Wednesday, 2 April 2014

The end of the road for radical approaches to PD

Two wasted decades?

With Ioannis Tsegos in Athens
I should have believed Ioannis Tsegos in 1995 when he said that it just wasn't possible to run a TC in a state service. As a new consultant and president-elect of the Association of Therapeutic Communities, I was invited to give a my first ever keynote talk at an international congress, in Athens. With far too much to say, and being as nervous as hell, I did the talk - and was then taken out to dinner by Ioannis and his wife.
Stained glass windows at Athens OPC

I had already heard about the 'Open Psychotherapy Centre' in Athens, as they had often presented startlingly radical papers at ATC's annual Windsor Conference, but after a visit to it the following day, I was utterly in love with their model. Group Analytic, democratic, integrated with training, economically progressive, open to all, playful yet very serious, profoundly radical, finely balanced between anarchy and control - it had everything I reckoned a TC should have.

As I left the building (an elegant three-floor block on a city-centre street corner) there was somebody storming out of one of the groups and wielding a razor blade with which she was threatening to cut herself - just like home! (Except that she was being treated with proper therapy rather than by by paperwork and risk management!).

But after twenty years of trying, as a consultant in the NHS, I have finally given up trying.This story has three layers, and I'll start with the simplest one - local. Then I'll see how it makes sense regionally, and then nationally. As I recently emailed to a longstanding colleague, I smell a rat - though I'm not yet sure whose rat it is. B F Skinner may yet be implicated, I expect!

Slumping in Slough

The local project that looks like it has bitten the dust is the 3 year long attempt to bring serious greencare to a rigorous NHS treatment programme for PD. Because the development of the intensive programme (in Slough) had hit the NHS times of austerity - it was started in 2010 - it had to be run with much less staff and other resources than would be ideal. So we tried to do it on an absolute shoestring - with volunteer staff (assistant psychologists looking for good clinical experience, or nearly - qualified psychotherapists doing clinical placements) and a hard-won lottery grant to provide afternoon greencare groups. But clinically, despite all the usual turbulence of a new TC, it was a joy to work in - and many people did fabulously well because of it.
Our therapy room - under construction

We tried our best to get the voluntary sector part of the programme (the greencare) integrated with the NHS part in several ways:

  • inviting local and senior NHS managers and commissioners to see the project and explain the project (they seemed to love it, but...).
  • building it into an 'alternatives to admission' programme for PD in East Berkshire (which is going very well - but would be even better if it took greencare seriously!).
  • applying for NHS charitable funding (still waiting, advised that it is unlikely to bear fruit...).
  • writing outlines of potential business plans, including applications for innovation monies (emails to relevant NHS officials never responded to)
  • incorporating it into junior doctors' training placements (much appreciated, but never recognised as a relevant element of training)
  • being a partner in a submitted application for National Institute of Health Research funding for a randomised controlled trial (decision awaited)

...But ultimately to no avail. Because of this, and other insoluble structural problems about the ways in which risk has to be over-managed in all statutory services, it has led to my retirement from full-time NHS work. I now consider it impossible to run authentic therapeutic community programmes within the health service - and will be using some of my time to develop them elsewhere. Without my role in the NHS side of the  programme, the two parts have little hope of remaining coordinated or being seen by service users as part of a coherent and emotionally containing pathway.

Thames Valley Trouble

The original patch
The 'Thames Valley Initiative' was funded by the Department of Health in 2003, as the largest of eleven pilot projects to explore and evaluate innovative ways of treating personality disorder in community mental health settings (of which, more later - see next section, below). Based on the longstanding model developed and refined over more than three decades at the non-residential Winterbourne Therapeutic Community, it modernised and adapted to model in line with contemporary requirements for equity, access and transparency.

"We had a dream" ...of services integrated across sectors, collaboration across the three counties, self-referral and no postcode exclusions to anybody, multi-centre research, integrated training programmes for all relevant agencies, free movement of staff and 'job-sharing' across the patch for personal, professional and service development, excellent service user and carer involvement with graduates of programmes having pathways into careers employed by the services, and flexibility to adapt to changing needs of service users and of the policy environment.

But what we got is:

  • Separate NHS foundation trusts fiefdoms, with very little managerial collaboration possible between trusts. 
  • Little appreciation of the particular needs of PD.
  • Very limited genuine service user partnership.
  • Commissioning with no understanding of the social and economic/political context of PD.
  • Managerialism and governance writ large.
  • Severe risk-aversion with a joyless culture of authoritarianism, hierarchy and compliance control.
  • Remoteness from senior management and strategy decisions. 
  • An increasingly biomedical framework for psychiatry.
But, to give due credit, we also got extraordinarily effective and innovative programmes from which many many people have been able to experience transformative therapeutic progress. With extraordinarily committed staff who have all been prepared to 'go against the tide' and suffer he parallel process of alienation from the mainstream.

National Personality Disorder Development Programme Dissolution

No longer a diagnosis of exclusion?
The National PD Development Programme was formally launched in 2003 at the Department with speeches by Jacquie Smith (a government minister at the time), Dale Ashman (the service user founder of 'Borderline UK') and others. Its guiding policy document was 'No Longer a Diagnosis of Exclusion' - and its key principles were (1) including the previously excluded, (2) service user involvement, and (3) working across sectors and agencies. It recognised complexity of human development - and how its disruption led to the emergent 'diagnostic entity' of PD. Its sister document 'Breaking the Cycle of Rejection: A Capabilities Framework for working with Personality Disorder', indicated how workforce development needed to include access to an escalator for all with suitable aptitude, and not just those with the correct documented experience and registered qualifications.

Its three activities were service development (the eleven pilot projects), evaluation (formally by Imperial College, and a later clinical review which was never published by DH) and training (which emerged as the Knowledge and Understanding Framework, KUF).

The training is still going strong, but seems to be increasingly disconnected from, and different to, the sort of instrumental, procedural and transactional 'training' expected in mainstream public service provision. It is delivered by service users in partnership with clinical staff, it is largely experiential rather than didactic, and it covers nebulous subjects such as the nature of relationship... This if course is exactly what makes it suitable for a radical approach to PD - but it is also what makes it like a round peg for the standard square holes of managed professional development.

The formal evaluation was undertaken early in the programme (published 2008), and provided useful information for those in the field, but the clinical outcome part of it was not a trial, and had no long-term follow-up, so it had little impact more widely. The less formal clinical review of the services (2011) gathered a great deal of very positive qualitiative data from each of the eleven pilot projects - including subtle variables such as the 'culture of a unit' and 'the quality of relationships' - and quantitative measurements that demonstrated economic and social return. However, it could not be processed and published by the Department of Health before the non-forensic part of the National PD Development Programme closed, in March 2011. All this data, and any more that has been analysed and published by the pilot projects themselves, is therefore unlikely to have any impact on the wider commissioning for local specialist ('tier 3') PD services.

Unfortunately, the large scale trials of 'alphabetti spaghetti' therapies are more likely to influence that, and lead to brand competition between therapies - inappropriately using a determinstic and commercial framework that denies human agency, the complexity of social context, and the importance of relationship.

The saddest part of this story is the pilot projects. Our own 'Thames Valley Initiative', originally covering Berkshire, Oxfordshire, Buckinghamshire and Milton Keynes,  is described above. We are fortunate in that it is likely to survive in some form, although that is likely to be different across the various areas for which it was set up. Other projects are less fortunate, and have either been closed or directly threatened with imminent closure.

More important than clinical coherence, service user views or theoretical integrity is now 'compliance' with regulatory frameworks - imposed through the Care Quality Commission (CQC) and Monitor (concerned with risk, liability, etc). This will be interpreted differently by each provider trust. This is likely to lead to 'lowest common denominator' commissioning: with the 'successful' programmes being those with lowest risk, highest replicability, easiest benchmarking and little chance of innovation through positive risk-taking.

By my reckoning, that means that 'messy' and 'complex' treatment programmes like therapeutic communities (that particularly require high tolerance of uncertainty) are going to be dead in the water. The neatly processed and packaged alphabetti spaghetti therapies (like DBT, MBT, STEPPS and numerous others) will get the contracts every time.

What has been learned from twelve years of tier 3 programmes is also unlikely to have any impact on the development of tier 4 services (commissioned as specialist services by NHS England) - as service specifications are explicitly not asked to include working across the tier 3/ tier 4 boundary (as they have different commissioning structures, and must meet Any Qualified Provider requirements).

SO... where's the rat?
I blame... the service managers for being frightened; the middle managers for being craven; the corporate risk-minded senior managers who have had all imagination and creativity squeezed out of them; the ignorance of commissioners about the unconscious; the authoritarian culture of the NHS (you-know-who that means, and I only hope his successor is better); the bankers for crashing the economy and putting intolerable screws on the public purse; the leaders of IAPT for making therapy look so measurable, predictable and controllable (back to BF Skinner); American business schools for modern managerialism and all its horrible trappings; psychiatric colleagues for losing most of their psychosocial roots and yearnings (and their will to make a fuss about what really matters - which is patient experience); politicians for failing to connect the idea of 'broken Britain' with broken people and broken services; Regan and Thatcher for rampant individualism; the Enlightenment - for letting us think that we could ever understand it all; and I suppose that man eating that apple a long long time ago.