Saturday, 29 November 2014

British TCs for Italians

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

Here's our prezi:

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

Therapeutic Communities in the UK 1942-2014

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Friday, 21 November 2014

The First Enabling Environments Annual Forum

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

Professor Dame Sue Bailey

Dr Clare Gerada

Monday, 17 November 2014

Rethink for PD

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

Saturday, 15 November 2014

The London WASP

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

Saturday, 8 November 2014

Founders group - London number two

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

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

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

The grand collection of volunteer group analysts

Thursday, 6 November 2014

We won!

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

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

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

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

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

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

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

The therapy yurt at Iver Environment Centre

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

Growing Better Lives CIC is a social enterprise committed to providing, training, and researching critical approaches to mental health. 

Saturday, 1 November 2014

A truly radical and critical conference

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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