|The BIGSPD 2014 Senior Practitioner Award, the glass dagger, presented at Lincoln|
So I’ll start with a quick bit of biography, which takes me back to my first ever encounters with psychiatry. The first things I learned about psychiatry were from elective social science modules I did in my final undergraduate year at Cambridge – where the Social and Political Sciences Faculty was a hotbed of radical and critical thinking – and I was particularly taken with the modules on child development, on psychoanalysis and – surprise, surprise! - on antipsychiatry.
Of course Ronnie Laing was still alive then, and he was guest of honour at the annual Cambridge 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 start as a clinical student at Littlemore Hospital in Oxford, on Bertie Mandelbrote’s firm, the Phoenix Unit. I had been warned by previous students that this was not somewhere to wear the normal tweed jacket and sober tie (which the standard medical students uniform for psychiatry at the time).
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 met a bloke wearing hardly any clothes sitting on the doorstep smoking a roll-up. Without any words, he 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 promotion 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. There was an excruciating silence (probably all of twenty seconds) before everybody introduced themselves.
After my initial culture shock of joining a therapeutic community, for that’s what I had landed in, 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 ever since – and (in most settings) been rather disappointed – hence moving from general practice to psychiatry to psychotherapy to group analysis to therapeutic communities to personality disorder. And I’m even disillusioned with them now! My own answer – which I hope will make sense in the next ten minutes – is currently greencare, and maybe even something about nidotherapy.
So – first – why am I disillusioned with therapeutic communities - when they have been my life’s work, and are the places where I’ve come closest to finding this ethical, authentic way of working that first struck me, back in 1980? Maybe the best word for it is that they have become institutionalised – and are losing the power and freedom to be open, to enquire, to question and challenge. The trouble is that this process of institutionalisation is about as inevitable as gravity, when they have to exist in a larger setting and system, especially one that is as authoritarian and rigid as the NHS. We tried to do something to ameliorate it with the ‘Community of Communities’ quality network at the Royal College of Psychiatrists – which I presented here at BIGSPD’s 2nd ever conference in Jersey – as ‘democratically derived standards - an alternative to manualisation’. And although that project is still going strong, but it is becoming increasingly apparent that it is not enough by itself, and it is also becoming somewhat regulation-bound.
Institutionalisation I think has a sibling - which we’ve already heard about from Glenys at the opening of this conference: industrialisation. I think it’s the same as what entrepreneurs call ‘scaling-up’. And the thing that inevitably goes with it is disempowerment, and maybe this arises because of the removal from the workers of the means of production, in managed health care, we clinicians have less and less say in who we see and what we do. So we suffer disempowerment – which is of course the opposite of what we try to do for our service users, who we hopefully try to empower. And, as individual clinical professionals, we have very clearly lost the battle against regulation, manualisation, and maybe industrialisation that will follow it: we are not to be trusted unless we follow explicit protocols, even about how to wash our hands and answer the phone. Even George Orwell couldn’t have made it up! I am now in a state of learned helplessness about it all - to the extent that Steve has twisted my arm in to writing a manual with him to describe how we do non-residential TCs in our Thames Valley services.
Which leads to my other disillusionment with TCs – that they have been misunderstood by people in the research world – when they are thought of as a specific treatment. I believe – and Steve and I differ on this to some extent – that the TC is actually a container for treatment, rather than a treatment in its own right. But the container has a considerable, and I expect measurable, impact on many other things about the treatment – such as engagement, attendance and attrition rates, user-satisfaction, staff-satisfaction and ‘culture’ (of which, more later).
The container also allows people to feel safe - emotionally safe – and this is something that they might not experience if they were just in ‘bare therapy’. It also gives them support from each other in the gaps between groups, and can really provide a deep sense of meaning to hold their different therapeutic experiences together - and this is helpfully from a reflective place that is slightly apart from the therapy itself.
However, ‘making a good culture’ is not as easy as sending people on customer relationship courses, or communication skills training – as it goes a lot deeper, and demands a level of commitment, openness to scrutiny, and personal insight that not everybody is able or willing to give.
And unfortunately, I am a bit of an extremist about these things and I happen to believe that every service or working culture should be an ‘enabling environment’, and that people who don’t want to work in an open and authentic way should go somewhere else. We’re working on this in the more recent project we have set up at RCPsych, with the ‘enabling environments’ quality mark to show that a particular environment meets ten basic relational standards – for how people relate to each other.
Delegates here from the criminal justice sector are likely to know much more about it than those in mental health – as the new programmes to develop ‘relational security’ in prisons and approved premises are going from strength to strength, with the development of PIPES (psychologically informed planned environments). The development of similar facilities called PIES (psychologically informed environments – but not planned in the same way they are in prisons) is also going well for the homelessness and housing sectors. But no such luck or government commitment in the health sector. They seem to be blind to the power of groups and therapeutic organisational cultures.
So back to TCs, where this culture is the most important factor in: within it, all sorts of therapies can be and usually are incorporated – and more distress and disturbance can be managed, with people being better held in a user-friendly way, than they would be with the bare therapy by itself. But I DO also believe that TCs are effective treatments in their own right – in other words ‘the whole package’ of container plus specific therapy - with the therapeutic meat in the sandwich, as well as with the bread which is the therapeutic environment. That’s what Steve and I are writing up as a manual of the method, as well as the complex treatment that Steve and Mike Crawford are researching in their RCT. First results expected soon, we hear!
But even if that trial is successful in showing effectiveness, I have worries about the consequences of ‘scaling up’ – and how it might well get industrialised and institutionalised into something that is not recognisable as a human-scale and personal treatment, by losing its autonomy and ability to reflect upon, and change, its own processes. I just fear the ‘ooh we can’t do that here, it’s not in the manual’ tendency taking over; in other words the staff and service users’ empowerment to reflect and think about what’s going on, and how it might be done differently, is fundamentally undermined by an authoritarian and non-democratic process of ‘compliance’, or similar. This is what has happened to most of the TCs that were around when I qualified – they became too rigid, or precious, or sanitised, or interfered with – and died. But maybe they needed to.
Well, first, it seems to reduce the whole serious business of improving therapeutic provision to a horse race, or beauty contest, of who can best market their wares; it does not encourage joining-up and cooperation – but fragmentation and competition, between people who should be working together in fighting bigger threats (like big Pharma and DSM 5! – oops, sorry, I’d better not get onto drugs or diagnosis or nobody will get lunch, or be home in time for tea!).
Secondly, it plays into the hands of commissioners who want everything very simple so they can buy one bundle of xyz therapy at such a price for 500 people a year and one package of abc therapy on special offer, for a thousand people a year. Market forces, managers with MBAs, a bit of sharp project management, and problem solved. But no - we should be telling commissioners, and policy makers, that PD is more complicated and complex than that, and that we (as therapists and clinicians) could come up with all sorts of transformational ways we can make mental health services better – but they can’t do so without thinking about it much more, and getting us involved in that process of thinking about it. But it’s not happening much, as far as I can see.
Thirdly, what I was saying about TCs just now – what happens in therapy is about the quality of relationship than about the specific technique. The Dodo bird verdict, as I remember Glenys talking about it, at Ravenscar, many years ago – “all the therapies have won, and all shall have prizes”. In the PD world, I always think it is something about trust and hope – as opposed to the usual risk and recovery agenda that is so predominant at the moment. But rather than just accepting the Dodo Bird Verdict and continuing with the inter-therapy horse races and beauty contests, shouldn’t we be trying to distil and better understand just what that ‘quality of relationship’ is all about? To be fair, maybe that’s what work like the competencies framework, and Glenys’s rat sandwich, are about.
Next, where is the voice of service users and carers in all this? I don’t mean as token members of various committees, but as equal partners in all stages of development of the field. We have a great opportunity here – there are very many keen and articulate service users who have a much better idea of it feels like to be in a lousy service and a good service than any of us professionals here do - and unless we really take that into account, I believe we will end up with ‘doctors-know-best’ type services that are more likely to annoy the hell out of service users, than do much good. Again, it’s about quality of relationship – something I think we did quite well in the late lamented national PD programme. But thankfully, we still have good representation here at BIGSPD – but I hope the impetus to sustain that last through times of severe NHS austerity. Service users are so much part of the solution rather than the problem.
Finally (you’ll be glad to know), the big one – whose game are we playing?
I would contend that this is the management philosophy of the American insurance industry, and although we are much less influenced by their partners-in-crime the pharmaceutical industry, the neo-liberal economics and its need for growth by the consumerisation-of-everything times we live in. The only way to commercialise relationships is called prostitution – and I don’t think we want to get into that. But because of this inexorable and global process, which I dearly hope is ultimately unsustainable itself, we are at risk of losing the human touch, being micromanaged into impotence, being persecuted by the compliance police - and all going to hell in a handcart. Thanks goodness for our service users – who I think are our only good defence against the tide!
All a bit depressing, really.
But I’ll finish off with my own solution – which is greencare. Vanessa and San did a lovely poster of some qualitative work on our own greencare project, in dear old Slough, it that was up yesterday. Greencare is usually defined as therapy including contact with nature, and it has been described as ‘the antidote to institutionalisation’ and as ‘mindfulness in action’, as well as the themes on the poster. But to me, by working with nature in a very explicitly psychotherapeutic way, we can ensure that we do not fall into the five snags above that I have just feared for PD. It is small, human-scale, not industrialisable, necessarily unpredictable (like the recent weather), and usually spontaneous and creative. But unfortunately, it does also mean that we don’t get any sustainable funding. But we’re working on that.
It almost brings me full circle back to Peter and his Nidotherapy. One reason Nidotherapy appeals to me is that it doesn’t have an acronym – but also that it is a concept rather than a method. I remember saying to Peter at a BIGSPD conference many years ago that I reckoned it was based on group analytic theory – because it didn’t look at the patient in isolation, but was equally interested in the environment around the patient (and that’s also like the figure and ground picture of the Gestalt). He didn’t particularly like that – but now I’m coming back to it. It’s not a commercialisable new brand of therapy – but a change of frame of thinking: from individual to context. That change of frame is what I think greencare is too – not worrying so much about the exact blow-by-blow ‘who did what’ and ‘who said what’ of therapy, but by attending to something that is more about relationships. Relationship between people, and relationship between people and their environment – what goes wrong in those relationships and what things might make them better, or at least a bit better.
Which, sort of, brings me back to where I started – in that crazy circle at Littlemore Hospital in 1980, like something straight out of Cuckoo’s Nest. But I think that set me off on a track that eventually led here – and who knows where next. But thank you very much, BIGSPD, for giving me the Senior Practitioner Award – it has been an honour to be able to rant at you for twenty minutes. And sorry to keep you from your lunch! But thank you again.