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…

Friday, 17 October 2014

The Bipolar Crowd

A depressingly corporate venue facing the manic sea... the Royal College of Psychiatrists 2014 Annual Conference of the Faculty of General Adult Psychiatry: ‘Reshaping Medicine’, 16 - 17 October 2014 Hilton Brighton Metropole.

Not a happy day - not only did we lose the debate (badly) - but it was even more badly after Peter Tyrer and I gave our talks. Although I think it's fair to say that we were given an almost indefensible position to argue: 'This house believes that the current diagnoses of bipolar II disorder and borderline personality disorder are indistinguishable’.

Click here for the link to the official RCPsych page on the conference. 

But, expecting a bit of rough-and-tumble about different ways of understanding BPD and bipolar, I was ready for anything, or so I thought...

But after meeting this lot, and a discussion that seemed preoccupied with genetics, diagnostic precision and academic jousting as only male white London Maudsley-types can do, I slunk away on the next train to East Croydon (with fond memories of platform 6 waiting for the Tattenham Corner train every day after school...). If this is way they are wanting to 'Reshape Medicine', I'm not sure I want all that much to do with it!

So this is what I said. 
It went down like the proverbial lead balloon. 
Judge for yourself...

Thanks so much for having me along to talk in this debate – I’m rather nervous about being here as I can’t work out whether I’m a fish out of water, or coming into the lion’s den. Maybe I’ll be able to tell you which – or hopefully neither – by lunchtime.

But when Peter asked me to be his second, I jumped at the chance – because I do feel that the world of personality disorders has been unhelpfully isolated from mainstream psychiatry – with most of it happening more in psychotherapy and in psychology – neither of which are sufficient to deal with the complexity, or hold the risks, of the more severe cases. And in many places, suitable services for PD do not exist at all. 

But there are a lot of good and manualised treatment programmes, with the right sort of evidence base to be commissioned, mostly run by psychologists, psychotherapists and nurses – but they are often delivered without medical input. So these will only ever help the less severely disturbed patients – who are ready and willing to accept therapy programmes. The more troubled people – who can cause whole systems and teams high levels of stress and disruption, and can get unhelpfully stuck on psychiatric wards for long or repeated admissions – will be with us psychiatrists forever, not least because they are extremely mentally unwell.

So I think PD needs to be, at the heart of all psychiatric practice. I’m one of that fairly rare breed of medical psychotherapists who specialises in PD – and the only one who does so in Berkshire (population 850,000) - so unless the NHS decides it needs a lot more of us (which doesn’t look at all likely at the moment), it is going to be up to you the general psychiatrists to do something helpful about it, for the vast majority of patients who could be diagnosed with PD.

Roots in Critical Psychiatry

To start with a quick bit of biography, which takes me back to the first things I learned about psychiatry - from elective modules in Social and Political Sciences – where, in what was a hotbed of radical and critical thinking, it’s hardly surprising that we studied Laing and Szasz – alongside things like psychoanalysis and feminist theory in the late 1970s.

Of course Ronnie Laing 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 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 was 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 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, 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’ and thinking about ‘it’ ever since – that quality of relationship - as I have moved from general practice to psychiatry to group analytic psychotherapy to personality disorder. A general term for it is ‘therapeutic environment’, and we have done a lot of work at the College’s CCQI to develop the ‘Enabling Environment’ award – which is a College kitemark to show that a ward or unit ha8s got it.

Personality Disorder needs a different approach

So I have been working in the personality disorder field for twenty years now – in several different places, including nearly nine years as clinical advisor to the national PD programme, which shut in 2011 in the wake of the financial crisis. Its work is now rather hidden away in a small corner of the IAPT programme, where I fear the complexities of PD are lost.

But until I started a new CMHT-based project last year, I hadn’t realised just how different a world it is from ‘mainstream psychiatry’ – how far apart they have grown - and I have been quite shocked at what I have come back into. The project is to get ‘revolving door’ and long-stay patients out of hospital and onto genuinely therapeutic pathways – and hopefully have them never admitted again. So far, with a day a week of me and a team of four – STR worker, social worker and MH nurse led by a counselling psychologist, we’re doing fairly well at that. Many many bed days in the previous year and almost none since. I think the important thing we do is to take a vigorous biopsychosocial approach – and immediately engage people with a detailed assessment and mutually agreed biopsychosocial formulation. Then lots of relationship-building, followed by psycheducational and psychosocial group work - which does lots of peer group relationship building.

The diagnoses of the people referred to us can be anything – although most commonly Borderline and Bipolar. Though I’ve noticed that the local vogue seems to be away from using the ‘borderline’ word, and favouring the crisp sounding four-letter abbreviation ‘EUPD’ (everything has to have an abbreviation or, even better, an acronym nowadays). And bipolar, of course in its big-tent ‘everybody welcome here’, socially acceptable, manifestation - of bipolar 2, 3, 4, 5 , 6 or however many it has got up to nowadays.


I’m going to make two specific arguments for the topic of the debate, and frame them as ‘provocations’ - being provocative to the currently accepted wisdom and practice. They are (1) Diagnosis is only an opinion, and the more exact we get at operationalising it, the more useless and dangerous it becomes. (2) This is becoming a turf war between different psychiatric factions, and is of no benefit to patients themselves.

So, to start with the first of the provocations:
Diagnosis is only an opinion, and the more exact we get at operationalising it, the more useless and dangerous it becomes.

I remember doing my mock clinical MRCPSych part ii exam, as it was then, in about 1990 – it was a long case followed by a long grilling by some severe and sadistic senior registrar. Very good for us. My patient was what I would nowadays spot in two minutes as severe borderline – and I presented all the history and the mental state examination in the very structured way we were expected to do it, followed by differential diagnosis. I made the mistake of putting BPD at the top of my list, with schizoaffective, agitated depression, dissociative disorder – and I expect a few others – underneath. Big mistake! I was roundly chastised for daring to suggest PD was the main proposed diagnosis – and strictly told that we do not make a PD diagnosis if there are other possibilities, and it must be at the very bottom of our least – because it is an unhelpful diagnosis for patients, it is not scientific and – anyway- it is untreatable. 

Nowadays, I encourage trainees to always think of PD – after all, we all have personalities, and nobody’s is perfect – and to do so as the underlying structure on which various psychiatric symptoms, conditions and disorders hang. We use the IPDE screener to get a ‘standardised’ idea – but the more important part of the assessment is the detailed history of emotional development, an often long history of troubled relationships, the underlying feelings of strong or fragile selfhood, and the quality of relationship or rapport it possible to build in the room. From that comes a formulation which we co-produce (ghastly word, but good concept) with the patient – so it is an agreed statement of why they are like they are.

Only then do we turn to diagnosis – and I always explain that, particularly in this area of psychiatry, it is an inexact science. We look together (there’s usually 3 or more of us in the room – it helps prevent difficult dependent dynamics) at the IPDE screener and the history and, usually, end up explaining that the diagnosis that fits best is BPD. If somebody strongly disagrees, I will not push the matter, but leave it there for now. The most important thing I often feel is that I (or one of the other staff) says to the patient that all that work of assessment and formulation shows us very clearly ‘that they are in the right place’ and our programme is likely to help them.

Engendering hope carries much more weight than ‘delivering the bad diagnosis’ of BPD. In the national PD programme, we found that it was a fairly even split between people who were upset by the diagnosis and those who were
relieved by it. There is, I think, a lot to be said against the simple juxtaposition of the two words ‘personality’ and ‘disorder’ in how it sounds like your whole personality – almost everything about you-  is in some way bad. And Geraldine Strathdee ducked a question about NHS resources for PD a couple of weeks ago by saying how she prefers to see it as ‘complex trauma’. But more important than the words is what goes with them. If it is a ‘therefore we don’t have any services here that can help you’ it will be perceived as yet another painful let-down and rejection; if it is ‘come along to such-and-such a session here next week’, some hope may be felt and a therapeutic relationship started.

People often ask us ‘what about these other diagnoses I’ve been given’ – and we talk through them. Bipolar is very common, and our general advice is that there is a great overlap between that and BPD – and it doesn’t add anything to help them to make fine distinctions between the two. The wording of ‘EUPD’ is worth looking at too: ‘emotionally unstable personality disorder’, in its very title, implies that mood and feelings will not be stable and remain the same all the time: how different is this from the rapidly swinging mood of the newly invented bipolar spectrum? And how could we tell even if it was different? And why do we make out that it matters?
I can think of two reasons: inability to tolerate uncertainty, and self-interest.

If we treat psychiatry as a purely biological discipline, we are making progress by becoming ever better by doing sophisticated regression and cluster analyses to ‘carve nature at the joints’ by diagnostic precision. But I would contend that that has now gone much further than can be justified by the evidence. The whole thrust of biomedical research has been to know what we have not known before. But what if it is not worth knowing – and there are many more interesting things that would have more positive effects on public mental health? That is a value judgement, and I suppose it comes down to the value that I have that a whole-picture view of somebody (including the biological) and a process that involves empathic human contact and building of a therapeutic relationship is to be valued more than minute dissection of superficial symptoms and signs. I am very happy to tolerate the not-knowing of a diagnosis, as long as an effective therapeutic process is happening. And ‘effective’ in that sentence means valued by the patient so they are likely to come back next time, and be developing some trust in what is happening.

The second, though, self-interest, is much darker – and from reading Joanna Moncrieff’s recent paper about ‘the marketing of the new bipolar disorder’, really rather sinister. She describes how the concept has changed – thinking back to that mock MRCPsych exam, I wouldn’t have even thought to include ‘bipolar’ in those days – we still knew it as a devastating mental illness called ‘manic-depressive psychosis’ - which was quite uncommon, and certainly not to be diagnosed lightly. The prevalence was said to be 1% although only a tenth of that number were ever hospitalised for a classic manic episode. 1998 figures claim that the incidence of full-blown mania was 5% with another 11% having the diagnosis of ‘bipolar II’. By 2003, the figure of what is now called ‘bipolar spectrum’ had increased to 24%. If you plot this on a graph, we will all have it in a few years.
Which is probably more accurate anyway – as irritability, bad mood, excitement and dejection, worry, occasional overactivity and spells of lowish mood are part of normal human experience, at least as I know it.

So, in the last two decades, it has become one of the most widely diagnosed mental disorders, and most commonly treated with either anti-epileptics or atypical neuroleptics. And this change has come about by the psychiatric profession, mostly but not only in the United States, gradually  changing the diagnostic criteria – as using popular media and the internet very effectively to publicise this ‘new condition’ and – of course – the pharmacological remedies for it. Joanna Moncrieff describes how this all came about through intensive work programmes of professional research bodies and journals, mostly funded by the pharmaceutical industry. Here’s a couple of quotes to give the flavour of it:
In 1997 the Zyprexa product team predicted that sales projections would increase more than fourfold if olanzapine could be viewed as a Depakote-like mood stabiliser than as a risperidone-like antipsychotic
Lilly formulated the concept of ‘complicated mood’: consisting of symptoms like irritability, anxiety, disturbed sleep and mood swings. Sales representatives were instructed to emphasise the broad action of olanzapine, and to encourage GPs to identify anmd prescribe to ‘higher functioning’ people at the ‘low to middle end’ of bipolar severity.

It certainly shocks me, in my clinical practice, about the number of people coming through – with or without diagnoses of bipolar – on olanzapine, valproate, carbamazepine, as well as full dose SSRIs. It shocks me in ethical terms that we now live with a health service where people who are experiencing ups and downs in their lives now commonly can just go to their GPs to get co-called ‘mood stabilisers’ and justify it to themelves, and their families and friends and employers, by calling it a ‘chemical imbalance’.

At least if somebody’s lifestyle choice is to take ecstasy or cocaine, they have to go out and find it and then pay for it!

So onto the second provocation:
This is becoming a turf war between different psychiatric factions, and is of no benefit to patients themselves.

In the national PD programme, we have also used arguments about the number of people not getting the treatment they need – and saying that 13%, or 5% of the population need treatment programmes for PD. Behind this argument is the belief, that for me is grounded in clinical experience, that people with PD – particularly the more distressed and florid manifestations of borderline – get a really bad deal in our services, and are often made worse by insensitive staff and rigid systems. This is not just mental health (though we are particularly bad at it) – but social services, housing, criminal justice (particularly women), A&E, many but not all GPs. Interestingly, and maybe this is only locally true, the police are quite well-liked by our patients – and we often hear stories about how they are more sympathetic than therapists. But maybe that’s just splitting!
We also like to claim that we are talking about profoundly serious mental illnesses, with the completed suicide rate for borderline POD being about 9%. So the overall picture is that this quite large proportion of MH patients (30 – 60% of inpatients, we cited in ‘No Longer a Diagnosis of Exclusion’) need better trained staff and more suitable services. And very slowly, that seems to be happening – through things like the KUF programme (who here has heard of it?), and the setting up of specialist services and specialist teams in community services.
The bottom line of what we’re saying is – we want more people treated in therapy programmes.

So what’s the equivalent argument for bipolar? Well, from what I’ve quoted a few minutes ago, the numbers are similar: barely 1% when I was a trainee (in contrast to being told NOT to diagnose it), and now maybe in the teens of percentages. The forthcoming ICD-11 changes will – with it’s proposed ‘personality difficulty’ and graded spectrum of PD severity, almost certainly put that up with the 24% I mentioned for the bipolar spectrum. But although the numbers are similar, the underlying motives for seeing an increase in those numbers are not. Ethically, I have already said that I think it very odd that people can diagnose themselves as bipolar, get a printout from an American website questionnaire to ‘prove’ it, take it along to a GP and be prescribed lifelong neuroleptics. I think it’s even worse than that, when we hear that the motive and resources to change the whole profession’s understanding of ‘bipolar’ come from the profit motive of the pharmaceutical industry – another quote to back that up, from

Confidential documents that were released in the course of legal proceedings make it clear that Lilly saw Zyprexa as the natural successor to Prozac, and the company set about devising  strategy to make Zyprexa into the ‘most successful pharmacological product ever’. This strategy hinged on repositioning Zyprexa as a treatment for mood disorders that could be marketed to the millions of people who currently thought of themselves as depressed and could be prescribed by GPs as well as psychiatrists.

The story she tells for paediatric bipolar disorder is even more troubling – but that is outside the scope of today’s debate.

So, to put it in parallel with what I have just said about the PD lobby’s intentions, the bottom line is ‘we want more people with bipolar to be treated properly’.

 But, as I have already argued, both are or have become very ‘soft’ diagnoses – with indistinct edges. Add that to a heavy reliance on the clinician’s interpretation of often vague symptoms – and the distinction becomes almost meaningless. Certainly, in routine non-research clinics where lengthy and precisely validated diagnostic interviews are not possible – the diagnosis will depend more on the clinician’s training experiences, the facilities and range of resources available, and established local practice.

So what?

Patients are not helped by this iron curtain between what we might call biological and social psychiatry. Aside from the lifelong effects of medication that might or might not be helping, and the necessary paternalistic type of relationship, the mechanical ‘me expert, you patient’ relationship of purely biological approaches is becoming much less acceptable to patients – many many of whom want to be advised by professionals on the whole range of options, and not told what is best for them or simply what they must think and do.

My final provocation is that most of them are the same people, who happen to have landed up in different parts of the service by something that is close to random good or bad luck. Some who land with us have no interest in or willingness to undertake a fairly rigorous and intensive programme of medium to long term psychological therapy – they need the expertise and choices that the bipolar approach would give them. Vice versa, the people with what we see as ‘biopsychosocial’ disorders landing up in a hard-line bipolar clinic should be advised on the different ways of understanding their condition, and making treatment choices based on that.

So to me, the actual question of the debate fades into irrelevance – many and perhaps most of these people have the same sorts of symptoms and backgrounds, so could justifiably attract either diagnosis. The challenge is not to get better and better at making accurate diagnoses, but to work together as a profession to offer them the best and best range of treatments to help them – and not to allow the dark and global forces of neoliberal economics to sway us from that.