making us all feel we were in it together – and it’s pretty obvious what we’re really up against (neoliberalisism, loss of meaning, commercialisation of all aspects of life, growing inequality, reducing support for the most needy). Particularly pithy pints included the phrase ‘malignant individualism’ and how ‘the government are turning unemployment into an individual psychological problem’
    Phil Thomas excoriates happy pappy claptrappery
  • Neil Armstrong followed with a rich and thick ethnography which told the tale of how a man diagnosed bipolar, in a ‘major teaching hospital’ nearby, was treated by the mainstream mental health system. It so well described the system’s power dynamics in how any subtelty of understanding his distress was boxed into computer-friendly progress notes – and how his wife had a much deeper understanding of why he had his difficulties, than the psychiatrist did. The real title of his talk was “why feeding the beast might be more than just a waste of time”.
    Neil Thomas tells it like it is
  • John Crombie descried an anatomy (maybe physiology?) of emotions, and introduced the concepts that underlay the ‘Power, Threat and Meaning Framework’, which was led by Lucy Johnson and has been mentioned here before. Lucy herself was present, although not giving a talk, and by the end of the day it was clear that some collaboration between the critical psychiatrists and the critical psychologists is on the cards. I’m keen to also involve the critical psychotherapists – and will aim to do so before the Totnes Limbus conference in November, which has a very similar anguished plea behind it.
    What makes John Cronbie feel sick
  • Helen Spandler – a properly radical academic from UCLAN who has been the longtime editor of ‘ASYLUMS: the journal of democratic psychiatry’ explained how the current scene has two major groupings: the ‘mad studies’ and the ‘psychopolitics’ people, both of whose founders have committed suicide (…). The former, at their most extreme, want to break all links with mainstream state-funded ‘psy professions’; the latter want to change the direction of travel by degrees. The answer was music to the ears of those of us in ‘relational practice’ work – raise consciousness by talking to each other and to those who ‘don’t get it’ until we get to a shared understanding. Oh, to have been old enough to have enjoyed the sixties!
    Helen Spandler does a great Patti Smith look
  • James Davies took us through some of the detailed venalities of the big beast we have so little chance of taming: the pharmaceutical industry, and how Hayek/Friedman/Thatcher economics have influenced it. But, with modern challenges to over-lenient regulation, at least the ropes might be tied round it to make it obey the rules, now that it has been so clearly identified how they are breaking them. Although obviously very worthy and worthwhile, I could not help picturing Gulliver being pinned down by the Lilliputians – and deciding to get up because he didn’t want to be.
    James Davies tell us of the even more evil empire

Tuesday, 20 March 2018

Our Trojan Horse

‘Personality Disorder’ thinking (short live the name!) is a trojan horse being slowly incorporated into the belly of the beast. The annual conference was in Cardiff this year, 20-22 March 2018, and the opening keynote talk was Janine Roderick, from Public Health Wales. It was a fresh (though not overly academic) angle on changing the discourse to one where everybody understands about ACEs (adverse childhood events). 
Do watch the video - click here. Trauma-informed practice is coming - even if not to DSM, ICD or RCPsych!

With titles of symposia and workshops like ‘The Quiet Revolution’ (for the general model being consulted on and written up by myself and Nick Benefield) and ‘The Golden Thread’ (for the way we are extending relational practice in Slough to the relationship between sectors), and numerous synergies between the positive riskified clinicians, the gloriously creative gang of experts by experience, and the inscrutable reseachers – it was a rich mix that felt at least like a break from the grim reality of NPM (new public management), and possibly even a glimpse of a different way of doing it all.

As well as that , there was a spectacular dinner in the Welsh Museum being sung to by a male voice choir; a last-minute election for change of BIGSPD president (which continues the three year term principle, which has been in place since the organisation began just before the millennium; midnight meetings in quiet bars to plan and scheme for a campaign and lobby function; and numerous research papers presented by the young and nervous, the established and confident, and the old and dotty.

But the thing I’ll take away – and push around the place – is that ‘relational practice’ captures something that we do well in the ‘PD field’, and not many others recognise as being as important as we think it is. I’m not sure we’ve got the language right yet, though…

Tuesday, 13 March 2018

What we're up against (part 1)

At last, somebody is writing a good book about the rot all around us.
Farhad Dalal, in fact - a group analyst who runs Totnes-based 'Limbus' organisation.

It is called 'CBT: The Cognitive Behavioural Tsunami. Managerialism, Politics and the Corruptions of Science. Here's the blurb I have written for the back cover:

We live in alienating world where malignant individualism and rapacious neoliberal capitalism are destroying the belongingness and social cohesion that give our lives meaning, as well as degrading the planet we live on. In the therapy professions, these forces are thwarting relational ways of working, and replacing them with government-run machinery to provide industrialised therapy. This book is what we have all been waiting for: a robust, detailed and psychologically sophisticated critique of the frightening place where modern managerialism, regulation, compliance and performativity have taken us. It provides evidence that our narrow view of ‘evidence-based practice’ is not enough.

And Limbus is hosting a conference on this theme in November, in Transition Town Totnes. Here's the link:

Friday, 2 March 2018

70 years in The Bush

Mulberry Bush School is one of our oldest and most modern therapeutic communities in the UK. It has done an extraordinary job of adapting to a changing world - and not always in ways that many of our TC fraternity would approve of. But it is still there, and no others I know of could say that after being around for seventy years...

Here is the foreword I have written for their forthcoming book:

Although many see our current times as dark days for psychoanalytic understanding, and complex treatments that defy easy manualisation, and frequent closures of well-established therapeutic communities, the flourishing of Mulberry Bush through several difficult decades says something else. At ‘the Bush’, the power of the underlying ideas, and the necessity of having a meaningful understanding of the deeply troubled children in their care, has allowed a profoundly psychotherapeutic school not only survive in several years of these dark times, but to flourish as a beacon of excellent practice  – and shine a light for others to follow, as they have now started to do.
Of course, this has not been without accommodations and adaptations to what could be called an industrialised and commercialised system of ‘state-regulated childhood’. And this system is regulated to such an extent that some utterly human emotional support and care – that has been a natural part of primate behaviour since we were only as evolved as Harlow’s monkeys – are now subject to state surveillance and scrutiny. We live in such an anxious and untrusting age that the exercise of ‘therapeutic ordinariness’ is becoming almost impossible – in the National Health Service, in social care, in criminal justice and - of course - in education.
 But despite the wider environmental toxicity, the Mulberry Bush has ‘followed the rules’ and somehow been able to maintain an oasis of sanity in this maddening world. They have managed to keep the therapeutic imperatives in the foreground, and to largely keep the modernist impingements in the background. The amount of work that is required to do that cannot be overestimated; it requires nerves of steel when put under cross examination about risk management, operational policies or safeguarding procedures by the regulators – who aim to act with precise and mechanical objectivity. If only they knew! Of course, at some level, they do. But such subjective and complex considerations are not allowed to enter the equation of modern public sector governance.
As a great believer in the implicit themes that weave the history of therapeutic communities, I cannot help but think of two images. One is of the tank commander Wilfred Bion in the First World War, long before he wrote his theories of group process. He knew that a tank under fire is an extremely dangerous place to be, with the ‘nameless dread’ of its unthinkable horrors and human degradation if the tank suffers a direct hit. And the universal need for that immensely powerful and primitive experience of containment when under any sort of severe physical or emotional threat – simply in order to survive, and be able to live afterwards. The other image is one I have always associated with the Mulberry Bush: of a fluffy round rusk, dipped in warm milk. It is given to a small child who is behaving as if his or her head is full of tanks and explosions and trauma – and feels utterly uncontained. Then that sensuous nurturant thing arrives: the experience changes everything and puts the world to rights. At least until next time.
These extreme feelings of love and hate, of care and terror, and of attachment and abandonment, are all the daily bread and butter of this work with children. Yet these children’s inner worlds have to be held and contained in the real external world of schools in twenty first century England. The staff and managers here have to meet the demands of OFSTED, cope with severely restricted local authority funding, and live in a popular culture that belligerently demands diagnostic certainty and quick fixes. However, the work of the Mulberry Bush has proved that it is possible to establish and maintain a different way of working in this safe space – protected from the primitive terrors that its children fear, and the grown-up madness that the adults live in.
The adaptations and accommodations have been in ‘learning the language’, and ‘playing the game’: those of us who work or believe in other therapeutic communities have a lot to learn from them. ‘Learning the language’ is about being up-to-date with concepts used in influential publications, policy and research – such as ‘evidence-based practice’, ‘trauma-informed care’, ‘adverse childhood experiences’, ‘emotional development’ and ‘relational practice’. It is not enough to just parrot the buzz-words, though. They need to mapped onto the deep understanding and language that the school has been accumulating throughout its seventy years, with their concepts like ‘unintegrated children’, ‘primary experience’, ‘core complex’ and ‘emotional distance regulation’, and to do so without forgetting the importance of these fundamental concepts in actually doing the day-to-day work. This book is full of rich clinical examples of these ideas in action.
‘Playing the game’ is more about organisational survival – knowing what to do so that commissioners, civil servants, council officers, regulators, and even banks, take you seriously. Networking is an important part of this – and having as good a view and understanding outwards as you do inwards. The social entrepreneurship needed for the Mulberry Bush’s Outreach Programme is an excellent example of this – but it also brings the benefit of their long and deep experience to help many other troubled children. The International Centre for Therapeutic Care has great ambitions to spread the word even more widely, and together with the field’s archive, will surely cement the Mulberry Bush as the jewel in the crown of British Therapeutic Childcare.
In a way, all schools should be therapeutic – in promoting emotional growth, enabling relationships, effective communication between people, and a robust sense of personal agency - if only they were! But this book makes it clear how the Mulberry Bush has developed its ways to do it with some of the most troubled children in the land - and intends to do something useful with its ideas.