Thursday, 3 December 2015

A Transcendental Indian Adventure (4) Mental Health Action with the forest tribes of Kerala

Until seven years ago, Dr Manoj Kumar was a consultant liaison psychiatrist setting up oncology services in Leeds, in the NHS. Now he leads an NGO based at Kozhikode (Calicut) in Kerala which runs 43 mental health clinics for the poorest people in the surrounding areas, and two Masters-level training programmes for psychologists and social workers: Mental Health Action Trust (MHAT) - click for website.

We visited two very different clinics in rural villages outside Kozhikode, and held a seminar with the psychology students at the MHAT training base in the city. Interestingly, Kozhikode has just been voted the second best city to live in India.

Talking to Manoj, he explained several hallmarks of MHAT that make it unique:
·        Volunteers are used to provide extensive psychosocial input, including home visits and day care centres.
·        There are many more volunteers than paid staff (who are qualified clinicians)
·        Nearly all the clinic administration is undertaken by volunteers
·        The volunteers in the village projects have support from Manoj who is available by phone to discuss medication issues etc
·        People are screened to ensure they are very poor. For example, having a mobile phone would probably exclude somebody. 
·        Supporting compliance with medication is often important, but it is also part of the psychiatric philosophy to ensure people are on as little medication as possible.
·        They engage with the family and head of the local communities.
·        The normal state service for those who can’t pay is entirely hospital inpatient-based, and best avoided.
·        People who can pay a little more would generally see a private psychiatrist and get little care apart from a prescription.
·        Unlike most of the rest of his career, he get up on a Monday morning excited and enthusiastic about going to work!

Manoj himself was very open and honest about how he can see mental health from three angles, and uses them all in his clinical conversations: as well as being a psychiatrist, he described how he had experience as a patient with a depressive disorder needing medication, and as a carer when his elderly father was dying with dementia. I got the sense that this sort of candour is even more unusual in India than it is in the UK - but what a powerful anti-stigma statement it is.

This way to the MHAT clinic!
The first clinic we visited, at Karakunnu, was a mature project which had an experienced team and was well-integrated into the village, here: . The things that seemed to stand out were how similar to good community mental health care, as we know it in the UK, it was - but predominantly run and staffed by volunteers rather than professional paid staff, and all in very basic premises. Apparently, he occasionally gets criticised for delegating responsibility that others think should be the sole province of professionals, but when the alternative is no care, for very deprived people indeed, it strikes me as what they call a no-brainer. Similarly, the means testing has been criticised on behalf of the 'slightly wealthier', but it is clear that they would be overwhelmed by demand if they drew the boundaries any wider. 
The day centre


Staff and volunteers - including two friends from Penukonda LLE

The volunteers proudly showed us the work they were doing it and how they documented it all (in utterly incoimprehensible Malayalam script, plus books of photos and artwork). Perhaps, and most noticeable of all, was the sense of espirit de corps and team cohesion: sadly not always the case in British services. A joyous bunch of mental health workers who clearly really enjoy their work, and are very proud to be doing it.

The clinic base - and mobile pharmacy - for the forest colony
On the second day we went to a new project, just a few months old, way up the Western Ghat mountains where they look after people in Wayanad tribal colony: If the people Karakunnu were poor and lived in very basic circumstances, the people here were even more poor, and made the community services at  Karakunnu look fairly familiar to western eyes. These tribal people were in some ways even lower than 'the lowest of the low' in the Hindu caste system - they had even less social status than those who were once called the 'untouchables'.

The children wonder who we are...
The forest tribes, of which there are dozens or hundreds in this part of Kerala, each comprise of about fifty people who have previously been living off the land, in thatched self-built dwellings, without contact with the commercial world of employment and money. In the name of progress and with government 'development' policies they had been relocated to 'better' areas where there was at least a possibility that they could receive education and health care (and so help India score better as a developed nation); the one where we visited two families with the MHAT volunteers was amidst scattered luxury Keralan houses for the affluent - which looked like the Indian equivalent of holiday homes. But the tragedy we saw was how the tribespeople who had been displaced here had lost their sense of meaning and purpose in being relocated, and many took to a life of total intertia and continuous intoxication with home-brewed alcohol. I won't presume to understand what was going on in the two consultations we saw - but the individuals we saw were in a very poor state to look at, as we were eagerly surrounded by numerous inquisitive and lively children.

Across the Western Ghats
Teaching session in Kozhikode
After the spectacular drive back down the nine hairpin bends on the road off the Western Ghats into town, we had an impromptu seminar with the Masters students about therapeutic communities and greencare - which seemed to be well received. Interestingly, one of the key staff at the teaching centre, Malika, is a Tavistock-trained psychosynamic psychotherapist - and the compassionate, boundaried and therapeutic understanding shone through in the students. Then (yet another) lovely Indian dinner,this time at Malika's home - and many passionate conversations with Manoj, Malika and her psychiatrist husband Ajay over a bottle of scotch...

And so to bed - before our return to Bengaluru and Sunday afternoon Christmas shopping with Anando's mother (surprising successful and enjoyable for one like me who generally hates shopping!)

Then up at 0245 for a drive through strangely deserted streets to catch BA118, the daily shuttle plane to Heathrow.

Thursday, 26 November 2015

A Transcendental Indian Adventure (3) A Living-Learning Experience like no other

When we started the British LLEs at Commonwork organic farm and study centre in 1995, an important part of the bonding ritual for the staff was to meet in Sevenoaks Sainsbury’s to do the shopping. We would travel from wherever we worked and gather, at about 5pm on the day before the workshop started, in the coffee shop. Then we would start in earnest and, after about two hours, end up heaving around four or five shopping trolleys containing all the meals, snacks, drinks, and everything else we were going to need for the three days in our Kentish therapeutic bubble. Even in those days – now between ten and twenty years ago – the bill at the till would come to something between seven and nine hundred pounds for about twenty five people. More recently, we have become a bit lazy – and Sue has done all the shopping for us with Tesco Online. Although it’s a lot more efficient, and tightly budgeted (it is now less than six hundred pounds), we have lost something in the process: we also used to treat ourselves to a meal out at the Chiddingstone Castle once we had unpacked it all – now we just cook something simple for our pre-workshop evening meal, in the modernised kitchen at Bore Place (the Jacobean manor house we’re based in at Commonwork), and have our pre-workshop staff meeting. For our Indian Adventure, the food was going to be a different experience altogether – and in comfortable city-lifestyle Bangalore, we had no inkling of just what that was to mean…

Not like Sainsburys
Getting it in the car
All four of us – Anando, Jan, Sandra and myself – turned up at a large supermarket in the city, in a car already stuffed with luggage to take the road 145km north to the women’s Training Centre near Penukonda. Not quite the same as Sainsbury’s in Sevenoaks! But as the main basis of a good proportion of Indian food is dry stuff – it was weighed out into huge bags of rice, lentils and chick peas. That, plus a bag with a couple of fish and a bag with a couple of chopped up chickens, and numerous packets of masala and spices, made up most of the substantial cooking we were to do. We decided to get the fresh vegetables and fruit from the market in Penukonda after we got there, so with a few goodies like chocolate bars, white bread, biscuits and jams, we manged to squeeze it all into the car quite easily: excluding the wine we had with meals it came to 17000 Rupees – about £170 – less than a third of what we spend in the UK. A final stop for the wine, then two hours and good dual carriageway past the new airport, and we were there.

 The dual carriageway gave us a false sense of security – and it was almost like an augur as we came off it and onto the village road and approached the training centre: no longer just animals, people and vehicles – but a bright green bush, the size of a small car, travelling towards us like something from another world. As it passed, we saw there was a wiry and athletic old man beneath the bush (which was a mass of freshly cut sugar cane), on a small scooter. But another world, it certainly was.
Arriving at the Training Centre

In India, we had become used to some of our normal facilities being intermittent or only available in some places – like air conditioning, broadband, mobile phone signal and hot running water, and to have short interruptions to electricity. But this was to test us much further – no chance of internet or phone signal unless you drove into Penukonda village (about 3km away), no hot water unless you boil it yourself over a log fire, no running water at all for hours at a time (seemingly something to do with the electric pump to the water tower, which also explained why water was pouring over the side and flooding the muddy path between the different buildings), a little bit of gas for cooking – but most of it needing to be done on smoky indoor log fires, and very intermittent electricity. And this is to say nothing about our safety being compromised by the voracious insects, snakes and other aggressive wildlife we fantasied about, and imagined we were hearing, at night. Then there are the termites, which apparently can eat all the wood in a door in about three months – leaving just the paint holding it together, and mostly dust where the wood was. Anando found this out when we tried to go into one of the dormitory blocks through the back door, half of which immediately disintegrated into powder as he pulled on the handle. Hence most doors in the place were metal – but the climate had taken its toll there too, with many of them rusted and either difficult or impossible to close and lock. Then there were the sliding metal grills, slightly rusty and stiff from lack of regular use, between the different sections of the training centre - mainly to isolate the kitchen and dining area from the outside. What were they for, and why were there so many of them?
The cooker

The washing-up room

The answer turned out to be the biggest animal threat that we encountered: a species much closer to our own than any of the ones we feared – monkeys. At first they seemed quite cute, a family of four sitting on top of the roof, watching us come and go as we unloaded our goodies from the supermarket. Then we returned after going to somewhere else on the site and noticed something wrong – where had we put all those pappadums? Didn’t we have five loaves, not three? And what were those bits of half-eaten banana under the table? Far from watching us with benign and friendly interest, they had been sizing up what we were putting where, and how they could half-inch as much of it as possible. And now they were not just a sweet little nuclear family, but an extended family – probably a whole village of monkeys – coming at us from all angles in the trees all around. The most audacious theft was when I was carrying half a loaf of bread to the kitchen to make myself some breakfast, slightly blurry with virus and fever I’d contracted, and suddenly something swooped down from the tree by the entrance grille, I felt little finders grapple with my hand - and before I knew what was happening, the half loaf was disappearing up a tree with several of the cheeky monkeys grinning down at me. So much for my curry-free breakfast of toast and marmalade!

The enemy
Before long, the fight against the food thieves became an all-out war – and we employed innocent children, fireworks and guns to fight our cause. One of the participant members of the LLE had bought along her two young girls, who delighted in being appointed as the monkey patrol when we were in our groups and community meetings: they would keep watch over all the food in the kitchen and dining room, and would chase off the monkeys however they could. We soon used up a box of the fireworks – loud bangers – which kept them away for an hour or so, so we sent Anando (aka Dobby) into Penukonda to buy more. But as matters worsened, Azad – the young farmer from Kracadawna who was a member of the community – borrowed an air gun to send them scurrying more effectively, with a few harmless but painful shots in the bum for various persistent primates. Some of the more rurally-accustomed members felt that a real gun, with real bullets, would be more in order – but thankfully we didn’t go that far. But we never won – they kept coming and going - but at least they didn’t get much more food.

After we had finished unloading the food and luggage, we had our traditional pre-workshop staff meeting, going through the application forms of everybody who was expected to turn up the next day, before going to Chandra Kanjilal’s house for dinner.

Chandra is a retired woman of extraordinary energy and experience, who had set up the training centre (link to Google Maps, earth view here) about twenty five years ago, with German international development funding – and has lived there with her daughter (an NHI employee, sometimes her son-in-law (who works away), an elderly dog, a young dog and four playful puppies ever since. Until the development funding methods and perceived needs changed about seven years ago, she ran numerous courses – for dozens of people at a time for extended stays at the training centre - to help empower local rural women, from all the surrounding areas. The stories she told us of how utterly disempowered they were seemed a far cry from what we think of as ‘disempowement’ in the UK. For example, how women were exploited by money lenders, suffered domestic abuse, sexual abuse and, if they were widowed or divorced or had mental heath problems, were terribly exposed to the likelihood of severe abuse, exploitation and ridicule. For women,the situation was, and to some extent still is, inconceivably awful for those if us  living comfortably in the west: although the enforcement of dowry payments is no longer legal, it still happens - and the effect of this has been to make girl births in jeopardy of infanticide.

But the centre had been unused since the last of the courses, in 2008, and it was rather sad to see many photo boards in the training centre rooms, faded and decayed with age, showing the place full of life, action and energetic people doing emancipatory things together. So Chandra is very keen that it takes on a new lease of life as a venue for the LLE mental health training – which is hopefully also emancipatory, and in the service of empowering staff, and ultimately patients, in a way that is progressive, sustainable and powerful. Hence a potential win-win situation in her relationship with HNI.

The community room
The LLE itself ran to exactly the same timetable as it does in the UK and Italy – with community meetings at the beginning and end of each day, three small groups which meet five times including one to cook a meal for the whole community, and the rest of the ‘community time’ to be spent however the community decides. We had seventeen participants – including HNI staff, psychology postgraduate students, an engineer, a Greenpeace worker, Azad the young organic farmer from Kracadawna (see India blog #1), and four workers from the Mental Health Action Trust in Kerala (see India blog #4). We had a staff team of four – Jan, Sandra and I each conducting small groups, and Anando in the role of Dobby the House Elf – lighting the fires, running errands, helping with the cooking and generally knowing where everything is and how everything works (no mean feat for a workshop in this setting!).

Safiya shows us how to cook when it's our group's turn
 It all passed in a febrile blur for me – with an upper respiratory infection and fever throughout – but particularly notable moments included the production of fine Indian meals from such basic ingredients, over wood fires which smoked the kitchen out,without need for many words or instructions; washing up without running water; cheering as we let Chinese Lanterns float upwards into the night with a wish; monkey trouble; a chaotic group game called Mafia (an Indian version of what we call 'killer'), and dancing round the bonfire in the courtyard

Hanging out
Although Sandra, Jan and I started with severe reservations along the lines of ‘how can we presume to sit amongst these people and conduct groups in our normal way, when we have so little idea of what their lives are actually like and how almost everything about the culture works here?’, we were surprised how it all worked out. By the end, we had all made relationships which we felt sadness at ending – and heard remarkable and moving tales of how people manage their lives a
nd emotions. Most seemed to have got a lot out of it, as had we. An extraordinary, and unforgettable, experience.

Follow the LLE link on the right if you want to try it for yourself…

Tuesday, 24 November 2015

A Transcendental Indian Adventure (2) Buzzing around Bangalore

NIMHANS has always occupied a place in my mind somewhere near the Maudsley and Institute of Psychiatry, and my own psychiatric training - with fantastically high institutional standards but also a punishing and paranoid culture for the poor juniors who work there. I remember this in Oxford as ‘the dark shadow of the University Department’ and how nobody walking its corridors ever smiled – and we all lived in fear of getting the dreaded ‘green memo’ from the heart of Mordor (the professor’s office).

NIMHANS - the gardens b etween the inpatient wards
But today that prejudice was really changed into something much more up-to-date and positive when we were invited to visit the Department of Family Psychiatry and Rehabilitation. As we walked in, there was a profound sense of it being a good space: a relaxed feel, colonnades of green walkways festooned with flowers, yoga happening in the spacious grounds, large airy and light-filled rooms, and people who rushed up to us and introduced themselves – as well as a few lazy and random dogs lying around.

NIMHANS - Family Psychiatry and Rehabilitation
We sat in a multidisciplinary teaching session where they used OSCE (Observed Structural Clinical Examination) methods as a teaching technique rather than an examination – with a role play of a mother from a rural area coming to ask for help about her psychotic son. The observing students then had to first comment on what went well, then what could have been improved – ‘Pendleton’s Rules’ as I remember from my own GP training. In the following discussion we explained how TCs have developed and changed in the UK. Although they were quite familiar with the underlying concepts, it is interesting that they still thought that all TCs were residential – but perhaps not that surprising as the same misunderstanding was present in several medical members of the UK group that developed the NICE guideline for Borderline PD. But we then had a lively and passionate discussion about how TCs can offer hope to people who have not received what they need from the mainstream mental health services, help those who are dependent on services to take responsibility for themselves, and hold out the possibility of authentic ‘recovery’ – whatever that may mean!

We went to a well-westernised coffee bar (multi-coloured LCD lights, not much Indian food on the menu and loud pop music) for our debriefing, with a burger and salad lunch. Unfortunately this coffee bar, unlike the ‘CafĂ© Coffee Day’ chain that seems to be spreading everywhere, had no coffee, and then the waiter told us that tea was off as well. So we went off to our next encounter: Athma Shakti Vidyalaya, ASV.

ASV is one of the first TCs which joined the Royal College of Psychiatrists’ ‘Community of Communities’ quality network - soon after it was set up in 2002. I was the external peer reviewer for its first review in October 2003, and remember being bowled over by how the culture and ‘smell’ of a TC was as easily recognised in such an utterly different culture as urban India as it was in London, rural Cumbria or the Home Counties. But this time we were a threesome, and we only had an hour and a half with them. The first difference I noticed was how a rural village on the outskirts of Bangalore – surrounded by big fields, wandering cows and children playing cricket - had become a dense urban development filled with apartment blocks, a new Hindu temple, tarmac roads and buildings everywhere. Such is the pace of Bangalore’s expansion, Anando explained to us.
We started off with a rather formal-looking session with the three of us behind a desk, and serried ranks of staff and interns arranged in rows filling the rest of the room. However, we soon got into an interested exchange about what we had in common, how we differed – and what had changed since I was last there. Then it was time for community tea – and we had milky tea (without sugar, by special request), biscuits and Indian sweets. We were enthusiastically welcomed by the members of the community: they wanted us to stay, or come back, or even work there!
With the staff at ASV

The members come from far and wide – and have a wide range of reasons for being there: some see it as their home for ever, some use it as a secure base from which they go out and try to get on with life and come back if they need to, and some seemed to want to get away from the place as soon as possible. It was clear how some members felt listened to in a way that made others therapies they had received seem superficial, and not able to fully understand their situation and problems. Most people there had their places funded by their families – who sometimes pay for them to stay indefinitely. Because there is now quite a number of long-stayers, ASV is considering whether to build a new block in the middle of their yard to house them. Of course, a treatment like ASV is inaccessible to most people as they don’t have any money.

The entrance to Christ's - a 'corporate university'...
...which still has a lot of students.

We knew the next day, Wednesday, was going to be hard work – but we didn’t realise quite how much Anando had packed in. We started with a three and a half hours lecture/seminar session at Christ University – which is what they call a ‘Corporate University’, meaning that the fees are much higher than a state university, for which the students receive pretty much the same education, but have much more comfortable and modern buildings and facilities.

The room in which we did our presentations was kitted out with a smart stage and all the usual digital projection – but the audience all seemed to be sitting in rows of bright red comfortably upholstered armchairs. There must have been about eighty of them, all full with standing room only – mostly with postgraduate students from the psychology department. We left just after 8am to get there for a 9am start, and Anando was surprised at how gentle the traffic was – but he spoke too soon. When we got to about a mile from the university, we hit the big-time Bangalore gridlock: probably similar to most huge cities in low and middle income countries – but with the trademark Indian addition of holy cows dotted amongst the vehicles, sometimes even lying down amid the noisy chaos. We arrived about 10 minutes late, and everybody on the red seats went quiet and stood up for us: we reassured them that we came from a tradition of flattened or fluid hierarchies and they didn’t need to do that – then we did three of our normal prezi presentations: the English national PD programme, the history of British TCs since World War 2, and why the philosophy of greencare is good for your mental health (click each title for link to presentation).
Talking to the Christ's University students
We left plenty of time for questions and discussion – and there seemed to be a good understanding of what we were on about, and us and Anando made several useful contacts.

After a quick rice and curry lunch in the students refectory – a vast space with an even more vast number of students in it (there certainly seems to be enough people around to pay the fees for their study at a corporate university) – we were heading off to our next assignment: a team meeting with all the HNI staff in Anando’s parents’ front room. Interesting facts we learned about HNI include the geographical spread of their activities, that some of their staff are volunteers, and that the non-volunteers are all paid exactly the same.

After this, just before the sun set, we were led up to the top of a nearby building where there was an airy terrace with views across the city, a bar, food service area and a circle of twenty-odd chairs: lovely evening views across the city, a gentle breeze and music of the city traffic just warming up for the rush hour. Beep beep beeeeep honk honk vrooooom vroom.
Sunset above the hurly-burly
This was the setting for the three-phase evening event to which all the HNI stakeholders were invited – the Social Evening.  The first part was a reception and general mingle as everybody arrived – Sandra braved the streets of Bengaluru for the two minute walk from Anando’s parents’ house with a couple of others HNI, got lost and arrived just in time for the next part. Which was a group discussion on ‘where to with HNI?’, in a conversational competition with the orchestra of traffic - which had now finished warming up, and was playing at full tilt. Which made the discussion a little difficult, a problem the group tackled by bringing all the chairs together into concentric circles so everybody was within a few feet of each other. Some good ideas were batted about, with plenty of energy and passion – particularly from the families of community members. Then it was time to eat, again. And beautiful food, again, with plenty of people and good conversations with people from all sorts of different backgrounds (the orchestra was quieter by now). And so to bed – in preparation for the biggest adventure of all: the Penukopnda LLE…

Links to talks:

Saturday, 21 November 2015

A Transcendental Indian Adventure: (1) Biodynamic Greencare in Mysore

Although it doesn’t look far on the map of India, and we aimed to leave Bangalore at 7.30 to get to Vivek and Juli’s farm by lunchtime, it turned out to be a good deal less straightforward. We didn’t quite get our act together to be on the road by 7.30 - which gave time for a lot of motorbikes, and cars, and dogs chasing the cars, and scooters, and buses, and tractors, and herds of goats, and lorries, and autorickshaws, and cows, and dogs chasing cows to get ahead of us. Beep beep beep beeeep said the chaotic assemblage of flesh and metal – but Anando took the immersive chaos as a challenge, and showed remarkable dignity, respect and restraint - and barely muttered a single peep of frustration all the way to Kracadawna.

After spending in an extra hour escaping the city, the first stop was for breakfast, at a tribal art and culture centre  - then another two hours of humans, animals, vehicles and villages getting to Mysore. Which we went round 3 times. The first revolution was for an ATM and a bank, the second was searching for a wine shop amongst the lime green and candy-floss-pink houses of the back streets – including a few dead ends and diversions to get over the railway track, and the third for a loo, which turned into a coffee shop stop. And we didn’t even see the palace once.

As we got further and further from the city, the roads got narrower and narrower - although still with the added interest of swarms of motor bikes, very slow buses, occasional cows and tiny villages with big temples. Overtaking motor bikes usually involved an excursion into the opposite ditch, while oncoming traffic often landed us in our own ditch. Getting past wheezing buses was even more exciting. After about an hour and a half, we turned off into a long and winding – and deeply rutted – track across fields and farms, until we arrived at the kitchen, a separate building which is the hub of life at Kracadawna. Here's the link to see it on Google Maps, earth view:

Kracadawna landscape
Kracadawna is a 25 acre organic farm run by the Cariappa family, who – over thirty years - have turned it from a bare patch of land into the sort of eco-paradise loved by ageing hippies like Jan – and the new breed of ecowarriors like Anando and Shama. Our safety assessment had to include various contingencies unknown to the NHS risk police: marauding elephants whose transit corridor goes through the middle of the farm, and a man-eating tiger who has already eaten eleven villagers who can clear the 10-foot electric fence designed to deter the elephants, with eight foot to spare. Also a group of wild boars recently had a rave in the cornfield, and trampled it to the ground. They may be back for more, at any time! And then there were the mega-bugs, snakes, rats the size of cats, chattering monkeys and poisonous spiders.
Thirty years on...

However, despite the self-evident unacceptability of such a place for patient-safety-conscious mental health endeavours, it is not quite as life-threatening as the risk assessment might suggest. Nobody from the farm, either family or staff, has ever been hurt by the local wildlife, and the ecological management of the site means that it is becoming a ‘biodiversity hotspot’, and might become recognised and registered as such if the family commissions a formal survey. It is also a seen as a radical social structure, as they are separate from the local village community, use organic production methods unfamiliar to local people, and the farm employs people who could not work elsewhere. Juli explains how people employed here talk to her about their open and egalitarian style leads to a level of trust that allows the local village women to talk about things they would not say to anybody else. And the village men were suspicious of their organic neighbours for many years – for flouting the conventions of social hierarchy and acting in a fair and equal way to everybody; but once they got used to it, they too could establish a new and almost unknown level of trust with other men outside their immediate socio-economic circles.
Sandra, Kabir & Angeli,Anando, Azad, Juli, Rex, Vivek, Shama and Jan around the kitchen table at Kracadawna

Although it is not yet a fully functioning greencare TC programme, we were told a story of a weekend visit here by some Bangalore TC members, including an autistic boy and a couple of other members - which made more difference to how they relate to people around them and their enjoyment of life than years of special schooling, and rigorous programmes of behaviour management: though it wasn't without ruffling a few feathers back at home!

Meanwhile we got to work - and had several hours of detailed, honest and frank discussion of how Anando and Shama can make the TC model work in India, under the auspices of their 18-month old charitable organisation, Hank Nunn Institute, HNI. Although I have some antibodies to management concepts like these - a lot was about good governance, time management and focus. Interestingly, the charity laws in India seem even more strict than they are in the UK: with rigid rules about trustee board membership, and even more draconian procedures for handling money. What emerged from discussions, site visits and more discussions were some fairly stark choices: urban or rural? From whom can HNI accept funding? Who will be the members they seek?
Where to from here, Anando?

Thursday, 22 October 2015

Where has the fire gone?

TCTC Windsor Conference 2017 - all went just as usual, lots of good thoughts and groups and plenty of dancing and fun with the greeks.
But the question for the large group, which was never really answered, is who has still got fire in their bellies to get out there and say why TCs really are radically different, and are proposing more democracy in areas where it is diminishing...
Although my own fire is not really going out - I want to turn it to places where it might make things change, and -very sadly- I don't think that is in the world of TCs any more. At least the 'pure' ones. But was it ever thus?

Thursday, 8 October 2015

Caring Community Slough

Geoff Dennis, Natasha Berthollier and Rex Haigh at IAGP Rovinj
For some years, our 'Growing Better Lives' greencare project has been combining the ethics and principles of permaculture with the passion and power of therapeutic communities. Both fit into a wider agenda - of disaffection with rampant mangerialism and an increasing realisation of a public human need for kindness, warmth and love - not just in our intimate relations and families, but in the way we treat each other everywhere. Maybe, just maybe, Jeremy Corbyn's election is a harbinger of things to come - though I fear it's a fifty year project, not five.
    But we're doing something about it in Slough, and we're starting to tell people about it. We have been to present some of our work and ideas at two international conferences, and together with the local launch of 'Hope College', have started to paint a vision of something inspirational (for the spirit), as well as transformational (for the health economists). Here's a few threads...
    A friendly strawberry and banana at the launch of Hope College

    • Our recent 'yurt events' have included a two day permaculture course, seminars on 'therapeutic towns', visitors from Italy, Taiwan, Colombia, India and New Zealand, a Nottingham University Social Futures research Centre Meeting with added yoga and compost, NHS managers discussing plans for an adolescent transitions group and Sicilian TC members cooking, singing and dancing
    • 'Hope College' was launched on 25 August, and Berkshire Healthcare NHS Trust chairman, John Hedger, was accosted by a large banana and strawberry - Fiona and Sharon from the Thursday Greencare Group, where the plot was hatched.
    • Geoff, Natasha and Rex presented the Slough work - particularly the ASSIST project - at the International Association of Group Psychotherapy Congress in Slovenia: Geoff explained how the financial 'dark clouds of Mordor' has led to opportunities for developing differently joined-up mental health services; Natasha how our first two years figures from the project show that psychotherapeutic approaches can keep people out of hospital and reduce costs; Rex described how Slough is starting to be a new sort of 'whole town TC' - based on ethical values and relational principles. 
    • The International Permaculture Conference in London was truly inspiring. We presented our greencare group, and got a great reception for it - - but more than that, we heard how our work and underlying therapeutic values are utterly in tune with permaculture (which we knew already) but also with the Transition Movement - which is about joining up small locally-grown ideas into something that people feel is really worth belonging to: Although most of them focus on sustainable energy, economy or food production, therapeutic thinking runs through a lot of the ideas and 'sustainable mental health' would be an ideal starting point for Slough. And we do have a track record - with our 2014 Royal College of Psychiatrists sustainability award...
    • The 'micro TC' Tuesday EMBRACE group celebrated its first birthday with more than four hours as a floating group in Groundwork's electric barge up and down the Grand Union Canal. Everybody learned the basics of good nutrition for mental health, then (in four teams) had a healthy cooking and healthy eating experience - Great British Bake-off watch out!
    • The second harvest from our organic allotment was cooked and eaten by members of the Thursday Greenccare Group, which is now seriously looking into being funded through individual budgets and social prescribing. We've just started collecting and planting seeds, peas and beans for next year.
    • We're hoping to write up the work as a service-user led action research study: the steering group is the three of us from Rovinj together with Trevor Lowe (a researcher who is experienced in using creative and spiritual methods in mental health) and Vanessa Jones (of GBL). It may also be  linked to the Nottingham University 'Social Futures' group as part of a major 'Utopias' research project that is being planned by TC academic and expert, Dr Gary Winship, and three eminent social sciences professors: Nick Manning from Kings College London (who started his working life in Henderson Hospital TC in the 1970s), Lynne Frogatt from UCLAN (see post from last December), and Lucy Sargisson (who enjoys the great title of Professor of Feminist Utopias.
    • With 'The Animal Sanctuary UK', which is about to move into new premises near Windsor, we're working up plans for an ecotherapy centre made of low-impact sustainable buildings.Their motto is "Together Therapy for people and animals with special needs - People Helping Animals, Animals Helping People"-
    Some of the exciting things we've got planned for next year are still under wraps - but watch this space...!

    Tuesday, 6 January 2015

    Trauma, Healing and Khiron

    Khiron House
    This week I started a new part-time job with the grand title of Medical Director of Khiron House. It is a residential treatment unit for people who have suffered from psychological trauma, including those with what can get diagnosed as 'Complex Post-Traumatic Stress Disorder' or 'Complex Trauma' as well as 'Borderline Personality Disorder' or 'Emotionally Unstable Personality Disorder'.

    I have written a small paragraph about the relationship between these diagnoses and the best way to treat them for their newsletter, so here is the expanded version.

    It is a talk I gave twelve years ago, in 2003, which seems just as relevant in 2015- and reflects the view I still hold, that the treatment programme, therapeutic environment and therapeutic relationship is much more important than the niceties of diagnosis or the rivalries and turf wars between different professions.

    With thanks to Sandy Bloom, whom I quote extensively, and was an inspiration to me at the time I originally wrote it

    Development of Borderline Conditions: the Trauma of Loss, Neglect and Abuse. Is there a difference between borderline personality disorder and PTSD?

    Rex Haigh, Consultant Psychiatrist in Psychotherapy

    Thanks etc.
    It’s excellent to be asked along to come and share ideas in a forum like this – where we come from various different background and trainings, and are involved in different ways of treating many of the same people. But more than ever at the moment, I think we are in this together – so I hope I’ll be saying things on which we can build a shared understanding, rather than an unhelpful rivalry.

    But Suzanna’s given me a whole hour! I hope I can keep you awake – I’ll start and finish with a bit of a rant so at least you should get the first bit and then wake up for lunch!


    I’m going to deal with my title the other way round – Suzanna and I came up with half of it each and that’s why it’s so long – I’ll leave you to work out who chose which bit.

    Of course there is a difference, but what is far more important is the similarity – and how services are just not geared for the millions of people with psychological injury – and what that says about the wrong emphasis we have in so many of our modernised, individualistic and paternalistic models of mental health care. It’s a system problem rather than individuals – everybody is working extremely hard in a system where many staff are prevented from doing clinically meaningful things – like talking to patients – by the burden of administrative diktats. In the name of accountability, and openness or transparency, we are so immensely preoccupied with governance, with targets, with protocols and with bureaucracy that our mental health services have almost completely lost sight of who we are really accountable to, and should really be open to – the people our services are there for, the human beings we are treating as a production line of faulty machines, who actually have feelings, thoughts and concerns that are not so different from our own. But… more of that later.
    The track I’m going to follow, if it helps to give a bit of a map, is to look at the diagnoses and how they relate to the rudiments of trauma theory – on which I must say I am no expert – and then look at other theories of just what borderline personality disorder is, and present a broad-based developmental model. This is something we use in therapeutic communities which is really based on a wider concept of trauma, and then the treatment implications. At the end, I’ll put that into a framework of critical theory – which I hope will illustrate how the scientific, technical and administrative structures we have may be necessary for good mental health services but are certainly not sufficient.
    So, let’s start with diagnosis.


    I won’t say much about diagnosis itself, except to say that sociologists have well noted the way in which it removes information in a formulation or assessment, rather than adding anything. Of course, it is useful shorthand, but it oversimplifies things in a way that, under pressure, can leave us basing treatment and management on just the diagnosis, and the protocol. That may be good practice for the paramedics diagnosing an acute heart attack which needs an anti-clotting injection immediately, but I think it is rarely good enough in mental illness. One of the effects is to create an illusion of certainty, of hard scientific truth – which may have superficial validity, but does nothing to address the areas of internal experience and meaning, which are rather important to most people. And of course, it’s the same process where we end up talking about “the depressive in room 6 on buttercup ward” or “the schizoaffective who was discharged last week”. The process defines a relationship with an “expert” making the diagnosis and a subject receiving it, and it fails to recognize individual differences in favour of uniform and standardised processes.

    But that said, the act of diagnosis does concentrate the mind and have useful communicative functions. So here are the current accepted definitions for PTSD and BPD.

    Here is the PTSD definition:                                                          [slide]
    I won’t go through it in detail (already done?), just to emphasise the different sections – (A) definition of the traumatic event itself; (B) intrusive memory of it; (C) avoidance phenomena; (D) increased arousal and then (E) about timing – and there are further criteria for acute and chronic, 3 months I think, and (F) that it has a significant effect on functioning. Just to particularly note the presence of an explicit CAUSE (here  in A). I’ll be coming back to some implications of this.

    And here is Borderline:                                                                 [slide]
    It starts with a general phrase about the parts of a person’s life it affects (relationships, self-image, mood and impulsivity), says it starts by early adulthood and then requires five of these nine be present:
    §  Avoiding abandonment
    §  Unstable and intense relationships
    §  Unstable sense of self
    §  Potentially self-damaging impulsivity
    §  Self-harm and threats of it
    §  Unstable mood
    §  Chronic emptiness
    §  Anger problems
    §  transient psychotic or severe dissociative phenomena

    There appears to be minimal overlap here – but this is because the one for PTSD is framed in a way that includes the cause and linked symptoms, while BPD’s definition is as objective as possible a description of enduring personal characteristics. Chalk and cheese, if you like, by trying to compare different types of definition. Axis I and axis ii of course. But it also carries profound legal consequences in PTSD – for an internationally recognised condition with an internationally recognised causal process gives legal certainty which few other non-organic psychiatric disorders can match. And there are numerous social consequences of having diagnoses decided as part of a legal discourse. This may be helpful for clinicians, patients and lawyers – but I’m not sure that defining diagnoses by litigation helps us much with thoughtful and reflective practice!

    Borderline has also only been elaborated in the last two or three decades – and really by rather acrimonious debate about whether it exists at all – which continues with minor academic skirmishes now, rather than full scale conflict. When I learned my psychiatry as an SHO about 15 years ago, it was pooh-poohed as a serious diagnosis, and was certainly something you would get a hard time for, if you mentioned it in the examinations! You were allowed to mention it to some friendly consultants, as long as you put it near the bottom of your list of possible diagnoses.

    Nick Manning, a social policy academic who I am currently working with in Nottingham, takes the line that the creation of the Borderline Diagnosis – and the work done on it since - is an act of territory-claiming by science and medicine. Borderline UK, the national user group, like it because it gives them a shared understanding of why they are like they are, and a lever to argue for better services. The upshot of the conflict is that it is in DSM-IV, but without any mention of trauma or causes – because professionals just cannot agree on that. I’ll be coming back to this.

    But the point for us as clinicians is that there are many people with these characteristics who are badly served by mental health services, yet cost a fortune in repeated and prolonged hospitalisations, frequently having identifiable episodes of depression, panic, psychosis and other axis one conditions. So without much doubt, I would contend that they are the business of mental health services. And the NHS guidance which was published earlier this year – “Personality Disorder – no longer a diagnosis of exclusion” now makes that a matter of public policy.

    I’d make the parallel with ichaemic heart disease – like PD, it is no longer a condition where people need to be treated just for their symptoms, like angina, and their heart attacks when they have them – but it is something they have all their adult lives – and which is amenable to amelioration and harm-reduction in individuals, and prevention in a population. As you should see when I talk about a developmental model of personality disorder, prevention is something quite close to what good schools do as part of the citizenship curriculum, churches and community groups do as part of their neighbourhood work, emotionally literate companies do as part of their management policy – and something that is done very badly by most of the health service. Of course, the most corrosive and destructive consequences are at the severe end of the spectrum and come from lifelong poverty, inequality and other forms of social alienation. But I hope that will make sense when I have explained how emotional developmental needs (which we all have) can be formulated.

    But let’s come back to how this relates to trauma with another analogy. Trauma is easily understandable if a single event happens to somebody, for which they need the right conditions to recover. If we consider a broken arm, the type of treatment will obviously depend on the nature of the trauma. With a greenstick fracture in a child, which is like a hairline crack in a soft bone, it just needs a bandage and gentle handling for a little while. Usually a simple broken arm needs a plaster cast to hold it in place for six weeks, until it has knitted together and solidified. If it’s more complicated, like a compound fracture which has broken the skin, it needs other thinks like soft-tissue surgery and antibiotics. Even more treatment would be needed in an unstable fracture, where it will never heal unless it is held together with pins and plates and rods and external metalwork. Well, I think by now the analogy with broken bones is creaking (and getting a bit arthritic…) – but the point is that a single definable trauma will be treatable by different means, depending on whereabouts it struck and how much damage was done.

    But what about trauma that goes on and on – or is more a lack of good input rather than a particularly bad experience? The first – when it goes on and on - is like a deformity you get early in life or are born with, and gets more complicated and disabling later in life if it goes untreated: like scoliosis (spine curvature) or club foot. Scoliosis is a good analogy because the pressure on the spine, as a child starts to walk is like repeated or continual trauma that is putting the joints of the spine progressively more and more out of line. The second – lack of a good enough environment - leads to “failure to thrive” in children – where they fail to grow enough, without any physical reason being detectable.

    The point I want to make is that all sorts of things can be traumatic – but if they are continuous and subtle, or hidden (perhaps because of shame or learned helplessness), they will not be easy to detect. In the literature we provide at Winterbourne and discussions we have with personality disorder referrals, we give the list as trauma, abuse (which can be physical, sexual or emotional) then neglect, deprivation and loss. As well as all being a sort of trauma, there is a good argument to be made that they are all actually loss – whether it is loss of something psychologically needed (like ability to trust when somebody is secretly sexually abused), or loss of something that you have never had (like a child growing up without the experience of ever being loved), or loss of security and sense of the world being a safe place as a consequence of an overwhelming event.

    Now I’m going to move on to how others describe it in terms of trauma theory, and then move towards some other – but recognisably similar – descriptions of borderline PD.

    Trauma theory

    Sandy Bloom is a psychiatrist and psychotherapist working in New York setting up “sanctuary” programmes and staff training for socially disadvantaged and delinquent adolescents. She is interested in TC work in this country, as it uses a similar technique of creating a suitable therapeutic environment. After describing simple trauma, she says:

    “Problems arise, however, when trauma does not stop, or when it is too severe for anyone to deal with, or it is a secret trauma who nobody else is allowed to know about.
     In cases like these the gap between everyday reality and traumatic reality can continue to increase. The individual cannot deal with the traumatic experience because it continues to pose some kind of life threat and the culture cannot or will not help the person come to terms with the experience. The person is unable to establish a coherent and consistent sense of identity because the traumatised self is directly in conflict with the normal self. He or she is unable to establish a comprehensive meaning system or philosophy of life because they harbour too many internal contradictions. Under these circumstances, dissociation becomes a way of life and disintegration of the personality continues”

    So, although she rarely uses the “personality disorder” label in her writings – she is describing, from an eclectic / CBT background, exactly what psychoanalysts have been using much more rarefied language about, for over a century. She goes on to elaborate:

    “Less understood [than the trauma of a single awful event] is what happens to children’s growing sense of identity when they are exposed to repeated and overwhelming stress. In these cases, their identity does not solidify around a solid core. Instead it remains fragmented, and the fragments are separated from and inaccessible to each other. The end result of this chronic dissociation may be a serious inability to understand or contend with consensual reality. On the surface, some non-violent forms of sexual abuse may not even appear to be traumatic. It is not necessarily the pain or terror that is the most traumatic aspect of a childhood experience but the betrayal that is so damaging. Children are helplessly dependent on their caregivers. In order to survive, they must trust those on whom they depend. When those caregivers turn out to be untrustworthy, children must deny this reality. Often this betrayal is denied or minimised by the perpetrator as well as by other family members and other members of the child’s community. This means that the experience of individual reality becomes increasingly divergent from cultural reality. The individual symptoms are related to the child’s or adult’s attempt to individually make sense of distorted reality. The child, in such a situation, must make a choice. Deny your own individual reality and fit into the culture, or defy the cultural beliefs and end up alone and eccentric or even “crazy”. It is an impossible choice.”

    This has strong echoes of some of the postmodern writers, like Wilke, who says that borderline is not a condition which needs treating in the same way as other illnesses, but is a communication of alienation which must be heard, and a way of experiencing reality which needs to be understood. And – if there’s any antipsychiatrists lurking I the audience – this is only inches away from what RD Laing said when he wrote about psychosis being understandable (Divided Self) and madness being as much a problem with society’s view of reality as the individual’s (Sanity, Madness and the Family).
    But …  Going back to a more classical view of trauma – based on learning models and fight/flight responses, Bloom makes what I think is the essential leap into subjective experience and the need for relationship and interdependence:
    “The alternating symptoms, of avoidance and intrusive flashbacks or nightmares, are the two interacting and escalating aspects of PTSD. As they come to dominate traumatised people’s lives, they feel more and more alienated from everything that gives human life meaning – themselves, other people, a sense of direction and purpose, a sense of community. It is not surprising then that slow self-destruction through addictions, or fast self-destruction through suicide, is often the final outcome of these syndromes. For other people, rage at others comes to dominate the picture. They are the ones who end up becoming significant threats to the well-being of the rest of us”.

    We have come up with a label for those particular ones in this country – or our policy-makers have – and it’s “DSPD”, dangerous people with severe personality disorder. Apart from where it has got money attached, I think most people are moving back to calling it Antisocial PD, or severe Antisocial PD. But  to return to Bloom, and how she started to recognise borderlines, she describes some of her patients:

    “Many victims of sexual abuse had serious psychiatric problems, and yet they were not psychotic. They often self-mutilated themselves, frequently on their breasts or in their pelvic region, as well as on their arms and legs. Many had been raped as adults as well. They tended to have extremely disturbed, abusive relationships. Their sexual adjustment was often very distorted. Commonly, they were either totally abstinent or promiscuous without ever truly enjoying it. They had multiple physical complaints and surgical procedures, often with negative findings in the face of severe and chronic pain. Eating disorders were very common including overeating, alternating with bulimia, interspersed with episodes of starvation, and a preoccupation with body image. They often had weird psychotic-like symptoms and heard voices or heard things that were not there, or acted in bizarre and spaced-out ways. They had established problematic relationships with people in their social lives and then with us. At first they were very good and compliant, the ideal patient, and then – at the slightest sign of rejection – they became unreasonably hostile, angry, rejecting and inconsolable. They were either all-good or all-bad, as were their relationships, as was the entire world. They shared symptoms very similar to other trauma victims. They showed physiological hyperarousal and hypervigilance. They were unable to self-sooth or modulate emotional arousal. They had difficulty managing anger and as a consequence often failed to self-protect adequately while acting aggressively towards others.

    So here we are seeing a mixture of the DSM features of PTSD and Borderline, plus several others too – classically the arousal and vigilance, but also the various emotional instabilities characteristics of the borderline definition. She now goes on to explain the causes and consequences of the psychotic and dissociative features:

    We began to understand that much of what we had called psychotic symptoms were actually the dissociated memories of previous experiences. The hallucinatory voices they heard were related to the voices and sounds surrounding the sexual abuse situation. The hallucinatory visions were fragmentary memories of the trauma. The paranoia was fear combined with temporary inability to separate the past and the present. The apparent lack of awareness of their own behaviour and the subsequent failure to take responsibility for it was related to the fact that they were relatively unaware of much of what they did in another state of consciousness. The self-mutilation was a form of self-control, a problematic form of self-soothing, an addictive behaviour that had worked in the past under severe stress but had taken on secondary meanings and uses over time.

    Then she goes on to write about the effect these patients had on her and her staff:

    We had termed these patients “manipulators”, “attention-seekers”, “hysterics” and “borderlines” – all a way of saying that our helping efforts were thanklessly frustrated.

    And then a dawning realisation that the way they had been conceptualising these people’s difficult behaviour was the problem, and not the solution:

    When we began to understand that these patients had suffered extremely abusive and depriving situations as children, had developed certain coping skills to survive, and had remained arrested in an earlier stage of development because of an extremely damaging, and often very secretive home life, our attitudes towards them changed dramatically. We became less offended, less threatened, by their symptoms. Now we could understand what they were doing, what they were trying to tell us about their past lives. And we could explain back to them what it was all about, why it all DID make sense, given the context. Once they were able to understand, they were able to begin the long process of gaining some compassion for themselves and their own suffering. Using this bridge of compassion they could start the process of rebuilding, of starting to mature again from the point where their growth and integrity was stopped.

    So here she is saying that what made the difference is listening to the patients’ communications (at all levels – presumably including when they are silent and uncooperative, or angry and attacking) and understanding that it was the consequence of trauma. Which is a good point to move to other accounts of BPD.


    Borderline personality disorder

    Over 200 years ago, Sydenham, of Sydenham’s Chorea fame, hit the nail on the head when he said:
    “They love without limits those whom they will soon hate without reason”

    Gunderson describes borderline people as those who feel they have been treated unjustly, have not received the right attention or protection, and are angry at this. Here is a table summarising and paraphrasing Gunderson’s ideas.
     Once these people are young adults, they look for somebody to make up for these deficiencies, and when they think they have found them (this may be intimate partners, therapists or others) they form an intense relationship based on very high expectations, and at the moment of disappointment – which almost inevitably follows such high expectations – they feel confused and abandoned. This includes rage, despair and self-hatred at causing their own rejection – with a strong impulse towards self-destructive and suicidal behaviour. In others, it can cause guilt to be felt, or protective behaviour, at their own perceived deficiencies – a process we call projective identification. But in a different model, if any of you know CAT – cognitive analytic therapy – this mixture of consequences and binds is exactly what goes into a reformulation diagram.
    In a forthcoming book about treatment environments for borderlines, an Italian psychiatrist, Aldo Lombardo, says:
    There are simply two core deficiencies – no control  of frustration, and inability to trust others. These and all the symptoms – anxiety, depression, criminality, paranoid ideation and self-harm in its many forms (including drug and alcohol abuse, promiscuity, overdoses, cutting, and eating disorders) – can be cured by the borderline person him or herself if they have a programme of therapy in which to develop sufficient ego strength to develop a core experience of identity.
    Then he goes on to describe how this can allow “total transformation of the individual”.

    But this is hard work - the Seligman experiments on animals in reversing learned helplessness have shown that it takes up to two hundred attempts of showing them that they won’t get the electric shocks and that “the world IS a safe place” before they learn it and believe it. There is no short term therapy that can alter what is a physiological, maybe even neuroanatomic, fact. Dragging people out of their metaphorical cages (like Seligman did with the animals who had become helpless at trying to avoid the electric shocks) is a difficult task and few helping professionals have the patience to last through two hundred potential trials, and nor does the health care system. But – as an aside – I would propose that people who have been through that process of recovery themselves, and been dragged out of the cage two hundred times, may be just the ones who DO have the patience and dedication and care to do it – and I think that is exactly what happens a lot of the time n a good therapeutic community.

    Just to bring a couple of other writers into the frame, Peter Fonagy describes this process as “disorganised attachment” which leaves an individual without a theory of mind. They have no understanding of the thoughts of others.

    Briere, who is a well-renowned Californian traumatologist who argues for the “complex PTSD” concept really sees borderline as the consequence of unrecognised and untreated PTSD.

    And Winnicott saw the absence of a secure base as the foundation of the “antisocial tendency”.

    The last point I want to make about trauma is how our systems and practices can be experienced like the repetition of an earlier trauma. When, for example, somebody expresses suicidal thoughts and gets detained under the MHA, the thought may well not have been an expression of intention – but a communication of distress. And this is an impossible-to-get-it-right bind for clinicians: the only apparent options are to take a risk, or act defensively. If one chooses to take the risk – it might be right, but we will have to carry it, and be able to defend the decision, not knowing for sure until we hear later – maybe much later - that patient is safe. And with borderlines who may feel abandoned and not taken seriously by a clinician who has a slightly brusque manner, or smiles in the wrong place, or forgets a small detail of their history, that risk is a real one – self-harm may well follow, and quite possibly an accidental suicide. On the other hand, by taking their rights away, it will either feed an unhealthy dependence (with a possible long and disturbed admission ahead) – or be something they feel hurt and devalued by – in which case they may well act angrily and destructively. So an act of professional taking-care, maybe done somewhat defensively because of the pressures in the system to not tolerate any risk, has repeated their developmental experience of over-reaction, inconsistency, or not being listened to. It feels like the same thing which left them unable to form trusting and fulfilling relationships is happening again. The trauma is being re-enacted in the transference, and it is about the dynamics of POWER. We have to handle that power so very carefully in these situations – and often cannot get it right whatever we do with the resources we have.

    The other solution – which is not available immediately at the moment in Berkshire – is to have an already established “safe space” for people in this sort of crisis to have their distress heard and their turmoil understood non-judgementally, and probably substantially by others who have been through it themselves. I’ll just give a quick example of my favourite service on earth – the Open Psychotherapy Centre in Athens.

    When they receive a call from somebody in distress, they immediately call a crisis meeting and assemble a “flying squad” of four: not people specifically on-call, just those able and willing to go when they have heard what the crisis is about - a psychiatrist, a non-medic, and two patient members of their therapeutic community. They go out to the home of the person in distress, talk to everybody for a couple of hours, and decide together with the family who needs help, and which bits of their therapeutic programme would help. (The programme there is a kaleidoscopic collection of different groups of different depths and type and intensity). That person (or possibly people) then join the programme, and plan their “care pathway” through the different therapeutic opportunities – which might be for a few weeks of focused work or several years of deeper more intensive group therapy. There are no beds – and some of the most psychotic and personality disordered individuals are contained more safely than as inpatients in the state service, and get something actually therapeutic, rather than sterile, empty, arid, and case-managed without any therapeutic core to the work. In my view, this Athens-type service, with all its user involvement and lack of bureaucracy, is what CPA should feel like, and the new crisis, treatment at home and assertive outreach teams should be modelling themselves on these sorts of ideas. With sufficient managerial support (particularly for training) over the long period it would need to develop, I think it should be possible for it to be a set up as a genuinely therapeutic environment IN THE COMMUNITY – dynamically managed as a clinical network of services. But that’s a talk for another day - back to the theory of personality disorder now.


    Developmental model

    What I want to propose is a simple theory that is a framework to the importance of the patients’ experience in determining the treatment they need. I believe that the internal experience is what is changes people - in the same way as our experience of life as we grow up makes us much of what we are.  It will use some sociological ideas, take some of the psychoanalytic concepts of object relations theory and borrow from the ideas of group analytic psychotherapy. It’s a way of putting several different theories on a map, which is centred on the experience of the patient.

    It is an overlapping sequence of five linked ideas - five concepts describing the essential qualities of a therapeutic environment.
    The way I have put them together is also a progression, a developmental progression - from the primitive vulnerability of attachment, through both supporting and controlling aspects (maternal and paternal if you like) of containment  -- to the social interaction of communication. Note how communication skills are always emphasised as if we can just be told to “DO” them – I am saying that other things need to come first. Then, after communication, onto the adolescent struggle of involvement and the adult and empowered position of agency - finding the self which is the seat of action, and for our patients to deploy their own power and effectiveness.

    But before that, I want to think how it fits alongside biomedical models of personality development - as I don't believe it is in conflict with them. Both are relevant, and completely intertwined.

    Emotional development - primary and secondary.
    In this theory, emotional development is something that happens to all of us. It is the sequence of necessary experience to end up with a normal personality. Of course, nobody's personality is perfect - but for most of us, our development has been "good enough" (as Winnicott would say) - so we survive in a reasonable way most of the time. But some people end up with personalities that mean they have considerable difficulty understanding themselves, each other or the world. They have trouble in much of their dealings with what we call reality: like education, employment and general functioning. I have already told you how Sandy Bloom sees this as a consequence of repeated or unresolvable trauma. In object relations language, these people lack object constancy, relate in a part-object way and live continually through intense transferences. In psychiatric terms, they have personality disorder and an increased risk of episodes of mental illness. Really, borderline is only part of it, but it is the part we are dealing with today.

    Is it genetic or environmental? Nature or nurture? I want to argue that the question is irrelevant, because it is more complex and unpredictable than you could ever analyse, and in a way it is all of both – and maybe more as well. A child is born with a certain genetic makeup, and history of nourishment, space, oxygenation and chemical milieu in utero. Before birth, these have an almost total effect on what sort of brain and body he or she has. Some children are born with much more difficult constitutions than others: more needy, we could say. For example, a child with certain random genes, severe anoxia at birth or exposed to much alcohol in utero will have a different brain to a luckier child. And some of those children will be "more difficult" - it will be harder to meet their emotional developmental needs.

    After birth, what happens to every child is development. For the lucky ones, as long as they have a "good enough" parenting, they will emerge well-adjusted. The constitutionally disadvantaged ones may come out OK if they have extra input for their emotional development - maybe that includes professional help. But any child who has a bad experience of emotional development will end up at risk of having an unhelpful view of themselves, other people, and the world - in other words, a personality disorder. By bad experience, I mean the things I have already mentioned – neglect, deprivation,  abuse, trauma, severe loss.

    Some with a fortunate or strong constitution may be protected, and able to cope fairly well as adults, because they have some good relationships to help develop a less distorted view of themselves, others and the world. Those who start life with a congenital disadvantage are very much likelier to suffer a severe impact from inadequate emotional development. Here is an oversimplified representation of this.
    And to make it more complicated still - and even more impossible to separate out the nature and nurture effects - both aspects (what we are born with, and environmental conditions) are continuously variable, and not simply "good" or "bad". Environmental conditions (including how much a child feels loved) also change over time. And I think modern neuro-imaging and neuroscientific techniques support this idea by showing us that environmental events can have an impact on brain structure itself. And of course, it works the other way too. The way a child behaves - because of its brain maybe - will have an effect on, for example, whether it is punished or comforted. So I think it is far too complex to ever say reductionist things like "personality disorder is 65% genetic" - it is never possible to separate them like that.

    To go even further, we can add the effect of human agency at every point – meaning we all make conscious or unconscious choices that may be adaptive or maladaptive at every decision point in our lives. These will have an impact on our thoughts, feelings, behaviour and subsequent choices – in a systemic way with multiple dependent and independent variables that is closer to chaos theory – than this simple 2 by 2 table. For example, ideas such as “sensitive dependence on initial conditions” (as the butterfly effect is properly known) and the complexity of what is called “deterministic nonperiodic flow” (from when they were first trying to work out the equations to define unpredictable events) – seem much closer to this than statistical techniques like regression, however many variables sophisticated computer programmes can now handle.

    So emotional development is something that needs to be considered for everybody - not just for those who end up with severe and incapacitating difficulties. And what I have described is what I call PRIMARY EMOTIONAL DEVELOPMENT.
    [slide - back]
    By that, I mean what happens - or largely happens – or should largely happen - as a normal part of growing up. So constitutional make-up + primary emotional development = personality. And I was taught as a medical student that personality + stress = neurosis (except we call it symptoms nowadays). Putting those two together gives constitutional make-up + primary emotional development + stress = symptoms. And the one I work with, and want to concentrate on here, is the emotional development.
    Psychotherapy, and therapeutic communities in particular, offer the opportunity to re-experience emotional development  which I call "SECONDARY EMOTIONAL DEVELOPMENT". Hopefully, from this, people can gain experience that leads to better adjustment, and less likelihood of breakdown with mental illness – in other words, the impact of their genetic and constitutional makeup, and external stress, will cause less distress and symptoms to them, and hopefully to those around them.

    So, back to the developmental sequence. I am saying that the five necessary experiences for a satisfactory emotional development are
    •   attachment (feeling connected, and belonging)
    •   containment (feeling safe)
    •   communication (feeling heard, in a culture of openness)
    •   inclusion (feeling involved, as part of the whole)
    •   agency (feeling empowered with a solid sense of self)

    Now I will just spend a minute on each to explain its roots, and how we try to recreate it.
    All individuals start their lives attached: umbilically, within the mother and with the blood of one flowing right next to the blood of the other.  At birth, this attachment is suddenly and irreversibly severed: it is the first separation and loss, with many others to come later.  How well the emotional and nurturant bond replaces the physical one was classically described by Bowlby. He describes problems resulting in anxious attachment or avoidant attachment -  and this, plus subsequent developments of attachment theory, have been well verified by experimental and clinical research; and of course prominent in that is the local work by Peter Cooper and Lynne Murray. But other writers have said it in different ways too. Balint's "Basic Fault" is about a lack of fit between mother and baby -the bond is not secure, and nor is the infant.

    When disturbance is this fundamental, the first task of treatment is to reconstruct a secure attachment, and then use that to bring about changes in deeply ingrained expectations of relationships and patterns of behaviour.

    What we so often find in working with these people is that attachment is powerfully sought, but strongly feared. This is the struggle between Fairbairn's libidinal and antilibidinal egos: the one desperate and needy, and the other angry and rejecting – the classic borderline split, if you like. Not enough stable ground has developed between them, and the demands of reality almost always meet the emotional responses of anger, shame, humiliation and pain. So clinically we need to understand and accept the turbulent and traumatic nature of disturbed attachment patterns. But we also need to be aware of the risks of dysfunctional attachment – like anxious attachment (with possible pathological dependency – and the serious consequences of staff having affairs with patients), and avoidant attachment (with people becoming dangerously isolated, and being likely to kill themselves).

    This one is about the experience of safety, and the capacity to trust oneself, other people and the world in general. A balanced internal representation of containment is both maternal and paternal – sorry to use stereotypes, but it is quicker. The maternal element is safety and survival in the face of infantile pain, rage and despair.  All those are certainly permitted, and this in itself may be a mutative new experience for deprived or repeatedly traumatised people, whose usual expectation will be to face hostility, rejection and isolation. Now, in a good therapeutic environment, they have the new experience of not having these powerful primitive feelings denied and invalidated. 

    The paternal element is about limits, discipline and rules. Again it is safety - but safety through knowing what is and is not possible and permitted. The same as knowing the limits, or enforcing the boundaries.

    Bion described this process best: he talked about the turbulent and primitive internal experience of the process, and its link to thinking and the earliest mental states imaginable, when islands of experience – such as hunger and discomfort - dominate the infant’s mind with such overwhelming emotion and ferocity, and how this is conveyed and contained by another, usually the mother. Winnicott described the sensuous and nurturant qualities of the environment in which it needed to happen: he talks about the mother who actively gives the infant a sense of its own existence. Here is the difference between Bion’s "containing" and Winnicott’s "holding" - one is mostly inside (in the mind), and one is mostly outside (in the environment).

    To create it, we need to have the patience and tolerance of a mother with a screaming infant which she is trying to feed, and the clarity of boundaries of what IS an IS NOT allowed. Good cop, bad cop I think you could call it  - hard for one person to do both.

    Tom Main wrote that the culture of a unit is more decisive in bringing about change in human relationships, than is the structure. He wrote of the "culture of enquiry" .  Nowadays, I think of it more as a culture of openness to make it less inquisitorial – it’s collaborative, not like the Spanish Inquisition. Of course, openness is what a lot of therapy is all about: "talking treatments", "putting it into words", and "being heard". It is very important, it is at the heart of therapy - but I think we must not forget what comes before it, and what needs to be done after. A demand on people for open communication is simply not enough: they must want it, and feel safe about doing it. This requires an intangible quality that must be present in the atmosphere. It mostly depends on establishing the first two conditions: attachment and containment - for it is only when a somebody belongs and feels safe that they can start to look at and think about potentially difficult and painful experience. Patients or staff, I would add.

    I think this is what Foulkes implied when he wrote
    "Working towards an ever-more articulate form of communication is identical to the therapeutic process itself"
     - so the therapeutic process is not just one of communication, but the struggle to get into a position to be able to communicate. This means establishing the network of relationship in which that can happen.  The term that group analysis uses for this is the matrix. Like for containment, producing this sort of open atmosphere is more an attitude than a specific skill – a way of “being with” rather than “doing to” as Heinz Wolff decribed it. I think you can train people for it, and although it’s hard to teach exactly what it is – it is like a capacity, and perhaps a competence.

    This moves away from models which fit with individual therapy, and are more specific to group dynamics – and TCs in particular.

    For 24 hours a day, all interaction and interpersonal business conducted by members of a community "belongs" to everybody.  The expectation will be to use it and understand it as part of the material of therapy. Not in isolation, but in the real and "live" context of the interpersonal relationships all around.

    In this way in a therapeutic community, individuals can find a very deep understanding of their place amongst others: this will be examined the whole time. People are responsible for themselves, for the others, and for the relation between the two. There is "no place to hide" as one of our members recently put it.

    When the group is considered together, this is basic group analytic theory. Each has a different but vital contribution to make to the health of the whole.
    "The group constitutes the very norm from which each member may individually deviate":
     the aggregate of all the individual elements produces a thing with its own qualities and a whole that amounts to more than the sum of its parts.

    Margaret Thatcher said that there was no such thing as society, Winnicott said there is no such thing as a baby, and Foulkes tells us there is no such thing as an individual:
    "each individual is an abstraction: determined by the world of which he forms a part".
    This is the opposite of our current individualistic views, and it gives us the possibility that the richness and variety of the web of relationships between people, with all the rights and responsibilities that implies, is itself a creative and reparative force - in group analytic words, the matrix.

    We create it by getting to understand each other (staff and patients) – and for staff to understand each other by having their own time and space to work out what’s going on.

    In 1941 at Mill Hill Hospital, Maxwell Jones found that soldiers suffering from "effort syndrome" were found to be more helpful than the staff at helping each other. At Northfield, Bion's experiment was stopped after six weeks when he refused to own total responsibility for the disorder of others, and he was replaced by Main, Foulkes and Harold Bridger. These two locations are the start of therapeutic communities, and the point I want to make is that both made fundamental challenges to the nature of authority. Now many of the challenges seem less strange, and they even have become part of Government policy, like with service users becoming experts about their own condition. But in other ways we have gone backwards – and patients and staff have become disempowered in a command and control structure that does not allow much professional judgement or flexibility at all.

    But for therapeutic communities, this aspect of user-power was always there. It like Jung's idea that the patient's unconscious knows better where to guide the therapy than does the analyst's expertise.  It also has a strong tradition in the teachings of Harry Stack Sullivan and the interpersonal theorists, as well as Kohut, where any power imbalance is seen as authoritarian, distancing and inimical to the establishment of a satisfactory therapeutic space.
    This is the principle of agency, where authority is fluid and questionable. It is not fixed but it is negotiated - and the resulting culture is one of empowerment. This goes much further than the original "flattened hierarchy" of democratisation, that everybody picks up on. Rather than being a fashionable idea, or a policy which is imposed on a unit, it demands a deep recognition of the potential intrinsic worth of each individual, and it is about REAL social inclusion – but where everything is open to scrutiny – so respect and authority need to be earned. Nor is it a "harmony theory" that says we simply have to find this positiveness within people - for it includes powerfully destructive, envious and hateful dynamics which exist in all of us and are sometimes beyond reach. However, working this way does presuppose the possibility of a considerable degree of professional intimacy, which is an intimacy that is safe, open and healing rather than previous ones which may have been frightening, dark and abusive.

    Having a second try at emotional development
    So Secondary Emotional Development is what we try to do by recreating these five conditions in a therapeutic environment. We are trying to provide a psychic space in which the things that went wrong or got stuck in primary emotional development can be re-experienced and re-worked in this artificially created "secondary emotional development". It can never be quite the same as first time round, or quite as good and nurturant, but we try to make it as good as we can get. People might not be fully “cured”, but we hope they’ll get a life – and go to college or get work, rather than living off DLA.

    But this secondary emotional development can also work the other way and produce an environment which is unhealthy, or anti-therapeutic. With a culture that discourages attachment, that does not feel safe or containing, with perverse and distorted communication, unspoken or top-down rules about what is and is not admissible, and power based on arbitrary criteria.  Where human needs for secondary emotional development are being ignored or obstructed. And this can be as much true of a school, office, company or a hospital ward as of a family or therapeutic community: any setting where a group of people are emotionally engaged in some sort of developmental task.

    So what I am talking about is not only about specialist hospital or prison units for treating personality disorders - it it about everyday life, and struggling to try and meet needs that we all have.

    So that is the developmental model of personality disorder – now I am just going to finish by pointing out some parts of critical theory where the same sort of arguments are being made: what two psychiatrists in Bradford have been saying, and a postmodern Guru from Leeds and somebody who was on the radio last year.

    Critical theory

    The pair in Bradford are called Bracken and Thomas. Here’s their opening argument:
    In a nutshell, this government (and the society it represents) is asking for a very different kind of psychiatry and a new deal between health professionals and service users. These demands, as Muir Gray has recently observed, apply not only to psychiatry but also to medicine as a whole, as society's faith in science and technology, an important feature of the 20th century, has diminished.
    According to Muir Gray, "Postmodern health will not only have to retain, and improve, the achievements of the modern era, but also respond to the priorities of postmodern society, namely: concern about values as well as evidence; preoccupation with risk rather than benefits; the rise of the well informed patient." Medicine is being cajoled into accepting this reality, but psychiatry  faces the additional problem that its own modernist achievements are themselves contested, and often with popular support, which is not the case in other branches of medicine .
    They go on to argue, incontrovertibly in my view, that mental health cannot only be a technical and scientific endeavour – and patients will be ill-served unless sufficient importance is given to social and cultural factors. It seems blindingly obvious really, but it has taken a well argued article in the BMJ last year for most of us to rub our eyes and say “oh yes, of course”.

    Their approach has a similar perspective to Zigmunt Bauman – a sociology professor in Leeds - about limits to how far we can tolerate modernity, and that it needs to be leavened with something softer and more human - less hard-edged, and more unpredictable. Here is a quote from a Bauman paper called “postmodern ethics”                                                          [slide]

    I won’t read it all – just to emphasise these sorts of ideas – in the middle sentence:
    Dignity has been returned to emotions; legitimacy to the 'inexplicable', nay irrational, sympathies and loyalties which cannot 'explain themselves' in terms of their usefulness and purpose.

    Bauman’s approach is also a call for accepting rather than trying to understand and control the complexity of phenomena which we are always immersed in – which has sympathies with the uncertainty and chaos theory that I have already mentioned. And it has a very strong echo of Keats’ negative capability: “When a man is capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason” – which is often cited as a requirement for creative thought. I also believe it is what we are getting at when we talk about psychological “containment” – how distress and disorder can be best be dealt with by being with somebody (in a helpful way, hopefully!), rather than doing something specific to them.

    The last connection I want to make is the Reith lectures last year – Dame Anora O’Neill. I remember I used to catch it on my Tuesday morning journey between Fair Mile and Winterbourne, and her main point was that we have now lost TRUST, in each other and in our institutions. And this is to such an extent that we now need to find ways to re-humanise so much of public life, policy and debate that has become so untrusting – and therefore dry and technical and sterile. I think we can see that sort of process in the early push to implement the National Service Frameworks – very heavily from above, with no local autonomy until trusts get foundation status – by having most of their targets met. Checkmate – no chance of doing anything off the tick list; perfect social control.

    But maybe there are a couple of grains of encouragement to finish with. Firstly, service users need to be seriously listened to nowadays, and they are not going to put up with services that further dehumanise and alienate them. I think it is exciting working with service users – because they have a fresh perspective that makes you think “yes, why DO we do it like that?” – and sometimes you can justify it and sometimes you can’t. But finding solutions that satisfy both of you can be very creative.

    Secondly, I think the opportunity is there for us as clinicians to put the flesh on the skeleton of “modernised mental health services”.

    What we need to end up with is user-friendly services within the given frameworks, so they are compassionate, and humane, and hopefully therapeutic in the widest sense - and avoid being bureaucratic, inflexible and insensitive to people’s subtle and different needs.

    We need to collaborate with our patients to do this, and I hope managers will be able to help us with the task once they let us get on with the job, which I seem to remember them promising a couple of years ago – when they were talking about management fading into the background.

    But if we can’t get back to having meaningful clinical input and working together on these fundamental patient-centred considerations – about things like the real trauma people have experienced, and the difficult way they relate to others - I don’t hold out much hope for our managers doing it by themselves with a bunch of flip charts and option appraisals.