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.