Wednesday, 24 October 2012

TCTC: born 22/10/12, Windsor, England


'The Windsor Conference' started in the 1970s, set in the right royal setting of Cumberland Lodge, in the gated community of extreme privilege of Windsor Great Park. Every autumn, the grand old founding fathers of the British TC movement all came to play here, every year, until 2010. With friends and colleagues from overseas, mostly the Netherlands at first; later Italians and currently Greek therapists, together with a smattering of like-minded clinicians, researchers and TC leaders from Switzerland, Germany, New Zealand, Australia, USA, India and Africa, they came along to an unbroken sequence of annual community meetings, and much besides, until last year.
Cumberland Lodge (rear)

What happened last year? Well, the organisation of ATC decided that it was time for a change – the most prominent reasons were that the 3-night conference, for up to 100 people in its heyday, had become too expensive for many, inaccessible to new delegates, and somewhat anachronistic and unrealistic in its expectation that all delegates must stay throughout the four leisurely days. There was a general feeling of it having become somewhat repetitive and perhaps ‘stuck’. It was therefore moved to a large and pleasant Quaker Meeting House in Birmingham in September 2011, but the membership soon made it clear that they wanted Windsor back! 

So, for the 2012 event, a new three day/two night format was introduced, which had a theme of INTEGRITY – with a different sub-theme each day and various guest speakers. Delegates were able to come for one, two or three days – and were made welcome with goody bags, a very professionally produced programme, and daily large and small discussion groups.


INTRODUCING INTEGRITY
The first day was called ‘Introducing Integrity’ and it was built around the ending of two longstanding TC organisations, The Association of Therapeutic Communities (ATC – for adult TCs) and Charterhouse Group (CHG – for children’s TCs), and the merger to form a single new body ‘The Consortium of Therapeutic Communities’ (TCTC – for all types of TC). 

On the shoulders of giants:
Nick Manning and Colwyn Trevarthan (front)
Rex Haigh and Gary Winship (rear)
Gary Winship – a longstanding champion of the movement – gave a spirited and funny précis of ATC’s forty years which he called ‘a cross between a love letter and a eulogy’. He peppered his talk with lively character vignettes of some of the main characters over the years, and criticised ATC for not having enough managerial ‘savvy’, and for being rather patriarchal in its choice of leaders; he acknowledged the organisation’s adaptability and relentless adherence to a radical political position, through the thick and thin of social psychiatry, Thatcherism, regulation and governance, to neoliberal economics. Richard Rollinson, with many years of CHG history, told of missed opportunities to come together sooner – and the different but oh-so parallel history of personalities and conflict, trials and tribulations in the history of the childrens’ TC organisation.

After saying goodbye to the old organisations, and a typically wonderful Cumberland Lodge lunch, the main topic for decision about the new organisation was introduced: what sort of organisation do we want TCTC to be? (TCTC2B??) Was it to have ‘more of the same’ (called the narrow focus), or was it to look to expand and cover new territory – particularly including the wider use of TC principles in different ways and settings? Almost a reprise of David Clarke’s ‘TC Proper v TC Approach’, or the more recent ‘Community of Communities’ and ‘Enabling Environments’ projects. The eight small groups, variously scattered throughout the lodge, thought about it and described a clear consensus: think wide. After having done most of the thinking, the inaugural AGM was mostly a formality; perhaps most interesting for electing six new board members, several of whom are ex-TC members.

The hour-long large group at the end of the day – now called a ‘community meeting’ – was reflective and open, if a little constipated. As its conductor, I was determined not to make any plunging interpretations and to positively nurture it as a warm and welcoming space. Indeed, nobody tried intimidating tactics of ‘Nobel Prize thinking’ (as originally described by Lionel Kreeger) – and  the Greek delegates seemed particularly appreciative of the simple opportunity to be together. When somebody thoughtfully asked them if they wanted any space at the conference to be in a Greek-speaking small group, they said that they could do that at home!  It’s widely acknowledged that being in a large group (this one was between 60 and 75) can be a weird emotional experience; I would add that it is even weirder to be conducting one.

PROMOTING INTEGRITY
The second day had three seriously impressive external speakers. The first was Professor Colwyn Trevarthan, from Edinburgh: the distinguished academic who introduced the concept of ‘primary intersubectivity’ (which impressed me first when I heard of it in my Cambridge social psychology days, and still does). With a title of ‘The Social Brain: The Healing Power of Emotions’, he put on a dazzling performance to demonstrate experimentally what we all feel and know clinically: that there is a lot more to relationships, and how important they are, than  transmitter neurochemistry, or detailed scans (even though discoveries such as mirror neurones support this), or indeed the multitude of clinical questionnaires and ‘instruments’ that we routinely use could ever meaningfully measure. 

A few gems – often of linguistic precision as much as empirical fact - which caught my attention, amidst the array of sparkling jewellery:
  • ·         “a project made propositional by their collaboration” (musical analysis of infant movements)
  • ·         secondary intersubjectivity – from about 9 months – includes understanding the intention of the other; “sense of shared dynamic intentionality” (catch up, mentalisation!)
  • ·         primary complex emotions = PRIDE and SHAME
  • ·         elemental need for playfulness / fun / imagination / creativity
  • ·         ‘Empathy’ is philologically the wrong word: sympathy is better, and mirror neurones would be more accurately described as ‘sympathy neurones’
  • ·         ‘being human’ is more limbic and subcortical than it is cerebral…


Mark Johnson was next with a powerful service user account, ‘Reclaiming Integrity after a Destructive Childhood’. Mark is a Guardian columnist and author of the very successful book ‘Wasted’, who founded the charity and social enterprise ‘User Voice’.

After lunch, we had Leonie Cowen giving us a refreshingly clear and radical view of how commissioning should be done. If only it was!

A panel discussion to explore the detail of the issues, followed by small groups, gave ample time and space to give the ideas due reflection and digestion. ‘Fringe sessions’ followed – and Fiona and I took about a dozen delegates for a walk to the copper horse, after explaining what greencare is  and showing some pictures of our project, yurt and all, at Iver Environment Centre. Unfortunately the gate was locked just shy of the copper horse itself, because it’s rutting season for the deer – but there’s greencare for you. And of course, in the leisurely old days of the Windsor conference, a whole afternoon would be set aside for walks in the park; later to be timetabled as ‘professional networking’ to avert the gaze of sharp-eyed study leave funders. No such luxury any more – unless we repackage it as ‘greencare’!

Large group, and a splendid dinner – hijacked as a magnificent birthday party by the Bard of East Anglia. Then there was drinking, and dancing, and more. I was long in bed by then.

DEMONSTRATING INTEGRITY
We all now know so well that is does not matter a jot what good work we do, if we cannot suitably demonstrate what we do, and justify it with the sort of evidence required by the prevailing demands of the superordinate system. So – enter the TCTC research group, ably chaired by Susan Williams and presided over by Nick Manning. 

They presented two streams of thought about outcomes: individual questionnaires so we can all be measuring what matters, and doing it in a way that facilitates comparison; and environment questionnaires to measure that elusive ‘atmosphere’ which is so easy to smell, but so hard to define. 

The two questionnaires which came top of their Delphi exercise were:
·         CORE (34 items for well-being, symptoms, relations and risk)
·         Euroqol EQ-5D (5 items for quality of life are almost meaningless taken individually, but are very significant to health economists and QALY calculations)

So these are now going to be recommended to Community of Communities to be included in the basic service standards. Others also mentioned included the Recovery Star, HoNOS, GHQ and its derivatives, and the social functioning questionnaire.

None of the environment questionnaires examined were quite up to scratch – too old and whiskery; too long; too complicated; or not particularly relevant for TCs. The committee is therefore going to design a new one, with help by piloting it in volunteer communities. Watch this space…

Equally significant, in that ‘deep and thick’ way that only rigorous ethnography or phenomenology can do, were some of the research presentations about PhD work under way. In fact, there are currently three qualitative studies under way at Nottingham’s Institute of Mental Health – which can only serve to enrich and expand the academic base for the field.

After lunch, the demonstration of integrity took a different turn – and we all assembled in the elegant drawing room for we knew not quite what. We first heard the story of Simon Clarke, told by himself – from a hopeless and chaotic existence, through Christ Church Deal TC (CCD), to a productive high-level academic career. The next was Jonathan Walker, from an equally troubled background through CCD to a very successful career as a Liverpool campaigner and street musician: we enjoyed two lyrical and moving songs. Finally, Matthew Shipton told us of his own similar trajectory from squalor and disarray to rediscovering his own musical aptitude. Then he lifted the lid on the grand piano and simply blew everybody’s socks off (as they say) with a twenty minute rendition of an exquisitely complex Chopin rendition. Being about conflict and its resolution, he prefaced it – but so much more besides.

Bedazzled, we collected tea and wandered into our final small group sessions, before the final presentation: a presentation from a modern-day progressive catholic foundation school in Leamington Spa, called MAL-HER-JUS-TED. It was led by a passionate and forceful teacher from Chicago (echoes of the Boys Republic?), and described how they gathered information from ex-residents of young people’s TCs as part of the Lottery-funded ‘looking after other people’s children’ project run by Craig Fees at the Planned Environment Therapy Trust (PETT) in Gloucestershire.

With just half an hour’s quiet and reflective large group to finish, most seemed appreciative of being with each other – and their various contributions.

The logo of the new combined organisation
Back next year, dates booked already. By then we’ll see if this new organisation is on the tracks we hope - to say and do something really significant…


Sunday, 21 October 2012

The Kindergarten of Democracy


Breakfast at 0715 for a 0800 start – on a Sunday! – but absolutely worth the effort.

The first session was presented by two extremely articulate and erudite Austrian psychiatrists, on the long-term consequences of war. Not only was their methodology presented to us in a way that made complex research easily understandable, but their humanity and compassion shone through. They also showed their  political understanding when talking about how core funding for NGOs makes coordinated action almost impossible, and the lack of leadership leads to a miasma of fragmented services.

A very interesting clinical point was about how ‘low intensity warfare’ could lead to a more complex form of PTSD, or personality change, suggesting the mechanism was not unlike that of childhood trauma and abuse: while still mentally recovering from one adversity, another happens and has a complex interaction with it. They also spoke movingly about how children and families being ‘repatriated’ from Germany to Kosovo showed very high rates of disturbance, and how the family disturbance would probably be passed onto the next generation. The terrible consequences of public policy on mental health – thorough adjustment, loss and emotional insecurity.

An odd random thought came across me during this: ‘we must do an RCT of greencare in Afghanistan’. Based on Steve’s methodology, and the vast disparity between the capacity of a single greencare TC and the unmet need there. Yousuf was soon interested in the idea, and we started thinking about the practicalities of genuine randomisation – and partnership with a respectable academic institution in the UK.

The second session – about the psychological aspects of the Arab Spring - was even more passionate and rousing. We learned how the Arab Spring, started by a single suicide, was sprung by years of pent-up and severe emotional disturbance simply being tolerated no more. We learned of Ghaddaffi’s longstanding severe disturbance and mental health treatment, following hospitalisation in 1971, and how it included the rape of many thousands of under-age virgins: sometimes five per day. And how Burgita of Tunisia was hospitalised in Geneva and later assessed by two psychiatrists, who were under duress themselves, to be found unfit to rule for reason of insanity. 

The exciting headlines, perhaps relevant for the future of the world, were:

·       “We are in the kindergarten of democracy” – which is never a fully attained goal, only ever a process and direction of travel (much as we say in TC practice)
·       Citizens – in a socially-networked world – can no longer be considered as ‘owned’ by single country or organisation. The fear of ‘them’ has disappeared. Again, like a TC?
·        ‘The cancer of multinational corporations’ with the dominance they have from their immense power and financial resources, can only be balanced by the power of the population – talking to each other. Just like they do in groups.

The closing ceremony was just four serious men in suits on the stage – and an interesting presentation of an elegant glass award to the young psychiatrist who asked the best questions and had the best discussions in the ’meet the experts’ sessions throughout the congress. We were also treated to a travel agent’s advert of all the wonderful forthcoming locations you could go to with the next year or so’s meetings of the WPA: Bucharest, Istanbul, Vienna, Melbourne, Ljubljana.

A final bit of wheeling and dealing to be done: Yousuf already knew him, but the rest of us introduced ourselves to the WPA Secretary-General to tell of our ideas for skills training, our links to IMH in Nottingham and the work we will do to work across the WPA sections - maybe for the Istanbul congress. He encouraged us to get information published on the website, promised us his wholehearted support, and would arrange meeting rooms for us. Watch this space…

Post Script. We started the process with two snag-ridden journeys; we had another on the way back. After we had gone through to the gate, Andrea noticed her mobile was missing: desolation and panic. But we phoned it, and, amazingly, it was answered by somebody who understood English – our mini-bus driver. After a complicated sequence of coordinating phone calls, he arrived back at the airport with it to meet Olivia (who had a later flight, and who had not gone through passport control). 600CKr (~£20) later, and with a handover in the back streets of Liverpool tomorrow, it will be back in Andrea’s possession. Hallaelluja!

Windsor tomorrow.

Saturday, 20 October 2012

Wheeling, Dealing and Scheming


Sadly the psychodynamics session was mediocre at best, but bumping into Bulent over coffee, I suggested what a good member of the Edcuation Section committee Yousuf would be, and he warmly agreed. Soon after this, I found Yousuf, and he invited me to a grand pow-wow of the heads of all the 67 sections of WPA, to which he had already been invited to be a gatecrasher. Enthusiastic at the smell of new blood (maybe) we were actively included in the discussions to promote cross-sectional working. So Yousuf agreed to be on the Education Section, and apply to be on Developing Countries Section – for which I fully expect him to be chair or secretary within a year.

For my part, I made contact with the Psychotherapy Section chair, and want to explore their interest in collaborating with the Education Section in promoting the importance of experiential learning and our KUF-style ‘quality of relationships’ training - which of course was the subject of our symposium on Thursday. I also recognised the potential that might come of joining the Social Psychiatry Section, to perhaps promote the new breed of TCs we are developing in the UK, and hope to do in culturally congruent ways in Afghanistan (and maybe elsewhere).

So, much as an autocthanous delusion crystallises out of thin air, here’s the game plan that Yousuf and I have cooked up:
  1. Following our symposium, we do what we can to promote experiential learning through the psychotherapy and education sections. Use our presentation as a springboard for the idea.
  2. Join that with developing countries section (hopefully under Yousuf’s leadership!) to develop training programmes such as we were planning for Kabul last year (see previous blog entries)
  3. See if this could be done as an activity of Putting People First, maybe in collaboration with IMH.
  4. See if IMH would be interested in developing cross-cultural KUF-type online material as part of the training effort.
  5. Suss out whether the psychotherapy section is interested in TCs.
  6. If so, plan a congress symposium in the next year or two as part of the section’s work. To include the Thames Valley TC model, Steve Pearce’s RCT, the cultural and economic benefit of adding greencare, and plans for Afghanistan. Maybe also including the Social Psychiatry section.
  7. If not, take that symposium to next June’s separate Social Psychiatry congress in Lisbon.  Maybe do this anyway.
  8. See if there is any other interest in such a symposium from people at the TCTC Windsor Conference this coming week.
Maybe they should keep us two apart!
Footprints on the pavement

In some need of an antidote to wheeling, dealing and scheming, I followed the antipsychiatry footprints on the pavement to the travelling film exhibition put on by the American ‘Citizens Commission on Human Rights’. Slick but extremely shrill,  I presume it is something they put on all over the world for events like major psychiatric congresses, to ‘put the other side of the story’. Although I was sympathetic with much of what they were saying, the message was drowned out for me by the high intensity invective and ‘hard sell’ – populist maybe necessary to transmit messages like this, but dumbing-down to this level patronises everybody and just insults most people’s intelligence.
Dumbed down
 The other footprints – much more numerous and continuous – led to a sinister black lorry identifiable by only a pharmaceutical logo. Inside, we were promised an frightening experience of what schizophrenia was like. As close as a theme park ride is to something really frightening, tabloid tales are to truth, or Hollywood is to real life. Lavish and clever – but that’s all most people expect nowadays isn’t it? Like the antipsychiatry roadshow, I suspect it treks round the globe to follow international congresses and events – although with very different purposes, intentions and values, with equal shallowness and lack of integrity.
A sinister lorry

Then I just caught Paul Moran presenting the rather counter-intuitive results of a feasibility RCT for crisis plans in BPD: the trend, without statistical significance, was to increased self-harm when engaged with a well-shared crisis plan. The economics data, and qualitative ‘successful engagement’  result, pointed the other way, but nothing was conclusive. Rather disappointing. Let’s hope Steve Pearce’s RCT of TCs isn’t as damp a squib…

More importantly personally, and in a whole-system way of thinking, was a few minutes conversation I had with Paul. Our unsubstantiated conclusion widened out the one that Yousuf and I reached yesterday morning: many psychiatrists in the NHS are being systematically devalued, disempowered and demoralised. In other countries, in other and kinder times, this would be a public mental health problem.

The day finished with a dinner cruise on the Vlatva River, which cheered us all up and was an almost perfect combination of music, food, fun and utterly beautiful scenery. With the added bonus of one of our team getting engaged in a deep and meaningful conversation with an e-psychiatrist , who presented papers on the power of cyber relationships, proposing a serious reversal of his professional practice – and requesting uncharacteristic hyper-proximity. She told him to buzz off, and the rest of us formed a human shield around her for the rest of the evening.


In wandering back to our hotel through the streets of the ancient quarters of the city, we chanced upon the dear old astronomical clock.  The midnight performance was a few minutes away, so we regained our favourite spot in the street café, and tried a few adventurous cocktails, all wrapped in bright red blankets against the chill of the night. Only to be sorely disappointed at the witching hour: no apostles, no Jesus, no lust, sloth, greed or even rattling death. Our waiter told us that silent night lasted from the last performance at 11pm until the first at 7am. 

And so to bed.

Friday, 19 October 2012

Ulysses or lithium?


A slightly later start for a more leisurely day: leisurely breakfast with Yousuf and an interesting conversation about the ways in which the anti-medical regime, in place at Winterbourne (and subsequently the Complex Needs Service) in Berkshire since 2002, has undermined and ended the careers of several senior medics there, and destroyed the culture of excellence for  training junior doctors. Determined not to be that latest victim, I am very unsure about what I need to do next.

Onto “Cultural Psychiatry, Empowerment and Best Practices in Europe” which was mostly rather dry and about the sizes and needs of people of different cultures - until the final presentation by Professor J Achotegui from Madrid. He told of the terrible desperation economic migrants felt, and the often fatal lengths to which they went, to land on the Spanish coast. There were severe psychiatric consequences of the displacement, alienation and rootlessness – as well as rejection, worthlessness and helplessness they subsequently experienced (not unlike life for doctors at Winterbourne since 2002!). In a crescendo of emotion, he described how their mental conditions, a sane response to an insane situation, were not well-captured by any current psychiatric diagnosis. With the help of Homerian poetry, anthropological reflections , a little economic analysis and a public education campaign, he had coined the term ‘Ulysses Syndrome’. Not everybody in the audience took to the cut of his jib, but nobody could deny him his fervour and passion for humanitarian responses to international civic bureaucracy.

From Spain to Germany – and one of the plenary lectures, on mapping care pathways, by Heinrich Helne. After a vaguely interesting preamble about principles and examples from Italy, Japan and USA he got thoroughly dug-in to the intricacies of the German system. Losing the will to stay awake, a walk in the fresh air through the ancient streets of the Old Town was called for. I caught up with Kath, Andrea, Emma and Olivia and we ambled from our hotel to the astronomical clock – arriving a few minutes after it had struck noon. With five ringside seats available in the pavement café next to the Old Town Hall, there was little choice but to sit down and enjoy the rare luxury of a lunchtime beer - while waiting for the disciples, Jesus, lust, sloth, greed and death to appear or jiggle for the one o’clock show.

We then ascended the tower in the tardis lift to see the two o’clock show from aloft, next to the lone trumpeter. Most impressive – as was the walk across Charles Bridge ominously watched by the  looming statues.

Back to the congress centre for the committee meeting of the Education Section – which I had recently been coopted onto. What were they on about, I wondered – and I simply had the intention to find that out, and whether any of them were friendly to psychotherapy and experiential training. Very friendly and welcoming, we heard of a couple of international surveys, proposals to have new psychiatrist educational seminars at future meetings, NY Cornell’s outpost in Doha (Qatar), and our free use of a Harvard project manager.

The extremely affable chair, Bulent Coksun from Turkey, took us over to dinner at the nearby Holiday Inn – but was profuse in his apologies for having to attend a form dinner elsewhere himself. The remains of us had a fairly raucous time being rude about each other’s countries and customs, and our own. Suffice to say that one dinner guest had to be restrained and told to be more compliant with his Lithium!

Thursday, 18 October 2012

More than 17 (just)



Arriving for breakfast at 0632, I was surprised (and very pleased) to see I was the last one there. We ate rather silently and nervously, and got the metro to arrive in our presentation room just after 7am. We put up our display posters either side of the stage, and leaflets on all the seats; we adjusted Yousuf’s powerpoints a few more times, and finally handed it over to the technicians. Then we waited…
Emma and Olivia - with the tree of hope

Nearly 17 by now...
Although there were only 3 attendees there on the dot of 0800 (our official starting time), somebody did say that lots more were outside the congress centre, just arriving – so we waited a few minutes before starting. Soon there were 17 and by the end we had about 30, though there was some coming and going. The talks went pretty well exactly to time and to plan, and are available on the LLE website www.livinglearningexperience.com  .  Afterwards, we breathed a sigh of relief and had the freedom to enjoy the rest of the congress.

C B Nemeroff (USA) gave the first plenary lecture – on Neurobiology of Child Abuse and Neglect – and gave a dazzling exposition of the genetic, neuroimaging and pharmacological bases of adult consequences of childhood trauma and abuse, and how the people with histories of maltreatment had different brains. Although he seemed to deliberately avoid the PD label, it was almost a return to the days of ‘endogenous v reactive’ depression – except over a life course, rather than weeks or months. Quite reassuring to those of us who fear being eclipsed by the biomedical juggernaut driven by the economics of the pharmaceutical industry.

Then to the posters – hundred of them from all over the world; interestingly all of those from latin countries bearing a prominent ‘no conflict of interest’ declaration, none of which would have suggested any such suspicions. Is this an international version of the UK ‘health and safety’ culture, used to destroy trust and spread persecutory anxiety? And next to the poster, a display of restraint cages through the years, and straitjackets exhibited like a fashion display. Was this deliberate irony?

Bed shortage?
PICU?

C&R?

straitjacket couture?

Next to a heart-warmingly reassuring session by Czech psychiatrists and therapists from The International Centre for Integrated Psychotherapy (Knobloch). Heart-warming because it was human-scale and clinical, reassuring because it is a TC by any other name. Although they only briefly referred to TCs, I asked if they recognised the British TC tradition, with Maxwell Jones and all, as their work seemed so familiar: and indeed they did. Somehow, we should be making friends with groups like this.

Towards the end of the afternoon, were workshops. The title of ‘Innovation in Psychotherapy Education’ was catchy enough to attract me, but for some reason, my heckles were soon raised once there. It was a sharply commercial presentation of an elegant and well constructed Moodle website for training in basic psychotherapy – not unlike KUF in its design, but lacking the radical ‘relational’ edge that I think is essential in any therapeutic engagement. A sales pitch, I suppose, when I was looking for realttitude change, I suppose – tackling ‘us & them-ness’ – ever seeking that dear old ‘quality of relationship’ again.  After an initial altercation which Yousuf and I had with the presenter – about the viability of hard evidence-based rules for all psychotherapies – I meekly shut up and watched nigh on a dozen video clips of very self-assured therapists teaching how to do CBT…

The final session was much more cheering, though. Professor R S Murthy was being presented with a special prize. The purpose, structure and committee for this prize was explained at great length before the ceremonial  exchange of gifts and flowers and the lecture could begin. Professor Murthy is recently retired Dean of the NIMHANS – ‘the Maudsley of the Subcontinent’ in Bangalore – and I explained to him before the talk about our link with ASV and the intention to do an LLE there in the next year or two. Maybe we should do a second one for NIMANHS residents! But he was great – talking our language like few others did here. 

Here’s the points from two of my favourite slides of his. This one gave seven criticisms of the current ways of psychiatric thinking and practice:
  1. 1.       Medicalisation of suffering
  2. 2.       Vague diagnosis
  3. 3.       Mainly pharmacological interventions
  4. 4.       Doubtful outcomes
  5. 5.       Insensitivity to local customs and practices
  6. 6.       Loss of personal context
  7. 7.       Psychiatric imperialism

And this one gave three points for the ‘paradigm change’ that’s needed for world mental health to improve:
  • ·         Recognition of the central role of people and families
  • ·         Information and interventions for them
  • ·         Professional development to share this

Back for a celebratory meal of stroganoff with dumplings and Czech beer at a cosy little restaurant just near the hotel. But rock on Professor Murthy – you’re my main man!

Wednesday, 17 October 2012

The Yerkes-Dodson test



First there were seven, now we are six. Sadly Lou, from Emergence, who was going to present the KUF model with Andrea, has to pull out a couple of days before we left. Then, just to test the rest of us for our ability to cope with anxiety, four of us nearly didn’t make it to the airport. Emma was coming from a village outside Norwich by train – and she had allowed for trouble by getting one train earlier than she strictly needed. But, with one train cancelled because the driver had a cold and the next one missing its connection, this was not enough. The next train from Norwich was running ten minutes late – but the airport passengers were relieved to be told that the connecting train to the airport would wait. But it didn’t, and sadly unsurprisingly to those of us who often use British trains, the staff at Ely were inflexible and unhelpful. One very expensive 50 mile taxi ride at breakneck speed did eventually ensure that Emma did manage to get to the airport in time. My own resolve was severely tested when I looked up the M4 on Google Traffic about half an hour before going to pick up Kath then Yousuf at different points along it, en route for Stansted. I usually prefer trains, but I had been watching the M4 at that time of day for the previous week, including going to work that way one day to check it would be okay for the airport run. But random events are much less forgiving than careful planning can always cover: Google Maps (bless it for its amazing technology!) showed a string of black with a few red beads along the M4. Black is stationary and red is very slow. Radio Berkshire was on in the kitchen and the Breakfast Show presenter was getting quite excited about it all – getting people to phone in from the stationary traffic jam and tell their stories of why it was so important to get to where they were going this morning. Purleez! – as they say. But Kath was going to on the train to Theale by now – so I had to go and pick her up. She and I discussed the various cross country routes and she much calmed my jangling nerves by pointing out that, although we had no idea of whether we would get to the airport on time, there were no more decisions to be made, once we decided to head up through Wallingford, and meet Yousfuf at Lewknor on the M40 near Oxford. Thankfully, Yousuf had emailed me his new mobile phone number about an hour beforehand… We made it. Not being at all superstitious, I did hope that those three (Lou, Emma’s train and the M4) were going to be our full measure of troubles. Well, there was the slight matter of being charged about double what we should have for the people-carrier taxi from the airport – ‘it’s on the meter, guv’ would be the London cabbie translation. But, reading the guide book, I just took that as NPP (normal for Prague).

The opening ceremony was what you expect – a long table full of civic dignitaries and big cheeses on a grand stage in a plush but three quarters empty auditorium, interspersed with Czech folk dancers and local musicians. Just an hour: quietly dignified, and quite good fun. But not exactly setting the soul alight with passion, imagination or fire-in-the-belly!

The ‘cocktail reception’ afterwards had a funny idea about cocktails – red wine, white wine, beer and tea. But with some interesting canapés – in good quantity – pressed upon us by friendly waiters. An hour or two there gave us time to do carpet bombing of hundreds of copies of our ‘come to our session’  leaflets we had brought with us, because we feared absolutely nobody would come to our session at 8am the next morning. My guess was 17 people.

The flier for our symposium (front)
The flier for the Kabul paper

But distributing the leaflets was quite interesting in itself – as most of the reception was in the congress’s exhibition area, which was dominated by a few vast and elaborate pharmaceutical company pavilions (eg ‘redicovering trazodone’), and a few small stands for organisations and future congresses. I rather enjoyed putting our leaflets on the Big Pharma tables, smiling and saying ‘maybe this is the antidote to too much psychopharmacology and neuroscience’. Yousuf and I took over one of the small non-drug company tables and finished our powerpoints, as everybody else’s were long done by then. We tried to check out our room, but it was chained up – although we did ask a technician how big it was, and were not exactly relieved to be told it seated 200. I kept my estimate at 17, others were more optimistic. Another glass of wine and back to the hotel for a rehearsal…

Because we had paid for the hotel in advance, we couldn’t get any refund for Lou’s room – though one of our number (I shan’t say who) had suggested we sub-let it on a half hourly rate basis as an income generation proposition. Instead, we decided to use it as our rehearsal room, and we all gathered there when we had done the four metro stops from the congress at Vysehrad to our hotel at Florenc. But once there, in the knowledge we had an early start, we had run out of steam – so we just discussed how we would coordinate the 4 talks. Then all went to bed, with the intention to be together again at breakfast, at 0630 sharp (5.30am UK time).

Sunday, 23 September 2012

Can IAPT ever really look after PD properly?



Sometimes I get into interesting email conversations with people I have never met, or from a long time ago. Here’s one from a medical psychotherapy colleague wanting some background on the National PD Programme for a talk. To save any embarrassment, I have redacted any identifying details. For me, it reminded me of how sad it was to lose a government programme that was really trying to introduce the idea of relationships - at group and society level as well as for individuals - being more important than ‘therapy products’. With a little more time and nurture, it could have introduced some truly radical thinking into mental health services for some of the most dispossessed. But perhaps this conversation shows that I may be feeling more bleak about it than I need be…

Colleague:
Remember me?  Its been a few years. I wonder if I could pick your brains about services for BPD and IAPT. I’ve been asked to step in and give a talk about IAPT for SMI and BPD, and I am going to talk about relational therapies. I just wanted some info about the wider picture, and how IAPT could improve access to services for people with BPD.
Hope you are well!

Me:
Of course I remember you – those research conferences were one of the most formative experiences of my career! Good to hear from you.
But you do ask the most sensitive questions…

My personal view is that IAPT does not have, in its leadership at least, a good enough understanding of the ‘complexity agenda’  that was the defining feature of the DH’s National PD Development Programme until its effective demise in 2011. This was specifically defined as cross-agency working, service user partnership at all levels, no exclusion criteria if diagnosable as PD, multiplicity of suitable therapeutic approaches often arranged in complex group programmes, whole-system interventions, staff attitude change, and a research agenda including the social sciences.

The programme had £6.9m annually (2002-11), and set up 11 Imperial-researched pilot sites across England (using different models) as well as the ‘Knowledge and Understanding Framework’ online awareness training plus a BSc and an MSc. What was the national PD programme has now effectively moved to the Ministry of Justice (where excellent work is being done, for example, on setting up therapeutic environments in prisons and training custodial staff in ‘relational security’) and DCLG (where there are similar champions for the housing and homeless sectors).
I suppose the underlying conflict - laid bare by the recession and thus the need to shoehorn any future PD work into IAPT - is that the DH’s PD programme was trying to do innovation and exploratory work in a very messy field that crosses almost all sectors and government agencies, and IAPT was ‘rolling out’ a precise delivery and measurement model for treatments that had already been through the ‘evidence mill’. And those of us in the PD programme were left feeling that IAPT was an entirely different type of thing, that would not well serve the needs of our service users - particularly the angry BPD people who were (I believe justifiably) outraged at the scandal of the poor treatment they have always had in the NHS, except in very few places.

But when we (the ‘PD exiles’) are feeling less aggrieved and more philosophical, we hope it is simply a matter of time scale. BPD treatment is so much less researched than anxiety, depression and all the common mental disorders, that we will need years to catch up. And - fundamentally - it is not yet possible, and may never be, to prescribe a simple suitable evidence based treatment programme for people diagnosable with PD, and all the relationship (dare I say transference) problems they bring…
Do get back if you want more info, or a phone chat, etc.

Colleague:
Hi. That's great. Glad I asked you!!!
I'm basically standing in at a talk which was going to be on CBT and personality disorders, and the need to adapt it. I'm going to review relational therapies instead.
The latest I've picked up from IAPT is the view it's about increasing access rather than recreating the wheel. But I'll summarise what you've told me.
Is essentially money being taken out of existing services? And diverted to IAPT or prisons?
Best wishes

Me:
What an interesting conversation!
In answer to your questions, the money that is being taken out of exisiting services is the pilot funding (£6.9m) which was always DSPD money, and meant to be picked up by PCTs (and now CCGs) once the pilots had shown their worth. Some of them have been taken on by local commissioners (often with substantial cost savings imposed, or requirements to ‘income generate’), but others are still needing the central funding to prevent closure. The idea is to reduce the central funding to zero over the next 3 years or so (although that is the message they have been given for several years now).

The bigger problem, in my book, is that only 12% of the English population was ever covered by the pilots - so 88% never had a bean (for local specialist non-residential PD services - what is called Tier 3. Tier 2 is as part of existing mainstream services - such as a small DBT clinic - which is more widespread, I think). Obviously in areas with powerful champions like Anthony Bateman, or commissioners with a particular understanding, Tier 3 services have developed - but most of the country is still a desert for people with BPD. Reading (where Jane and I set up Winterbourne TC in the 90s) was rather reluctantly incorporated into the big 'Thames Valley Initiative' pilot, and still struggles on quite successfully (clinically) in an unsympathetic milieu and hard-nosed health economy .

Back in the early days of the PD Programme (2004-5-6) the expectation was for more funding to roll out the successful models across the country, with a continuing  R&D programme to support it: but it never happened. Maybe it was the recession and inevitability of hard times, by my feeling is that there was a deeper resistance - maybe denying the size of the PD problem, or the diagnosis itself, or the messy uncertainty and chaos that goes with the territory, or (my favourite) that people with PD challenge authority and the established order in a way that is just not tolerated. Many stories to tell there, over a beer or two, if we ever get the chance!

Another interesting piece of the jigsaw is ‘Tier 4’ provision - which has been grumbling on as an unresolved issue since the Henderson and its replicates were shut down. The commissioners involved did recognise that there is a severe unmet need - particularly for those people uncontainable in non-residential services, who tend to cause chaos in acute wards and often end up in expensive and un-therapeutic long-term forensic care. So that has now re-emerged as a workstream of the National Commissioning Board, and last I heard they were looking at something like £33m revenue for 500 people in treatment at any one time in up to 10 regional centres - but they will be very different from the Henderson model - with a lot of emphasis on outreach, forensic liaison, consultation and training, and – under ‘Any Qualified Provider’ – are likelier to be run by independent, non-NHS, providers. And - even more important maybe - to exert leverage on CCGs to provide better Tier 3 services in the localities (our experience in Thames Valley is that the need for BPD referral to a residential out-of-area unit is rare when good local services are in place).

As you might gather - PD services have been my main preoccupation (and headache) for the last few years!


Colleague:
Thanks again for all your thoughts. Amazingly helpful! Not sure how it will end up but the people involved with PD at IAPT seem very aware of the complexity issues. And IAPT seems to be the only bus in town at the moment.
I think it's a big ask  ....... but I think it depends on the evaluation from the demo sites. If some show  clear savings... better chance of leverage with CCGs.
A beer would be great some time. You need to run for president of the college. We haven't had a psychotherapist since Fiona Caldicott. 
You've got my vote! 

And then, after the meeting, to several of us who had helped.
Hi
This is just to say thanks to you all for your helpful comments, thoughts, data etc.
I thought I'd just give some feedback:
Their remit appears to be to implement IAPT for SMI including PD, and are keen to get away from the idea that IAPT services will deliver treatment as they have done for the adult primary care initiative. But they appear to recognise the complexity of the problem and also that there are therapists and resources out there who have trainings that could be utilised to treat people with BPD.
The meeting was attended by a mix of people but mainly heads of psychology services and senior managers.
The main issue was about how commissioning and resources could be both protected and strengthened for people with BPD. No clear answers ! 
I suggested a strong case could be made for funding on the back of potential cost savings and there was evidence in relation to this both from RCTs  and comparative and before and after studies. Presumably when Imperial report their findings re the 11 pilot sites there may be some additional evidence.
I also made the point that the relational therapies did not need to be 'adapted' for treatment for BPD as they were either initially designed or developed for people with BPD or were tailored for use with BPD many years ago. I also suggested that there is a wealth of experience re treatment of BPD within CAT, PIT and MBT therapists, and that CAT in particular had an established training and system of accreditation which was popular and accessible to a wide range of psychological practitioners. 
People are grappling with how services can be organised and how any therapists undertaking work with people with BPD can be supported and assimilated into current support and treatment networks. Clearly the current IAPT stand alone model won't work.
It's quite interesting standing outside the psychotherapy system and seeing and hearing people's concerns. RAID had a transformational effect on liaison services, together with  a variety of policy and strategy documents. So if there are significant savings demonstrated from some of the 11 pilot services and these can independently verified, that's likely to have most effect with GP commissioners.

Cross references:
- Has CBT killed the human spirit? (June 2012)
- CBT rules in the House of Lords (October 2012)
- Alphabetti spaghetti therapies (June 2008)

Sunday, 26 August 2012

I have just been asked to write a foreword for a book by Father Hank Nunn, a Canadian Jesuit now aged 82, who set up Athma Shakti Vidyalaya - a therapeutic community in Bangalore.

This is a first draft, which describes something of my experience of ASV when I visited it in 2003. I hope it will help to promote the book, and the work of this remarkable therapeutic community.
The view from ASV, the road towards Bangalore city centre
 In about 1980 I remember being sent to a strange place. I was a medical student, and we were often sent to strange places -  from theatres where the surgeons wore space suits and do operations by remote control to rural GP surgeries with afternoon tea and linen table cloths; from rooms where babies are born to rooms where corpses are dismembered. This one was even more different, though.

I had been warned by previous students that this acute psychiatric admission ward, the Phoenix Unit in Oxford, was not somewhere to wear the normal jacket and tie. So I kitted myself out in a big red sweater and jeans, and I arrived there on a bicycle a couple of minutes after the suggested 8.30, and I was casually pointed in the direction of a large dilapidated room where I soon had to forget any ideas I had of hospital hygiene. I squeezed into the room to be confronted with a large circle of chairs - perhaps 40 people - where it wasn't possible to tell the consultant from the cleaner.  I had to find my own chair and pull it up next to a large restless man who just looked at me and laughed. "What's your diagnosis then, eh? You must be manic like me with a jumper like that." He trumpeted this at what felt like 120 decibels, and I just wanted the ground to swallow me up.  There was an excruciating silence (probably all of twenty seconds) before everybody introduced themselves.

After my initial culture shock of joining a therapeutic community, I went on to thoroughly enjoy it. I found something completely different about the way people were with each other - I learnt my psychiatry the same as other students who were on traditional wards, but I also got an inkling of something that is very hard to define or put in words. It was something about being allowed to be yourself, about playfulness, and creativity.  
That short experience set me on a quest and an adventure that I am still following, thirty-two years later. What is it that makes somewhere ‘feel’ safe? How do you set up places where staff enjoy working, and give their best? How do you run mental health services for love rather than for money?
I have tried to capture this essence in different ways since 1980 – not least by training as a psychiatrist, and soon realising that the elusive secret was not to be found in that territory. I was getting warmer when, training as a group analyst in 1994, I tried using my course dissertation to put the theory I had been taught into a developmental sequence called ‘the Quintessence of a Therapeutic Environment’. And perhaps even warmer when, as chair of the Association of Therapeutic Communities in 2002, I helped to instigate the ‘Community of Communities’ as a quality network to identify and set standards for therapeutic communities.

The entrance to ASV - created by the community, of course
One of the absolute highlights of that exciting time was a visit I made in November 2003, to a therapeutic community in Bangalore, that was hoping to join the project network. I knew that they used a reparenting (‘cathexis’) model of transactional analysis, for I had met people from their sister project in Birmingham. I knew cathexis had been controversial some years previously, in the United States and international transactional analysis organisation, as well as locally for the Birmingham therapeutic community. But my only intention was to go with an open mind, and see what I could find of this elusive ‘essence’ in a setting so different from all my previous experience of mental health services. As always, I was more interested in the ‘general therapeutic conditions’ than I was in the intricacies of a particular model of treatment.

Three memories stand out for me: I will call them ‘warmth of welcome’, ‘unlabelled living’ and ‘fight for survival and growth’.
The neighbours - mid monsoon season
The warmth of welcome was deeply moving, and I could tell from the moment I crossed the threshold that the intangible quality, which was so elusive and difficult to define, was present in abundance. I remember telling somebody when I got home that you could tell a therapeutic environment by ‘its smell’ – which didn’t exactly mean the physical aroma so much as the unconscious, primitive, limbic sensations that emanate from the social field your are joining. Within minutes, I remember playing backgammon with a community member and not having any worries about exactly where I was sleeping, what was on my timetable for the visit, or who was who. Several thousand miles from home, in a place where everybody was new to me, I felt I had arrived home.

The ‘unlabelled living’ was fascinating to me as a mainstream, though psychotherapeutically-minded, psychiatrist. The hard lines I had learned between psychosis and neurosis, between schizophrenia and personality disorder, and between traumatic and biological causes - dissolved into thin air. People were being treated as themselves, for themselves, each according to their own needs. Echoes of Laing, I wistfully remembered. But here, being done with compassionate meticulousness in a economic climate where the alternative was a social exclusion harsher than anything we know back home. To me, the therapeutic intention – and the palpable manifestation of it – was orders of magnitude more significant than any specific therapeutic techniques or methods.

The ‘fight for survival and growth’ was sadly familiar. Those of us who choose to work in these complex and indefinable ways always need to establish an ‘island of containment’ within which the work can continue. In the process of economic globalisation and market managerialism, the natural tendency will inevitably be towards instrumental rationality – with easily defined treatment processes and specified outcomes, which is of course antithetical to therapeutic community practice. I remember animated discussions with a parent, and being excited by plans to set up a similar unit elsewhere in India: ‘how could all this excellent work fail to be properly recognised?’, I thought. I was, and always will be, rather naïve about these things.

Father Hank Nunn, November 2003
But all these experiences now make me realise the enormous task of the leader of a therapeutic community, and the ever-increasing impossibility of the task of mere survival, never mind the possibility of growing and thriving. In ASV, one man has held this vision alive, through many years of surviving, thriving and carrying a flame through a hurricane, and this book is his account of that Herculean task. It tells Father Hank’s own story, laced with illuminations about the links with his Jesuit faith, his philosophy of compassion and the detailed methods he uses. It is a true and authentic account of what it means to love thy neighbour, profoundly understand another’s distress, and be human in the wilderness.



Saturday, 28 July 2012

It smells like a dead horse


It was a horrible job - almost like an autopsy of a very large creature that had become a close companion. Foolishly dressed in sandals and shorts, the first job for Fiona, Tim, Sophie and myself was to make war with the dense thicket of nettles surrounding our twenty-one foot mongolian gur. After we had taken a coal shovel to them, with a vengeance that could only come from numerous painful stings, we started the dissection.
First the canvas came off - quite a neat and tidy job. Then the innards. Too gross to give a blow-by-blow account, I shall just copy the report of the autopsy finding that I emailed to the colleagues involved...


Hello all

As you probably see from my other emails, I am very worried about the state of the yurt and how much of our energy it is taking up. We need it to be a fully-functional therapy room by the end of August if we are going to meet our targets for starting up the groups we have said we would for the EcoMinds project.

I am so worried that this just won’t be possible that I have written to Jamie asking if there would be space to use some of the classrooms at Iver, instead.
The felt layer - with mouse and other damage, and a very nasty smell

The cotton lining - once as white as snow...

Here’s what we found when we took it apart yesterday, and various thoughts about it:
  • The canvas layer (three sections plus cap) are dirty but structurally OK - now folded up and covered with cap at the site.
  • The five sections of felt are mostly dry now - but some are ex-mouse-infested, and all are mouldy, decayed and rotten in places. Also they are holed where the mice were, heavily stained and full of spores in some spots, and altogether extremely smelly. All five pieces are currently in the conservatory at TDU in Wexham Park Hospital - but Niddy has said it cannot stay there if the smell penetrates into other parts of the unit.
  • The cotton liner is unevenly brown-stained all over from the felt beneath and green-stained in steaks with the mould from the wooden ribs. It also has extensive areas of pin-pricks of black mould/mildew. It is also in the hospital conservatory.
  • The wooden frame is still standing and seems structurally sound - though several of the ribs in the area opposite the door are disfigured and sagging, presumably from the continual weight of wet felt above them.
  • Both the trellis walls and the ribs are covered in different colours of mildew and mould, with many spores visible on the ‘furry’ surface.
  • The wooden crown appears to be clean and in excellent condition!
  • The door has lost its varnish in several pateches, and the metal door furniture is rusty. It does not fit in its frame, so cannot be fully shut (though this is a longstanding problem).
  • The wood-burning stove is currently in pieces and very rusty. The backplate needs moving from the top to the back to accommodate the flue, but the bolts holding it are seized up with rust which has not been released with WD-40, oil, grease, brute force etc.
  • The new flue is dented and slightly squashed from transit, but we know this is not remediable, and should be fittable.
  • Our other equipment (like fire extinguisher, first aid kit, toolbox etc) are all OK.


Questions to decide
·         Do we want the wooden floor that we agreed? Whatever floor we have, it will need a damp-proof membrane installing under it - which will almost certainly require the wooden structure to be fully dismantled.
  • ·         Things we could do ourselves are:

o   install damp-proof membrane under the floor;
o   disinfect/peroxide bleach the woodwork and maybe paint with fungicial sealant;
o   scrub the outer canvas;
o   purchase new lining
o   purchase new felt layer
o   paint and restore the fire to good order
o   clean up the door
o   buy the furniture we need and decorate it to make it a good therapy space
o   Take the whole thing down as necessary and re-erect it (but this needs at least 4 people for 1-2 whole days)
  • ·         Things we probably need help with are:

o   install the fire and connect the flue;
o   clean/bleach/disinfect the cotton lining;
o   get the door working properly so it shuts properly and is lockable
  • ·         Things we definitely cannot do ourselves are:

o   mend the felt (although there is a possibility that it will be OK when fully dried out - though I would not be confident it doesn’t contain some infestation or other that will recur or cause future problems)
o   find the time and manpower to do all these things!
  • ·         At the moment, my favoured solution would be to get somebody to do it all for us - perhaps an English yurt-maker - and pay them whatever it costs - and include renovating and installing the fire and flue. This should all be possible to do before this coming winter.
  • ·         Another option would be to buy new felt and lining from the original manufacturers in Spain, and restore and rebuild the whole thing ourselves. If this is what we decide - I think it will probably not be possible to get it up before the winter, so we will have to be without it until Spring 2013.
  • ·         The minimal but fastest option is to make do with what we have got - damp-proof the floor, scrub the woodwork, put the felt back on when it’s fully dried, either clean or replace the cotton liner, and put it all back up ASAP. However, this does mean that we need to find a lot of people and time to do it all - and I doubt that we could get a new cotton liner at all quickly (which needs to go on the wooden frame first, in good weather)

  • Can we discuss and decide how to proceed before the end of this week please, folks?

David, Susan, Peter and I will have to approve any spending - but I think the stress it is putting on us all, and the whole project at the moment, is currently so much that we might need to just agree to pay for it all to be done for us.

Rex