Tuesday, 16 December 2014

The Enabling Society

Having been recently discussing the power of the TC approach with people here and there, I have been making some ideological friends up at UCLAN this week: I was asked to be a speaker on a keynote panel at the inaugural conference of the recently formed Association of Psychosocial Studies, alongside Richard Wilkinson (of ‘Spirit Level’ fame) and a couple of other academic heavyweights. A very different world from psychiatric academia – but the TC ideas went down well – our session title was ‘the Enabling Society’. Lynn Froggett (a very articulate professor from UCLAN) wants to do some fundamental TC research with us in Slough. It might help give us a solid but very different sort of evidence base.

Drinks reception and book series launch with 6 titles
Going there was like a day of deep psychosocial immersion in the strange academic land between psychology and sociology, and I could only be there for the first day. For a bit more than 50% of the time I was fascinated with what they were saying – though the rest was like rocket science to Fred Flintstone.
There’s good number of Lacanians amongst them, and Winnicott is staging an emergence from retirement – and although Bion still plays strong, they haven’t yet got the rhythm of Foulkes’s numbers…

A weirdly compelling day!

Here's the short talk I gave: 

Thank you very much for inviting me to this – I really believe in what this association is trying to do, although I’ve been rather nervous in thinking about what I could write and have to say to real academics and intellectuals in a field that seems so far away from what I know anything about (which gets less as the years go by, I do feel). But then I saw Sasha do a talk at the Institute of Group Analysis a few weeks ago, based on her own research, and had one of those ‘aha’ moments: we’re actually thinking about the same things – that are very difficult to put words on – but are fundamentally about relationships. I felt that she was talking about ‘how we find our place amongst others’ – which is one of the emotional development principles behind a lot of TC work.

The relationships which we’re both talking about are with the world, with our own culture and tribe, with our acquaintances, with our family and intimates, and ultimately with ourselves. As I’m growing into a green and grumpy old psychiatrist, I’d also say relationship with the planet and nature. As I said at a Royal College of Psychiatrists event a couple of weeks ago, the aim of our current work to run therapeutic community programmes in an environment centre is to “connect people to each other and to nature, to help people to see that there is a life worth living, and on a planet that is worth living on.”  But more of that later – that is where we are going; we have to get there first.

So, once I had clicked that we are talking about the same fundamental things, just in different languages as it were - I felt that I could probably say something to this audience and in this discussion with my rather awe-inspiring colleagues on the platform. So I’m aiming to tell you a bit about the forgotten (and I feel neglected) story of therapeutic communities over the last thirty years or so. Somebody said, in a large group at an NHS campaign meeting a few weeks ago that ‘TCs are the last remaining vestige of truly democratic practice in the NHS’. I didn’t know him, but I wanted to rush across the room and kiss him – but that wouldn’t have been within the acceptable boundaries of large group practice, of course! However, I do feel that there is some extraordinary work being done in therapeutic communities, which is very much in the face of increasing regulation, which is very individualistically and rights-driven, and experienced as persecutory. The whole thrust of it denies any importance to interdependence, mutual responsibility, social cohesion, and group process – let alone what we call the dynamic unconscious and the whole irrational realm of how humans operate at their best. Which includes things like spontaneity, holding uncertainty, imagination, and what I call ‘therapeutic ordinariness’ and ‘creative chaos’.

I won’t labour this point, but it does feel like we all now live under a public management tyranny that is based on the ideas of cognitive-behavioural therapy, with an underlying principle of instrumental rationality. I was looking for the right words for this thing, and ‘instrumental rationality’     seemed to capture it best – the definition (Wikipedia, I’m afraid) is "A specific form of rationality focusing on the most efficient or cost-effective means to achieve a specific end, but not in itself reflecting on the value of that end, nor the means of arriving there".  So the way we work in TCs is to some extent an antidote to that way of thinking – although it is becoming increasingly difficult to protect the space within which the TC can happen. And maybe this means that we in the TC field – and perhaps wider therapy world - need to change our tack, rather than keep trying to ‘keep calm and carry on’. And I think that’s what I’m here to talk to you about – TCs, and the philosophy and values behind them, being a radical force for challenging the prevailing view that instrumental rationality is good for your mental health.

My own educational background is relevant, because – in the days when being a medical student was paid for by the state and we received a maintenance grant from the county council – I did an elective third year of two subjects which were at war with each other: experimental psychology and social psychology. In some ways, the experimental psychology was a doddle – we had already done half of it in anatomy and physiology the year before. But in other ways, the critical theory in the social psychology made me doubt that you could believe anything in the experimental psychology, for example IQ testing, because of the political framework it was in. At the very least, what actually mattered more to me (as a rather confused undergraduate) seemed to the reading we did of Laing and Winnicott, than of Skinner and Eysenck. And in a way, I have lived in that polarised professional world ever since – physical sciences versus social sciences, ‘real medicine’ versus psychiatry, CBT versus psychodynamics, diagnosis versus formulation, biomedical versus psychosocial, mental illness versus personality disorder, and perhaps TCs versus the rest!

So, back to TCs. In the 1950s the British social psychiatry movement was storming the world. In 1952 the World Health Organisation published the following advice:
'The most important single factor in the efficacy of the treatment given in a mental hospital appears to the Committee to be an intangible element which can only be described as its atmosphere, and in attempting to describe some of the influences which go to the creation of this atmosphere, it must be said at the outset that the more the psychiatric hospital imitates the general hospital as it at present exists, the less successful it will be in creating the atmosphere it needs. Too many psychiatric hospitals give the impression of being an uneasy compromise between a general hospital and a prison. Whereas, in fact, the role they have to play is different from either; it is that of a therapeutic community.'
And at the forefront of this movement was the Henderson Hospital, where Maxwell Jones was the medical superintendent. Maxwell Jones was a respiratory physiologist who ran a programme for battle-shocked veterans at Mill Hill Hospital in the Second World War, and started to realise that they were better at helping each other to get over what we would now call PTSD, than he was. He was giving them lectures about how their breathing makes them panicky, but – in the time between lectures as it were – they were sharing the emotional meaning of their symptoms with each other. So when he set up the Henderson after the war, that was the principle it was based on. An anthropologist called Robert Rapoport did a detailed ethnography on it, resulting in the book ‘Community as Doctor’ – which boiled it down to four themes: democratisation, permissiveness, reality confrontation and communalism.
·        Democratisation: every member of the community (all patients & staff) should share equally in the exercise of power in decision making about community affairs
·        Permissiveness: all members should tolerate from one another a wide degree of behaviour that might be distressing or seem deviant by ordinary standards
·        Reality confrontation: patients should be continuously presented with interpretations of their behaviour as it is seen by others, in order to counteract their tendency to distort, deny or withdraw from their difficulties in getting on with others.
·        Communalism:  there should be tight-knit, intimate sets of relationships, with sharing of amenities (dining room, etc), use of first names and free communication
Although these made Henderson famous throughout the world, Maxwell Jones didn’t like them – and nor do I. Not because they are wrong, or it wasn’t good research, but because they don’t capture that ‘essence’ that the WHO was talking about. Apart from perhaps communalism, they are very behavioural – and don’t at all capture the quality of experience and particularly the quality of relationships that members of a TC – both staff and service users – actually experience. A more modern version of ‘TC theory’ that is now quite widely used is much more inclusive of different types of TC (apart from just the Henderson model), and is based on five necessary experiences for emotional developmental, and how we recreate them in a TC: attachment and feeling a sense of belonging; containment and experiencing emotional safety; openness of communication in a culture of enquiry; inclusion and interdependence by finding our place amongst others, and empowerment or personal agency through finding an authentic sense of self. But that’s a different talk for another day.

We all know that everything changed in 1979, and I’m sure that most people here can articulate that much more eloquently than I can. But one of the consequences in our corner of the mental health world was that selfish individualism (for want of a better word) made TCs less and less acceptable. I think the same is probably true of group therapy in general. In their heyday, the 50s, 60s and 70s, every psychiatric hospital in the country had a residential TC, some whole hospitals were run on TC principles, and community day centres were run as TCs. Then everything changed as the wind came from a very different direction – and without giving a grizzly account of all the closures – there are now precisely no residential TCs in the NHS, the non-residential day units have been reduced from 5 to 3 to sometimes one day per week and most of them shut altogether; the latest one I have just set up in Slough is just two hours – the rest the ‘patients’ do themselves and elsewhere, and I’ll say more about that later. There was a brief respite during the Department of Health’s National PD Programme between 2002 and 2011, when several new non-residential TCs were set up in the NHS, but most of those are now being closed because they don’t fit into the IAPT programme – which is where PD now sits in the Department of Health policy terms.

Yet we pay seven million pounds for new fences at Broadmoor, and send ‘difficult’ patients to locked wards in the private sector which cost £250,000 per year, where they receive a trivial amount of trivial therapy, and have quite expensive and extremely individualistic mental health services which Sue Bailey, described as a ‘car crash’ as she recently retired from being president of the Royal College of Psychiatrists. Our policy priorities have certainly changed! But I must stop ranting like a grumpy old psychiatrist, and get back to TCs.

It is true that a few of the TC principles from the social psychiatry revolution live on, though in a very attenuated and pale form. Examples include service user involvement, community meetings on some of our ghastly inpatient wards, and maybe some hope and creativity in parts of the contemporary recovery movement. But these are grounded in the soil of marketised and commodified mental health care, and lack the radical roots of people really taking responsibility for themselves and each other and challenging the power base of the system. They are still fundamentally paternalistic.

But I want to turn to where we are right now in 2014. I think a tide is turning and there might be opportunities for a new form of TC value base to have a wider influence – hence the link to the ‘enabling society’ of our title here. We have been doing a lot of work at the Royal College of Psychiatrists since 2002, when UK TCs were probably at about their lowest ebb. With lottery money, formed a quality improvement project called ‘Community of Communities’ – and we’ve had just under a hundred members for the last twelve years. At a formal level, it works just like any other audit or even action research cycle – decide and set the practice standards together – review them – action planning – make changes – start all over again. But where it differs is the fact we insist on communities visiting each other, and being visited, each year – not for an inspection process, but for support and nurturance from like-minded people. And of course, it includes both services users on these visits, as well as staff of all seniorities.

From this, about five years ago we distilled a set of ‘core TC values’ as well as the more prosaic ‘service standards’. The service standards define what TCs need to do, and most other places don’t do, but the core values are not TC-specific at all: they are as close as we have yet got to the ‘essence’ that the WHO directive identified. And with that set of ten values we have established a different sort of quality process – what we call the ‘Enabling Environments Award’ – which is as applicable to a prison or office or school or church or business as it is to a therapy unit. It’s going down very well in the criminal justice sector – and we’ve just had a launch of it for the health sector, with endorsement by RCPsych for it as a potential solution for lack of compassion in the NHS, in the wake of the Mid-Staffordshire crisis.

Finally, a few wilder ideas on the fringes of enabling environments – which are to a wider RCPsych initiative called the ‘Positive Environments Framework’, to our tiny social enterprise called ‘Growing Better Lives’ and the Institute of Mental Health in Nottingham’s ‘Social Futures’ centre. These are just vague threads at the moment – and I have no idea if they will come together or not, but quite a lot of us are trying…

Greencare is the inclusion of nature in therapy programmes – and combined with TC-type groups which our social enterprise runs in a yurt at an environment centre between Slough and Uxbridge, they seem to be very acceptable and effective. We’re also thinking of using permaculture and transition town ideas to give it a more than just ‘group therapy plus horticulture’ by itself.

A psychiatrist colleague in Columbia, Alberto Ferguson, is in his seventies and has run TCs all his life. He has experienced a similar TC trajectory to what has happened in this country: first residential, then day units, then without dedicated premises. To me this shows that ‘the TC in the head’ matters more than the TC in the building – and in his small town near Bogota there is a widespread understanding of TC-type social cohesion. Ex-patients now run groups there to bring together families and individuals involved in the drug conflicts, to make reparation and have the different factions come to some understanding of each other.

So, to finish off, and take these ideas back to our 2-hour per week TC in Slough. The phrase a few of us are putting about – perhaps a bit mischievously, but only half tongue in cheek – is ‘Slough as a Therapeutic Transition Town’. Instead of the ‘TC’ being seen as the two hour group we run every Tuesday, that is just one hub for all the other therapeutic things people can plug into: from mindfulness and psychoeducation groups run by the NHS psychologists, to a very successful mental health choir, to greencare in our yurt, local sports for health groups, a therapeutic digital photography group with Arts Council funding. People’s experience is then of the whole range of activities - delivered by all sorts of different organisation – as being THE therapeutic community. Yes, I am talking about poor old Slough – if you believe that is possible, you’ll believe anything. But we’re going to try!

Wednesday, 10 December 2014

NHS morality and care based on compassionate values

It is difficult to disagree with the main thread of Cox and Gray's argument (1), that the NHS as a whole has lost its grip on being person- centred in any genuine way, amidst the industrialisation and authoritarian managerialism of the modern NHS. However, I would take issue that the College Centre for Quality Improvement (CCQI) is being idle about the matter.
For over twelve years, I have worked with CCQI staff to set up and develop three projects to promote exactly what Cox and Gray are asking for: robust systems of quality assurance and quality maintenance which focus on the emotional experience of the patients in their particular treatment environments. The Community of Communities quality network (2) for therapeutic communities started in 2002; the Enabling Environments award (3) (which is suitable for any setting) was established in 2009; and the National Enabling Environments in Prisons project began to improve relational-based practice in participating British prisons in 2009. All three projects continue to flourish, and more are planned.
The Enabling Environments award is based on a set of ten value statements which define 'relational excellence' in work environments. These value statements have been processed to form ten standards, each with several criteria for demonstrating that they have been met. Naturally, compassion and the quality of relationships are at the centre of the expectations. The standards are measured by submission of a portfolio - for which we have designed a flexible and hopefully enjoyable process, rather than a persecutory inspection. Rather than being part of the regulatory burden that many units nowadays feel, our experience to date is that participants take great pride in the process and receiving the resultant award. It is important to note that the existence of this award was prominently mentioned in OP92: "The Enabling Environments Award recognises that good relationships promote well-being, but that many organisations and groups fail to address this aspect of people's lives". It therefore already forms part of the College's response to the Francis Report.
Unfortunately, the response from NHS organisations (mental health and others) has not been encouraging - and the award is much better used and recognised in the prison service and all sorts of different third sector units. I believe this may be caused by a deeper malaise in the NHS, very much in line with what Cox and Gray are arguing in their paper. In short, the NHS is being run with a competitive business model to such an extreme and aggressive extent, that 'soft' values such as empathy, emotional intelligence and kindness are given no force.
Related to this, it is worth mentioning that the Institute of Group Analysis, alongside other organisations including RCPsych, are running a six-month listening exercise to gather information from staff across the range of NHS professions and specialties (4). When the information is collected and collated, it will be used to negotiate with politicians of all parties in advance of next year's general election. As Cox and Gray argue, this is a moral question - and a profoundly important one for all of us who want the NHS to survive in a form that we can once again be proud of.
1. Cox J and Gray A, The College reply to Francis misses the big question: a commentary on OP92, Psychiatric Bulletin, August 2014 38:152- 153
2. Haigh R., & Tucker S. (2004). Democratic development of standards: the community of communities--a quality network of therapeutic communities.Psychiatric Quarterly, 75(3), 263-277.
3. Johnson R., & Haigh, R. (2011). Social psychiatry and social policy for the 21st century: new concepts for new needs-the 'Enabling Environments' initiative. Mental Health and Social Inclusion, 15(1), 17- 23.

4. http://careers.bmj.com/careers/advice/view- article.html?doi=10.1136/bmj.g5185 (due to appear in BMJ print edition 23 August)

Saturday, 29 November 2014

British TCs for Italians

And so to Rome again...
To the second conference of the international network of democratic therapeutic communities, where Jan Lees and I have been asked to explain what British TCs are all about to an Italian audience.
It was another standing room only conference, at an adolescent TC about five miles out of the centre of Rome - but clearly, from the state of the decor and furnishings - a state sector TC.
But a good day seemed to be had by all.

Here's our prezi:  http://tinyurl.com/uktctalkrome

And the text, which we needed to have pre-written for the live interpreter:

Therapeutic Communities in the UK 1942-2014

Slide 2
Although TCs in the UK can trace theoretical and philosophical roots back several centuries, and across countries, the British Democratic Therapeutic Community Model is considered to have developed in its current form during the Second World War, with the work at Northfield of Bion, Rickman, Bridger and Main, and Maxwell Jones at Mill Hill.

Until recently, there were two models of TC operating in the UK – the British democratic therapeutic community model, and what was once known as the American model – also known as concept-based, and hierarchical TCs, but now widely referred to as addiction TCs. In the past, these models were regarded as very distinct, but more recently they have begun to become more similar – democratic TCs are increasingly treating people with substance misuse issues, and forensic histories, and addiction TCs are increasingly treating people with mental health as well as substance misuse issues. Rex and I named these cross-over TCs ‘Fusion TCs’, in a paper we wrote for the TC journal in 2008, and the similarities and differences are discussed at length there.

Slide 3
There are seven types of TC in the UK. There are mental health democratic TCs, which are part of the NHS; there are mental health democratic TCs, which operate in the not-for-profit sector; there are democratic TCs in the Prison Service; there are TCs for children and young people, etc., and residential schools, run along modified democratic TC principles; there are TCs for people with learning disabilities; there are addiction TCs; and there are other ‘lifestyle’ TCs, which include intentional communities, faith communities, greencare etc.

Slide 4
A we have already mentioned, British democratic TCs have their roots in a number of fields – in the ‘moral treatment’ ideas and practice of Pinel in France, and Tuke at The Retreat in York; in the ‘progressive education’ field, with the work of Homer Lane, David Wills and A. S. Neill; in the experiments in rehabilitating psychologically wounded soldiers in both World Wars, but particularly Bion, Rickman, Main, Bridge and Jones, and after the war, with the founding of Henderson Hospital by Max Jones, which became de facto ‘the British democratic TC model’; the setting up of HMP Grendon – the only prison to have therapeutic communities, and no other prison provisions; the Cassel Hospital, set up by Tom Main; and many others all over the UK.

Slide 5
The British democratic TC model was based on, amongst others, the following principles: it was to be an anti-medical model; hierarchies were to be flattened, and it was to be as egalitarian as possible – no uniforms, no name tags, no deference to rank or status; everything that happened in the TC was to be available for treatment, and to become part of the treatment – Jones’ ‘living-learning experience’ in the ‘here-and-now’; there was to be a constant ‘culture of enquiry’; there was to be shared decision-making, based on the democratic principle of one person, one vote; peers would be therapists for each other, and taking this therapist role was part of the treatment; in its purest form, there was to be no individual therapy, and all treatment would take place in large and small social and therapy groups. Rapoport, in his study of the Henderson Hospital – the Community as Doctor - in 1960, suggested there were four themes to the principles and practice of the British Democratic TC – permissiveness – initially at least , tolerating most behaviours from TC members in order to gain a picture of them and their difficulties; reality confrontation – to then face TC members with their behaviours and the effects on others, and help them consider other ways of relating to others; democratisation – allowing TC members to be actively involved in the day-to-day running of their TCs, and to take roles related to these tasks, which would increase in the level of responsibility over TC members’ time in treatment; and communalism – whereby all tasks – whether treatment, work or social, were shared amongst all TC members and staff, and were done together – including cooking and eating, and cleaning the loos.

Slide 6
TC fortunes have oscillated considerably over time. The 40s saw the beginnings of the British democratic TC; the 1950s saw the development of social psychiatry, which Max Jones argued was an extension into the community of TC ideas and practices; the 1960s saw the development of the anti-psychiatry movement, which fitted well with TC principles; and many TCs were set up in the 1960s and 1970s. However, by the 1980s, because of economic pressures, and an emphasis on individualism rather than community and society, TCs began to be closed. The 1990s saw the closure of nearly all NHS residential democratic TCs – there are now none left; however, the 2000 (noughties) saw some growth in prisons TCs, and other TCs through the National PD programme. Although modified TCs – especially day TCs - had been around for some time, in the 2010s their potential has been developed and expanded.

Slide 7
These changes, and particularly the closure of residential TCs, have led to the development of what we refer to here as ‘reduced dose’ TCs, particularly in the NHS. The 5-days a week – day TC - had been around since the 70s, operating from 9.30-3.30, Mondays to Fridays, and some British TCs adapted and changed from residential to day TCs, which helped them survive longer. However, even these struggled in times of economic stringency, and the desire for quick, cheap fixes, so many of these were reduced to 3 days a week, which allowed staff two days to do other activities, such as assessment and preparation groups, which were set up to try and improve retention. Since then, and largely as a result of the National PD programme in the UK, 2 day and 1 day mini-TCs, or 1 day and one out-patient group, have been developed. Latest variants include TCs which only last for 2 hours a week – called the micro-TC, with an argument that the TC is carried in the head, but also many other activities happen during the week, but without staff present.

Slide 8
Hub and Spoke TCs came about as a direct result of the National PD initiative, with its exhortation to be more creative with services, but particularly to try and increase access to services, particularly in more remote areas. The hub is a central TC – usually for 2-3 days a week – in a large town or city. The ‘spokes’ are one day a week TCs in several smaller towns. The same staff work in the TC hub and in the different spokes. This helps make therapy more accessible across a wider area.

Slide 9
The National PD Programme also prompted further creative adaptations to TCs – ‘itinerant’ and ‘virtual’ TCs. Cumbria developed a TC which met in a rural area for one weekly community day, and for the rest of the week, the community participated in an on-line moderated secure group. Edinburgh service users set up a purely virtual TC – it was an on-line community only, with agreed rules, like other TCs, together with occasional social activities.

Slide 10
Since 1978, the British Association of Therapeutic Communities has run ‘transient training TCs’, and for the last 20 years they have also helped run these in Italy. These TCs are 3-day, stand-alone, residential TCs for TC staff, to give them a living-learning experience of what it is like to come into a TC as a member. They are facilitated by experienced TC staff, and involve intensive group work – community meetings, small therapy groups, cooking groups, and creative and social activities. Like any TC, the whole group is responsible for what happens in the TC, including food, leisure time, choice of small groups, and what to do in case of crises.

Slide 11
We also believe that there are other treatment environments currently being developed in Britain which are not directly organised as TCs, but where the providers and staff have a ‘TC in their heads’. These include therapeutic environments; PIEs – psychologically informed environments for homeless hostels; PIPEs - psychologically informed prison environments - for prisons; and therapeutic child care; all of which are now being quality assured by the British Royal College of Psychiatrists. All of these are called Positive Environments, which is a new, beginning initiative, again within the Royal College of Psychiatrists.

Slide 12
With continuing adaptations and modifications of TC provision in Britain, I became clear that Rapoport’s themes were becoming out-dated, and that there was a need to develop a new theoretical basis that could cover these changes. It needed to be based on what were currently felt to be the necessary developmental experiences needed by TC members (based on various psychological theories), and particularly that we all need to experience primary emotional development for good mental health. What we recreate in a TC is secondary emotional development.

Slide 13
In 1999, Rex Haigh published a chapter in Therapeutic Communities. Past, Present and Future, called The Quintessence of a Therapeutic Environment – Five Universal Qualities. This work was partly an attempt to update Rapoport, but also to distill the common factors of any TC or therapeutic environment. These five universal qualities were defined as attachment, or encouraging a sense of belonging, and helping the patient reconstruct a secure attachment, so these can be used to bring about changes in relationships and patterns of behaviour; containment, or creating a culture of safety, of holding and of boundary-keeping, whereby difficult experiences and feelings can be tolerated and processed; communication, or a culture of openness – making contact with others, talking about experiences and feelings, and being able to symbolise them, and feeling understood, and building relationships; involvement, or a culture of participation and citizenship, and interdependence – the living-learning experience, where everything that happens can be used to therapeutic effect; and lastly agency, or a culture of empowerment, particularly in relationships, where the patient is their own expert, and a therapist for their peers, as well as being able to take positions of authority and responsibility, and make decisions about their treatment and how it is delivered.

Slide 14
Another new development in the TC field in Britain in the 2000s (noughties) was the development of the Community of Communities project, for quality assurance and improvement in TCs. This provides a national peer review process, which is more in keeping with TC principles and practice. Standards are democratically derived through representative groups of TC staff and service users, and are regularly reviewed and change by these groups; TC staff and members visit each others’ TCs and review them, and the reviews are reported back to an Annual Forum. This peer review process has now been rolled out through all the Royal College of Psychiatrist quality improvement networks, and covers many types of TCs as well as other therapeutic environments which are not pure TCs but any TC member would recognise elements of the environment.

Slide 15
The old asylums of the 19th and early 20th centuries in Britain used to provide farm working or horticultural therapy as part of their treatment programmes. These elements of treatment largely disappeared with the closing of the asylums, but recently have been undergoing something of a revival as greencare. Greencare is based around a relationship with nature and the earth, involves horticulture and farming, as well as animal therapy, and the use of therapeutic spaces. Greencare is increasingly being taken up by TCs, as well as many other treatment services, as an anti-dote to the industrialisation and capitalisation of mental health. For example, this year a horticultural unit in Cumbria has started a one day a week TC alongside their huge greencare project – 10 acres of fruit and vegetables. Rex and Jan are also directors of Growing Better Lives, a greencare TC project, based in a yurt near London.

We think all these developments demonstrate the creativity and adaptability of the TC as a mode of treatment in Britain.

Friday, 21 November 2014

The First Enabling Environments Annual Forum

Was a great day - I'll let our main speakers say it for themselves...

Professor Dame Sue Bailey

Dr Clare Gerada

Monday, 17 November 2014

Rethink for PD

I don't remember quite why I agreed to go to deliver a free three hour seminar to several people at Rethink HQ on why PD matters and how it is different from most of the rest of mental health, but the view from their seminar room alone was worth it. We even had to take our own sandwiches.
Unfortunately, because it was completely unscripted and unprepared, I can't remember anything that was said - although I have a vague recollection of getting quite excited, being rude about the government's mental health policy and using a couple of swear words. 
But by the end, everybody seemed happy and appreciative.
An odd afternoon, but I hope they end up doing something sensible about PD - they certainly seemed to get the point. But they are one of those big corporate NGO-type organisations - so you never can quite tell.

Saturday, 15 November 2014

The London WASP

A rather disappointing event deep in the windowless and airless bowels of a London hotel, improved considerably - at least in wackiness - by Peter Tyrer's family and friends rendition of 'Browning- An Operetta'.
Peter claims it was in the service of giving the new and rather sterile Royal College of Psychiatrists HQ a soul.
The Peter Tyrer show
Graham Thornicroft did his set piece on Global Mental Health, which I saw him repeat a couple of weeks later at the parliamentary launch of  "Mental Health for Sustainable Development" for which Adrian Worrall and I submitted evidence to the committee, and yet it emerged with no mention whatsoever of groups...
The Graham Thornicroft show
Robin Johnson and I followed, with our 75 minutes truncated to 60, giving the WASP the benefits of EEs, PIPES and PIEs. Here's the prezi:

Saturday, 8 November 2014

Founders group - London number two

...and as I added - it's not surprising that it's depressed when it has been so badly emotionally abused for such a long time. It's showing typical signs of long-term abuse - learned helplessness, always in fear of yet more persecutory demands, and anhedonia.

But what a fabulous building is the professional home to the nation's 600,000 nurses!

The grand staircase at the RCN
And what a good meeting we had - it ran like clockwork: some of the organising team thought it was too gloomy and pessimistic, but I reckon that's exactly what we need at this stage.
For more info, go to the group website - which is going to be a major resource for the campaign.
But while that's being built, here's an HSJ article about it all: http://tinyurl.com/fginhsj

The grand collection of volunteer group analysts

Thursday, 6 November 2014

We won!

Which is very ironic, to win a sustainability award for a project that is financially unsustainable...

But here's all the info from the press release:

‘Greencare for Personality Disorder’, run by Growing Better Lives Community Interest Company, has been named Outstanding Contribution to Sustainability Psychiatric Team of the Year 2014 by the Royal College of Psychiatrists. The annual RCPsych Awards mark the highest level of achievement within psychiatry, and are designed to recognise and reward excellent practice in the field of mental health. Three members of the team were presented with their award by Dr Daniel Maughan, Royal College of Psychiatrist’s Lead for Sustainability, at a prestigious ceremony held at the College’s London headquarters on 6 November.

Rex Haigh, Fiona Lomas and David Hare
‘Growing Better Lives’ is a social enterprise based in a yurt at Iver Environment centre near Uxbridge.  The team work with Slough NHS patients to provide an intensive ‘bio-psychosocial’ programme for patients with personality disorder, who have often suffered severe childhood abuse. There are weekly therapy groups based on principles of modified therapeutic communities, ecological sustainability and ‘greencare’ (therapeutic horticulture, animal assisted interventions, care farming and other nature-based approaches).  The team includes ex-service users, horticultural therapists and a medical psychotherapist. Iver Environment Centre is run by Groundwork South, who are partners in the project’s delivery.

Competition for the RCPsych Awards is extremely tough, and the judging panels were impressed by the quality of this year’s entries. The judges said: “The Greencare for Personality Disorder programme demonstrated really excellent environmental awareness across all aspects of the service from care delivery, reducing energy usage through to local food sourcing and using green spaces therapeutically. They also engaged both staff and patients in the service with improving sustainability and gave a high priority to improving environmental awareness”.

Professor Norman Sartorius, probably the most distinguished psychiatrist in the world, who also received an award at the same ceremony, endorsed the idea of therapy in a yurt when he recounted his experience in one in Mongolia, commenting that “it’s a circular space which is very non-threatening, very non-violent”.

When receiving the award, Dr Rex Haigh, the psychiatrist in the team, said:
“NHS services for personality disorders are often very poor, and greencare is a holistic and economically viable alternative to treatment with medication and hospitalisation.
Sustainability is about connecting people to each other and to nature, helping people to see that there is a life worth living, and on a planet that is worth living on.”

The therapy yurt at Iver Environment Centre

The interior of the yurt - an ideal setting for group psychotherapy

Website: www.growingbetterlives.org
Video: http://tinyurl.com/greencaretalk
Contact: fionalomasnpd@gmail.com
Growing Better Lives CIC is a social enterprise committed to providing, training, and researching critical approaches to mental health. 

Saturday, 1 November 2014

A truly radical and critical conference

... held in the medieval grandeur of Dartington, with its Bohemian and Arts and Crafts roots, and Transition Town Totnes - an inspiration for anybody with a sustainable thought in their head.

This was the inaugural Limbus Critical Psychotherapy Conference, title 'Challenging the Cognitive Behavioural Psychotherapies: The Overselling of CBT's Evidence Base'. Official site here. There were six talks, with lots of large group plenary discussion time, good spaces for small group reflection around our tables - and a bar with decent beer in the evening!

Farhad Dalal opened the proceedings with a short impassioned plea for the values of being authentic and human.

The first session was Jonathan Shedler: What is the Evidence for Evidence-Based Therapies?
Jonathan Shedler
A lovely critique of the over-egging of the academic mountain of papers 'proving' the effectiveness of CBT.

  • "the master narrative"
  • "Evidence Based Therapy has become a brand and its apparel is all marketing, with a vast chasm between the buzz and the research "
  • "the inverted pyramid of shame"

The next session was Goran Ahlin: Waiting for the tide to turn: Aspects of the rise and expected fall of CBT in Sweden.
Goran Ahlin

A decade-by-decade trip through fifty years of Scandinavian psychopolitics - though I'm not sure I'd be as optimistic as he was about the tide turning any time soon.

  • "New Public Management" (a rather chilling concept which ran through much of the weekend)
  • Sweden was saved from the worst excesses of the post-1979 economic system
  • "Fascistic state of mind" (from the discussion)
  • 'Intolerance of any uncertainty" (ditto)

After lunch was Patrick Pietroni: Improving Access to Psychological Therapies: Where we were, where we are, and where we are going.

Patrick Pietroni
Turning IAPT into something meaningful - a vision of how an integrated primary-care based therapy system could deliver real therapy with much more benefit to everybody - rather than the superficial, transient, overcontrolled and often inaccessible system of Lord L and David C. And it has already started in Shropshire!

  • "A different kind of space"
  • "healthy human relationship systems"
  • "social determinants of health"
  • "Every MBA in DH should do an MBWA: management by walking about"

First up on Sunday was Oliver James of TV and book fame: Happiness, CBT and Apple Pie. Not to be confused with Jamie Oliver of course! 

Oliver James 
A gripping tale of intrigue and skulduggery as an elderly lord of the realm meets a sinister man-in-black psychologist - and try to make everybody happy. With solid genetic and social commentary.

  • "Drivel"
  • "La-la land"
  • "Weasel words"
  • "Happiness rubbish"
  • 'Thrive' as a 'completely irritating' book

Next was Del Loewenthal: NICE Work if You Can Get It; Evidence and research cultural politically influences practices.

Del Loewenthal
This was a dense intellectual argument from deep in the academic world of non-positivism, and a scrupulous picking apart of the NICE machine

  • "post exisitentialist"
  • "relational psychoanalysis"
  • "How dreadful it would be if psychotherapy became an agent of social control" (in discussion)

    The formal presentations finished with Farhad Delal: Statistical Spin, Linguistic Obfuscation; The Art of Overselling the CBT Evidence Base.
    Farhad Dalal

    This was based on a close examination of a prominent CBT 'evidence' paper, and showing just how slippery both the numbers and words are - and how the impact it therefore has is a long way from the science in it.

    • "3rd wave CBT" (about acceptance rather than control)
    • Mischievously incudes words like 'Compassion-based'; 'Mindfulness-based'; 'Attachment-based' and 'Resilience-based'. 
    • Parallels with Ben Goldacre and Bad Pharma
    • "reduction" of risk of relapse does not equal prevention
    • "CBT did iatrogenic harm" to those who had <3 depressive="" episodes="" li="" previous="">
    • "MCBT (mindfulness-based CBT) is a perversion of an Eastern philosophical tradition." 

    So, together with conversations setting up a SW event for the NHS campaign - and lunch with one of the key players in Transition Town Totnes - and scheming other cunning plans: a very stimulating and exciting weekend. I hope the 'Totnes / Limbus / Dartington Conference' becomes a regular fixture on the psychotherapy calendar.  

    Monday, 20 October 2014

    The Windsor Conference 2014

    I started coming to this in about 1990, and have a very intense love-hate relationship with it.
    I love it because you are fabulously looked-after in a three day conference of like-minded people talking about and doing interesting things.
    I hate it because you are fabulously looked-after in a three day conference of like-minded people and many many people who should be there can't be, because it's too expensive.

    This year's was even more conflicted for me, as the organisers (of which I am one) made a decision (without me) to base it on the 'Quintessence' paper I wrote ages ago and am still not happy with - with me doing the opening talk about it. And, although I don't mind ranting to people I hardly know, I feel quite self-conscious and embarrassed doing it in from of professional friends..

    The Windsor Conference - 10 years ago
    Anyway, here's what I had to say this year:

    First, thanks you for inviting me – this is like the anchor point of the TC year, like the annual residential community meeting for us all in this beautiful park. And I think this is the biggest number we’ve ever had, which is great to hear.

    And it’s a great privilege to be asked to speak here, so thank you very much, organisers.

    What I’m going to do in this talk is go back to an old soap-box of mine – about the experiences people need to have in TCs. It’s a theme that I started in about 1994 and will never get completely finished. But a fairly up-to-date version of it was published in the TC journal last year – as the ‘quintessence of a therapeutic environment’ – with five sort-of developmental themes that make up the emotional experience of being in a TC – and actually the experiences we all go through in our own development, for better or for worse.

    So as part of this introduction to the conference, I’m going to
    explain what drove me to it – and what is still driving my enthusiasm for TCs –
    explain how it’s relevant to the speakers who are here for the next three days,
    and finish off by
    thinking about where we are now with the TC ideas in it, and where we might go.  

    So, to start where I started in it all – with a bit of my own story.

    I got a bit of a shock – a good shock – as a medical student when I did Social and Political Sciences for my third year. It was very different from the logical and orderly world of anatomy and biochemistry and pharmacology that I had been in until then. Cambridge was a hotbed of radical and critical thinking in the late 1970s  so the first things I learned about psychiatry were about Laing and Szasz – alongside things like psychoanalysis and feminist theory.

    Of course Ronnie Laing himself was still alive then, and he was guest of honour at the annual MedSoc dinner that year (although sadly incoherent with the abundance of fine wine on High Table). But it was with these ideas fizzing around in the back of my mind, that two years later, I was about to have my first ever encounter with clinical psychiatry, and start as a clinical student at Littlemore Hospital, on the Phoenix Unit. Being sent to the Phoenix Unit - a phrase that struck terror into the hearts of medical students when they learned that was their allocated psychiatry placement!
    I had been warned by previous students that this was not somewhere to wear the normal tweed jacket and sober tie (which was the standard medical students uniform for psychiatry at the time), and to be prepared for anything. I was not to be disappointed!

    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 had to get past a couple of blokes wearing hardly any clothes sitting on the doorstep smoking roll-ups – like bouncers at the disco, maybe. Without any words being spoken, they looked me up and down and casually pointed me in the direction of a large dilapidated room - where I soon had to forget any ideas I had of hospital hygiene, with most people smoking and a thick fog I could barely see across. I expect they would go bananas nowadays if the infection control matron or the health and safety people saw it.

    I squeezed into the room between two people’s backs, 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 on the other side of the room 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 about 120 decibels, and I just wanted the ground to swallow me up and go back to proper medicine.  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 – just being human together yet also be able to be fully professional. And I have been looking for ‘it’ and thinking about ‘it’ ever since – that quality of relationship.  I have visited dozens of TCs all over the place, and worked in quite a few, and nearly always been inspired by them – because it’s there. Which is sometimes a problem because I can get inspiration fatigue – ‘oh no, not another marvellous, warm, welcoming and impressive TC’ – and quite forget that the rest of the world isn’t at all like that, and come to realise with a bump that it isnt!

    I think there’s several reasons that it is hard to put a definition of this essence into words. My first thought it that it is about preverbal areas of experience that simply exist before words we had words, to describe it with; in the quintessence these are the first two experiences – attachment and containment – that are mostly experienced non-verbally.

    And this probably fits into some of neuroanatomical ways of looking at it: it is about the emotional and motivation systems of the brain, which are technically primitive, and were there way before the evolution of our big cerebral cortex which does all the things like thinking and talking. I think this idea – that maybe a lot of important things about us that aren’t just in the cortex - was elegantly and vividly covered by Colwyn Trevarthan when he gave his talk here at the Windsor Conference two years ago.

    Another neuroanatomical angle on it does involve the cortex – or at least half of it – in that ‘it’ is something much closer to connectedness and relationship (to each other and to the natural world perhaps) and about that sense of holism, imagination, creativity and ‘the big qpicture’ …than it is about… sequential and logical  problem-solving.  I have recently read Iain McGilchrist’s ‘Master and his Emissary’ book which is a very impressive and erudite account of the difference between left and right brain functions – and by mentioning it so briefly, I know I run the risk of oversimplifying a very subtle concept – but the sort of qualities I am trying to pin down are much more akin to right-brain functioning than left. For most people the language centres are in the left – so communicating this essence through words is not going to be so easy (like it is about communicating things like numbers, and outcomes, and logical processes). But this shouldn’t be a cause of worry for us – because it means that what we’re exploring is more interesting and mysterious – and harder to grasp through words than it is through ‘just being somehow or other’ – what I have called ‘therapeutic ordinariness’ before. It does however, make it difficult to get it over in words – in other words to explain what we do - to the accountants, and commissioners, and outcome-measurers, and budget-holders, and policy-makers who live mostly in a left-brain world.

    Another relevant neuroscience angle on it comes from what Chris Holman was talking about in his Maxwell Jones lecture a little while ago: how mirror neurones can give us a model for how empathy works – with adjacent brain cells being activated by seeing or experiencing something rather than necessarily doing it. I know that’s an oversimplification, but it makes the point that something like empathy – that can only be described in clumsy verbal expressions like ‘putting yourself in somebody else’s shoes’ or ‘I feel your pain’ – has a mechanism there in the brain for being communicated from one person to another without the need for words. And I would say that most of the business (or ‘emotional work’) that happens in a TC is like that – it’s not the words that matter, but the whole experience.

    Putting it in good words is probably more of a job for poets and songwriters and artists than people who are primarily clinicians, or academics and researchers. But that doesn’t and mustn’t deny the reality – or seriousness - of this ‘thing’ we’re grappling with. If we ignore it because we can’t describe it very well, we will be left with something very unsatisfying – and thin and arid – that misses the point about being complex and emotional – and human. Perhaps like over-manualised CBT treatment – effective as far as it goes, but actually rather superficial.

    So the quintessence paper was my way to have a first go at pinning down this thing that people experience in a TC – or an ‘enabling environment’ or a ‘psychologically informed planned environment (PIPE)’ or a psychologically informed environment (PIE)’, or what I’m now trying to describe more broadly simply as a ‘positive environment’. Whether these five things are present or not in our social worlds makes an awfully big difference to our lives, qand the people we are there with.

    The quintessence paper itself, in the 1994 version, was the theory paper or dissertation for my IGA training – and it was a collection of the different theories that I had come across in that and my psychiatric training – assembled into a sort-of developmental sequence. It was my attempt to make sense of what was going on in the therapeutic communities I had come across and worked in. It was also a reaction against the dominant theory at the time, that seemed to be an over-identification of just one particular way of doing TCs – which was Robert Rapoport’s description of what he saw, as an anthropologist, at the Henderson Hospital in the late 1950s: democratisation, permissiveness, reality confrontation, and communalism. That troubled me for two reasons – first that it seemed to be a ‘recipe-type’ approach to standardise TCs. It became a definitive statement of ‘this is how it works so this is what you must do’, and it didn’t fit with my experience of many other TCs which couldn’t really justify using those words – or could only do so at a stretch which rather distorted their meaning, in order to fit. I think it could be called reification of the concept: – it made ‘the TC’ into an solid entity rather than a complex and never-quite-pin-downable attitude, process and ‘quality of relationship’.

    The second thing that worried me about it was that, when I read Rapoport, I couldn’t find any trace of a whole range of qualities that I knew I had always found in the TCs I visited. Again, there is that ‘how do you put it into words’ problem but it’s about nurturance, genuineness, authenticity, belonging, playfulness, joy and perhaps love – just to pick a few words out of the air. It’s close to attachment too, though I think is more than just ‘attachment theory—type attachment.

    So to turn to a quick resume of the quintessence, attachment is where I start, and indeed how we all start: umbilically, within our mother and with her blood flowing right next to ours, separated by only a thin membrane.  At birth, this physical and physiological attachment is suddenly and irreversibly severed: the smooth and fairly tranquil life of swooshing around in a warm ocean that is your whole world, without ever needing to eat and breathe, is over.  It is the first separation and loss, and many more will certainly follow.  The effortless existence is lost, and experience suddenly becomes discontinuous or bumpy: with good parts and bad parts, and if you are lucky, with people close enough to help you through it.

    For the baby who is fortunate, the physical and physiological bond will be smoothly and seamlessly replaced with an emotional and nurturant one, which will grow and develop until various features of that too are invariably broken, lost and changed in the relentless inevitability of development. This secure early attachment gives the infant a coherent experience of existence, and protects against being later overwhelmed by life's vicissitudes. This places loss - of contact, of relationship, of security, of hope - centre stage in the process of individuation: attachment must take place so that loss can happen. It is through the successful endurance of loss that we all have to survive and change to live on. So I want to emphasise that attachment- as I see it – is not a soft and cuddly sort of process – it is all about a sort of fall from that perfectly nurturant and peaceful world before birth through a series of tragic losses throughout life, to the ultimate loss of our own death – and most importantly, the things we pick up on our journey through life to make it all bearable.

    For a less fortunate baby, born with greater needs, or for whom the process does not go so well, the emotional bond is not secure. Attachment research shows that if the bond is not secure for the infant, nor is the adult who grows from it. When the failure or deficiency of emotional development is severe and incapacitating, people can well end up with lives of unrelenting pain and chaos – not just for themselves but also for people all around them.

    And we are very fortunate to have Gwen Adshead with us here at the Windsor Conference to guide us through some of this attachment territory – Gwen has been, for many years, a forensic psychotherapist at Broadmoor Hospital, dealing with people who have had âqparticularly severely disturbed attachment, with some of the most disturbing and ghastly coinsequences imaginable. She also – referring back to my utopian vision of how the baby smoothly graduates from a physical bond to an emotional one – has a particular interest in what goes wrong when parents, particularly mothers, abuse and sometimes kill their own children. So, we will be hearing about the not-so-cuddly side of attachment, from a world authority in it.

    One of the other earliest things that "grown-ups" do for babies on that bumpy ride through infancy is to be there and accept their extreme feelings of primitive and boundless distress. This process is the template for containment, the second theme of the quintessence - and for infants who get a satisfactory experience of it, it forms the basis of a safe world in which experience – a lot of which which feels intolerable - can be survived.

    I look at this as having both maternal and paternal elements, although I know that isn’t very 1politically correct in ‘Modern Families’ terms! But I don’t have any issue with who supplies what – but just that they do actually get supplied.  The first is safety and survival in the face of infantile pain, rage and despair. In a therapeutic community, these primitive feelings are often re-experienced, and survival without hurtful criticism or rejection may in itself be a mutative new experience for members, whose usual expectation will be to face hostility, rejection and isolation. Now they have the novel opportunity to have these powerful primitive feelings accepted and validated. 
    An aspect of safety which comes a little later for children could be called the paternal element: about limits, discipline and rules. This is the safety of knowing what is and is not possible and permitted - done through the task of enforcing boundaries.  This is somewhat at odds with the view of permissiveness as a required quality of therapeutic communities: if the experience of containment is to be achieved through holding the boundaries as well as holding the distress, although the emotions may be boundless, the actions they precipitate are within agreed limits. It is therefore more fundamental for a place to feel safe than for anything to be allowed. And emotional safety is exactly what is experienced in the culture of a community when it is well-contained: it needs to tolerate severe disturbance so it can witness and then digest violent emotions, and still feel safe.  However, the size of the stage on which the dramas are played is not limitless - and members need to know where its edges are so that they can feel that safety.

    The holding process also depends on the sensuous and satisfying qualities of the environment. These qualities will bridge the gap between the reality of holding and the experience of being held.  It is the difference between "containing" and "holding" - one is mostly inside, and one is mostly outside.  Each is weaker without the other: sympathetic and compassionate holding is unlikely to be usefully internalised without a deep and significant internal experience of containment of powerful emotion, and that containment at this Áintensity would be difficult and somewhat sterile without some grounding in the qualities of real relationships - which people experience within a community, and within a therapeutic community.

    One of the odd things I’m involved with at the moment is a campaign to recognise that staff do not feel ‘contained’ or safe in their working life in the National Health Service at the moment. The working environment, if you like, is toxic – and fails to recognise the emotional needs of staff. One of the people who has written most lucidly about this – and what may lie behind it – is Penny Campling, who tomorrow is going to talk to us about how institutions contain – or fail to contain – the anxiety and emotional distress that they need to. Penny, together with John Barratt, have recently written what musty be the most psychologically sophisticated management book for a long time: called ‘Intelligent Kindness’. I know it’s important, because my wife – who is a senior nurse in the operating theatres in Oxford – was recently told to read it by her own managers, and she went out and bought a copy before she even knew that I already had one on my bookshelf! So we are a two-Penny household. If anybody wants to borrow a copy, we have two! Penny and I have been TC colleagues for many years – and I have always enjoyed her talks at Windsor – and am certainly looking forward to tomorrow’s.

    Now, once the primitive and turbulent preverbal work is in hand, a major developmental task is to make language-based contact with others, enjoy mutual understanding of common problems and find meaning through this connection. This is what I chose as the third of the five – communication. For children, this of course starts in earnest once they begin to talk - although there is very deep and rich communication in the primary intersubjectivity which starts growing in the primary bond immediately after birth – which Colwyn Trevarthen told us about so clearly here, a couple of years ago. However, it is by striving to put it into words that symmetrical contact is made through symbolic representation, that existence and identity is confirmed through mirroring - and that despair and distress can be articulated and made bearable in a more symbolic and less primitive way than through the largely unconscious processes of attachment and containment that I have been talking about so far.

    This openness is unremarkable for ‘ordinary psychotherapy’, where the therapist is protected by the ground rules of whatever therapy they are using (like being an opaque analyst, or a problem-solving CBT therapist, or a circular questioning systemic therapist) -  but working in a therapeutic community does not give that protection. For a therapist, it is reasonable and relatively easy to have a "therapeutic demeanour" in a group, but much harder to know just "how to be" when sitting together at lunch, or playing a game together. When this rough and tumble of this everyday milieu is avoided by staff, the openness gets undermined by "us and them" feelings, which can be very unhelpful in a therapeutic community.

    A whole approach to therapy that I have come across in the past year is based on this sort of utterly transparent communication – where no conversations about service users even take place in their absence. It is called Open Dialogue Approach, and it has been developed in Southern Lapland, in Finland, over the past thirty years. It has the benefit – which we in the world of TCs lack – of having collected, analysed and published enough outcome research to be taken seriously. Several NHS mental health trusts are starting to train staff in it, and I think it is really helpful for our conference here – and perhaps helping us to think ‘out of the box’ as they say – that Val Jackson is coming to talk about it to us tomorrow afternoon. Val is in the vanguard of pioneers in the approach in the UK, having done quite a lot of her own training in Finland. The approach comes from the same roots in 1960s and 70s critical psychiatry as TCs do – so I hope it will help us to think about, its similarities and differences to us, and what it has done to get itself recognised. SO I’m looking forward to hearing about that tomorrow afternoon.

    The three principles described so far - attachment, containment and communication - could apply to different forms of psychotherapy, in different measure. But the next two are more specific to therapeutic communities: perhaps they take the developmental sequence through adolescence into adulthood - and real life - in a way that other therapies do not. They also provide a radical challenge to the nature of managerial authority, which I fear is currently being squashed by ever less democratic management practice.

    The term living-learning experience was Maxwell Jones’s early description of therapeutic communities, and that is part of what this principle represents. Everything that happens in the community - from who makes the coffee, to the board games, to the requests for holiday - can be used to therapeutic effect. A disagreement in the kitchen can be more important than a therapeutic exchange in a group; it is as much part of the work of a junior doctor to play rounders or go swimming with the community as it is for him to formally assess patients' mental states.
    This goes beyond openness, in that it requires the sum of the experience of all the members all the time to come to bear in understanding ourselves in relation to the human environment. So the meaning of an individual's existence is as much in the minds of others as in the physiological or biochemical reality of an isolated person: we are mindful of others and they are mindful of us. One member of a community is held in mind by all the others, and they are all held in his mind. In a community where people are together for considerable time at considerable depth, and often uncertain definition of where their edges are, this is an almost tangible realisation of how we are only meaningfully defined through these social processes.

    In the old residential therapeutic communities, this holding in mind was made utterly tangible: no longer a fantasy, but reality. For 24 hours a day, all interaction and interpersonal business conducted by members of the community belonged to everybody. In day TC units, other ways are used to bridge the gaps and ensure that ‘out of sight’ does not mean ‘out of mind’. The expectation will be to use all aspects of interaction and understand it as part of the material of therapy. Not in isolation, but in the real and "live" context of interpersonal relationships all around.

    This discourse leads to a position where any separation of an individual from society or constitution from environment leaves the definitions empty and meaningless: the very opposite of an individualistic world-view. Social cohesion becomes the dominant aim; interdependence emerges through intersubjectivity and its perceived responsibilities - more than by demanding rights; fragmentation and alienation are reduced through finding meaning in relationship to others.
    In some ways, we take this interdependence to the limit in therapeutic communities. Each has a different but vital contribution to make to the health of the whole.

    I think we are moving into a world where we can’t do these things in a way we want to and maybe we always have - a point I will be returning to in the last section of this talk – and any communities that rely on whole time programmes with their own buildings and rooms will find it much harder to survive than those which exist in a much more open and flexible way. That probably isn’t true for ones where people are necessarily resident anyway – such as prisons and children’s homes and housing organisations, but others that only come together to be a TC, I think, will need to find different ways to do it. The importance of the TC is IN THE HEAD - of which, more later.
    And to give us an insight into the world of ‘real world adaptation of TCs’ we have Clare Richie to come and talk to us on Wednesday morning. Clare is a commissioner for services for homeless people in London – and she is one of the people who has been promoting ‘PIEs’ – or psychologically informed environments. These are units which deliberately use that difficult-to-put-into-words attribute – which I call the ‘quality of relationships’ in a context where it would be impossible and unrealsistic to try running a ‘proper TC’. If I were to put it a little more provocatively, I could say that this is about making TCs fit for the real world out there - that we now live in, whether we like it or not.

    So, onto the final quin of the quintessence – agency and empowerment.
    In 1941 at Mill Hill Hospital, Maxwell Jones was running a unit for soldiers suffering from "effort syndrome" (probably called PTSD nowadays) and he soon noticed that fellow-patients were more helpful than the staff at helping each other. At Northfield, Wilfred Bion was taken off his therapeutic rehabilitation wing after six weeks, probably because his experiment was unacceptable to the military hierarchy. These two locations were the start of therapeutic communities as we know them in mental health, and they both made fundamental challenges to the nature of authority. At that time, they probably seemed countercultural and somewhat subversive, but in many ways they were ahead of their time - and many subsequent social changes since have undermined our notion of traditional authority, and made us re-evaluate how it is now carried and administered. Although most psychiatric providers have moved from a traditional authoritarian model to a modernist managerial one, to provide an environment for the development of authentic personal agency demands a further move – to a world where a dazzling array of relationships and networks makes any sense of ‘firm ground’ open to challenge. Perhaps it could be called a ‘postmodern perplexity’.

    But for therapeutic communities, this challenge to authority, and the primacy of the ‘network of relationships’ over any social hierarchy, was there at the beginning. It’s also close to Jung’s idea that the unconscious (of patient and analyst) know better where to guide the therapy than does the analyst's expertise -  and the general belief that most therapeutic impact comes from work the service user does, rather than the therapist.  In group therapy terms, it is at odds with the models where therapists do individual work in the group (where group therapy started from), or only offer group-level interpretations (the Tavistock model). In both of these there is an underlying assumption that the therapist "knows best" or at least knows what is going on: information which the group members 1cannot know, or which is delivered to them under close control of the therapist. 

    In communities where members are afforded this sense of personal agency, things are different. An asymmetry and difference between therapist and patient is accepted, but an automatic assumption of authority is rejected: members acknowledge that anybody in the group might have something valuable to contribute to any other member. This is the essence of therapy by the group, and it deconstructs the powerful ‘us and them’ dynamic. Authority is fluid and questionable - not fixed, but negotiated. The culture is one in which responsibility for all that happens within specified limits is shared: members are empowered to take whatever action is decided. However, a major part of the non-clinical work is to specify those limits and ensure that the space within them is kept free from authoritarian or managerial contamination.

    Extrinsic authority and rank will come to mean much less than intrinsic authenticity and demeanour – back to those non-verbal hard-to-define qualities. Only through this process of experiencing parts of real relationships, beyond the transference, can a true sense of personal agency develop. Then action and feeling will have a clear connection to a true core self, and they are not held by a role or prescribed behaviour.

    When members of a community take responsibility for each other as part of a live and intense process or relationship that really makes a difference, it is worth infinitely more than a risk assessment, or a procedure, policy or protocol.  It demands that authority must always remain negotiable - authority is something that exists between people rather than in individuals or policies.  Of course this is not anarchy or wholesale delegation of responsibility - or an unreal world with no outside references.  In reality, we all work within a framework in which we are accountable for what we do. But what we are currently up against (at least in a lot of the public service) is a sort of tyranny of American management techniques – driven only by data and economics, where things only matter if they can be measured, predicted and controlled. Uncertainty is not tolerated and human factors – like the quality of relationships – are not relevant. But we are replacing a linear form of authority with an open, continuously negotiated – and dare I say more democratic – form of getting things done. Not all organised in advance by a strict project management process – but allowed to happen in an organic and emergent way.

    But I had better stop my rant there, as I am going off track for our final speaker’s contribution to the conference. Hanna Pickard is an Oxford philosophy don from All Soul’s college – and she has been working for several years with Steve Pearce and the team at the Oxford TC, which is one of a small handful of surviving non-residential TCs in the British National Health Service. She has used her philosophical expertise, together with experience of the TC therapy, to analyse what happens in TCs and construct some rigorous philosophical theories about why TCs are different, and what is special about them. She and Steve have published papers and articles about it in, for example, the British Journal of Psychiatry and other influential places. It should round our conference off, on Wednesday afternoon, with a very clear and erudite message that we in the world of TCs have got something important and unique to offer.

    So that is a quick rundown of the main talks that are happening here over the next three days – but before I finish I want to think a little about where it is all going. What seems to be in keeping with the times (so likely to flourish and grow)? and what seems likely to be lost in the Darwinian struggle to survival that we all face?

    There is one more part of the quintessence paper that we’re not particularly talking about here at the conference – but I think runs through the whole theme. It is that this isn’t just a description of theory for some rare and specialised treatment units – which we call therapeutic communities – but it is about the experiences every one if needs to thrive, and grow, and survive the vicissitudes of life. This is quite like the difference between what David Clarke once called ‘TC proper’ and ‘TC approach’ – and what is now at the heart of the ‘Community of Communities’ (which brings ‘TCs proper’ together with a common understanding of what they’re doing) and ‘Enabling Environments’ (which is a process to recognise a ‘TC approach’, wherever it might be happening).

    And moving into that area has opened up some exciting possibilities, and set some impressive initiatives going. First, just to recap on the process that led from therapeutic communities to enabling environments. In the early years of Community of Communities – and even before it – we regularly received comments like ‘this is all very well, but we’d never be able to be a real TC and meet these standards’ or ‘why can’t you change it to include our sort of place, and units that aren’t just TCs’ or more dismissively ‘you’re doing this community of communities things for such a small speciality that it is irrelevant’ or – perhaps most famously - ‘TCs are an evidence free zone’.
    At this time, about six or seven years ago, we were evolving a set of what we still call the ‘core standards’ for TCs – the things that other places didn’t generally do, and TCs nearly always do. There are ten of them, including things like:
    ·       ‘Community members work together to review, set and maintain the rules' and
    ·       ‘Community members share responsibility for the emotional and physical safety of each other’.#

    So we then decided to hold a series of workshops – wherever we could really – with TC members to find out what the values were behind these ten statements. The question we started with was without thinking about the particular techniques or structures, what are the values behind what we do in TCs?’  I remember doing it in some completely different settings – like the TC we know in Bangalore and at the TC conference in Melbourne I was invited to go to tell them all about Community of Communities. For me the most interesting thing was how the same words and ideas kept coming up, wherever we did it – so it was not a difficult task to derive the value base for TCs, which was again a list of ten statements. So these are about what we in TCs believe in, but think could be applied much more generally. Again, I’ll give a couple of examples:

    ·       A safe and supportive environment is required for an individual to develop, to grow, or to change.
    ·       Each individual has responsibility to the group, and the group has collective responsibility for everybody in it.

    From these values, the team at CCQI wrote standards so that it was possible to work out whether they were happening or not in a place. And now remember that this is ANY PLACE AT ALL where people work, or hang out, or play, or even pray, together. And if they can show us that they do so – in a way that is rigorous for the Royal College of Psychiatrists to recognise that it’s true – they are what we now call an ENABLING ENVIRONMENT. The process of showing it is actually through putting together a portfolio and having it reviewed by the team – and people often find that the process itself, of thinking about how they do what they do, for example about how they support each other, is a very positive thing itself. As if teams come together to recognise why they are good at being a team, and get even better at it.

    Okay – so back to the Darwinian struggle to survive. One of the facts of it all, in this country at least, is that a lot of TCs have not survived the last ten years or so – and most of the rest have had a real tough struggle to survive and not be shut down. I’m not going to go into all the possible reasons for that, and I’m sure there are very many and it would make a fascinating research study, but just make the general point that they have not been able to fit well enough into their own environment. External changes – in funding, or regulation, or accepted practice, or whatever else, have meant that many TCs have not been able to change enough to fit with the changes around them. Others I know have changed too much, and wouldn’t be recognisable to us as TCs any more – like the Norwegian network of TCs that went along with the research evidence to reduce their programme where it was’t essential – so stopped all the social activities and eating together - and completely lost that intangible quality that makes a TC, and left them as group therapy clinics almost without a soul – and, from what I hear informally, became much less appealing to work in - and not able to hold onto some of the more troubled group members who they had previously helped.

    But if this is true of how ‘therapeutic Communities PROPER’ are struggling to survive, I don’t think it’s so true of the ‘therapeutic community approach’. There are two projects which have really taken off – and I expect there are many more we don’t know about. These are the PIPEs and PIEs. PIPEs are ‘Psychologically Informed Planned Environments’, which is the phrase used for a specific programme being used in the British Criminal Justice Sector for prison and probation facilities that have particular training for the staff, and are working towards becoming (or already are) Enabling Environments with the process which Sarah and Susan and the team have set up at CCQI. And very successful they are too.

    PIEs are ‘Psychologically Informed Environments’ – which are catching a lot of interest in the housing and homelessness sector. However, they have been promoted by a different Government department – the Department for Communities and Local Government – in a much looser and more flexible way than the prison programme. They don’t necessarily join the Enabling Environments process, and Clare Richie – who is talking to us on Wednesday morning – is the commissioner in Lambeth who feels very passionate about their value. So they have different ways to be part of the ‘extended family’ of what we’re calling ‘Positive Environments’. That’s a phrase I’m going to be pushing hard over the next year or so – because it covers all these things that have the sort of value base that means they have a ‘therapeutic community approach’. So I’m going to finish off with three thoughts about where we need to go next, to thrive as a movement - as well as a modality of treatment.

    Firstly, we need to think therapeutic environments – or positive environments – or PIPEs, or PIEs, or EEs, or whatever they get called – and not just ‘pure TCs’. As a field, we need to start working on how top apply TC principles more widely.  TCs are a tiny thing in this country at the moment, and after about 25 years of being involved with them and hoping for it, I’ve finally given up the idea that they will ever be as influential again as they were in the heyday of social psychiatry. But, as the world and all the systems around us get more industrialised and mechanical in the way they treat humans, people are crying out for positive or therapeutic environments. So TC expertise is just what’s needed to make ghastly wards and ghastly prisons and many other ghastly places a bit more humane and user-friendly. So my message for this one is – think positive environments, and make them happen.

    Secondly, we need to think about the ideas behind what we do as a way of containing and sustaining us, as a movement, rather than the specific structures and exact procedures which have evolved over the years.  Containment is only ever an illusion.  Once we’re out of that old womb, it’s based on an act of faith. Of course it is much more secure for us to have bricks and mortar and a written programme, and a manual, so you know what you are actually doing: but we must be wary of using these things to build a bunker and hide from the real globalised world that we all now live in.  The therapeutic community – or positive environment - is going to be safest and most effective of all if it is in our heads and our hearts, not in buildings or policies or particular structures. Which means my phrase for this one is the TC in the head, because that’s where it matters. That might mean all sorts of new structures and forms – but with these experiences we’re talking about at the conference as the core.

    Thirdly and finally, we need to think of all the other people and things and movements and organisations that are growing up with similar ideas. Whether it’s use of social therapy, or alternatives to medication, or service user involvement, or new types of group homes, or the ‘recovery approach’ – there are many people sharing and using the same sort of ideas that were once TC ideas. I don’t think it’s any good for us trying to claim them back – as if they were our intellectual property. We need to share them out and invent new things in collaboration with non-TC people. If we take a line like ‘this is the way we’ve always done it, and we know it works best’, we will become increasingly isolated and irrelevant. As I have already said, I think the answer is going to be through using the TC in the head wherever and however we can - to make positive environments in what is currently a pretty negative world…