Wednesday, 14 December 2016

Getting it all together in the PD World

Several years ago, the National PD Programme's learning network seemed to be a thoroughly useful and productive way to learn how to set up numerous different services, without the need to follow a recipe first tried in America - or fearing the next flying visit of the compliance police. Sadly, the two or three events per year dwindled to nil as the DH's programme ran out of steam, influence and money before it was finally shut in the aftermath of the 2008 financial crash.
But if the message at that closure was 'you are on your own now', this event shows that those of us in the field - at least those who believe in genuine co-creation with service users, and a need for different services in different local contexts - are starting to get together, and get it together to make a noise about what good serfvices are.

This might - given a fair wind - all come together under the umbrella of BIGSPD, of which this was the second national event for PD services to come together. It is designed as the 'Community of Practice', and will move between different places across the country - and link in with other active processes such as the Tier 4 specialist commissioning with NHS England, the quality network process at the Royal College of Psychiatrists Centre for Quality Improvement, Enabling Environments and 'Relational Practice', and perhaps some increased political lobbying and public awareness.

Thursday, 10 November 2016

GASI Danish Discussions

The Group Analytic Society Individual takes research seriously - and the meeting in Aaarhus, my first ever time in Denmark, was a good mix of type I evidence, politics, progressive thinking, and the usual argy-bargy about the alphabetti spaghetti therapies.

Here's an edited version of my two-pennyworth:

Therapeutic communities for the future:
surviving modernisation and staying at the radical edge

Therapeutic Communities (TCs) developed from models of treatment that broke from traditional practice, and posed profound challenges to dominant thinking at various times: at the end of the eighteenth century (Tuke, 1813), during the Second World War (Bion, 1961; Harrison, 1999), and in the 1960s (Foucault, 1965; Goffman, 1968; Laing, 1967; Rapoport, 1960). More recent descriptions encourage medication reduction and use of other radical ideas (Haigh, 2007).  Their clinical work also takes account of the interface between the individual and their social and cultural setting (Jones, 1956). Therapeutic communities involve user empowerment, and the development of a sense of agency; democratisation, through user involvement in the day to day running of the community, shared decision-making, and peer therapy (Haigh, 2013).   Therapeutic communities, both democratic and substance abuse, operate all over the world, in diverse countries and cultures, and have had to adapt to local demands (Haigh and Lees, 2008).

Many clinicians, academics and service users who understand therapeutic communities believe that they are guided by an underlying radical challenge to authority and oppression (Baron, 1987; Jones, 1979; Spandler, 2006, 2009) that was articulated in the 1960s (Cooper, 1968), and if that underlying therapeutic philosophy is lost, they will have moved from being an emancipatory movement for the dispossessed to becoming a mere therapeutic technology in a crowded field.

This intention of this paper is to illustrate the adaptations that democratic therapeutic communities have made in the last two or three decades in the United Kingdom. To turn from ideas of revolution and emancipation to the subject of survival, these changes have been undertaken in to cope with threats in the real world. Although those threats can be seen as ontological, ideological or existential, they usually impinge in a less abstract way: with economically-driven closure of services, loss of clinicians’ jobs and the sale of property and land. The response to the threats has been underway for more than twenty years, and is presented in four different areas. To start with a ‘what TCs need to do’ list:

1.    TCs need to… Know what they are doing and doing it well: quality improvement, such as the Royal College of Psychiatrists’ Community of Communities project, started in 2002 in the UK. Also developed in Australian TCs since 2007 and in Sicily since 2012.
2.    TCs need to… Understand what they are doing, and showing that it works: this is producing the research evidence in the right way for people who run and pay for mental health services. Nick Manning, the eminent sociologist calls it the ‘politics of data’: to what extent can we work with ‘the system’, and to what extent do we need to resist it?
3.    TCs need to… Offer training which can convey the unique experience of having the sort of relationships people have in therapeutic communities, which is difficult to describe without experiencing it.
4.    TCs need to… Be willing to operate therapeutic communities differently, to spread the ideas beyond therapeutic communities – and join forces with others who have a similar therapeutic philosophy.

These four themes are quality, research, training and innovation.

1              QUALITY: Knowing what TCs are doing and doing it well.

The ‘Community of Communities’ started in London in 2002: members of the steering group of the Association of Therapeutic Communities (ATC) approached the Royal College of Psychiatrists to set up a project, initially funded by the National Lottery, to bring therapeutic communities together. The methodology reflected the beginning of the ATC in 1972 – with communities visiting each other, and sharing their ideas and practice - but also incorporating the rigour of contemporary quality assurance. The aims were to reduce isolation, increase professional confidence in the TC ways of working, and provide support – as well as measuring and improving quality in a way that was accepted by the formal organisations and institutions which the field needed to relate to. It also had to be done in a way which was based on TCs’ democratic and relational principles.

The idea of written standards was incorporated – to ensure sufficient objectivity, and have the authority of the Royal College behind us. But the standards were democratically developed, using therapeutic community principles. All participating TCs were involved in the discussion, and in agreeing and voting on the first version of the standards. This ensured that the member TCs felt that they were meaningful, and owned by ‘the Community of Communities’ (Haigh and Tucker, 2004). By contrast, national standards overseen by regulatory organisations are often seen as persecutory inspection undertaken in a mechanical way by people who did not understand the processes being inspected.

This project rapidly became a recognised quality improvement process, as well as a way for therapeutic communities not to feel isolated, or not knowing if ‘they were doing it right’. Member communities became quite comfortable using language like ‘sharing best practice’, ‘benchmarking’ and ‘action planning’. We had been ‘modernised’, done the right thing, called ‘quality improvement’ - but in a therapeutic community way, that we could live with. And several other British quality networks in mental health have used some of these ideas – such as how to co-create a process with service users being completely involved, and develop a friendly informality within which the formal work is done.

By believing in the central importance of relationships, in process as well as content, we had also produced something that was more meaningful than a treatment manual. Perhaps this has introduced something of a Trojan horse, to spread a message of gentle subversion and quiet revolution, into the dry and technical world of the Royal College of Psychiatrists, and all their quality processes. There is only one quality network there that is older than us, and about twenty newer ones – covering everything from ECT suites to mother and baby units, and acute wards to psychological services. We introduced them all to working in a way that we call ‘an antidote to inspections’.

The standards and the process are all available on the RCPsych website (Royal College of Psychiatrists, 2015) – and versions have now been adapted and used in Australia, Sicily and Northern Italy.

2          RESEARCH: Understanding what TCs are doing,
and showing that it works

As a product of globalisation, medical research has become very standardised across the world – and the only ‘language’ that everybody understands is numbers. Statistics and graphs can be understood without much translation. However, those who work in complex interpersonal and relational systems do much that cannot be measured in numbers. Also, many ‘scientific’ or ‘biomedical’ psychiatrists say that the only evidence that is ‘good enough’ in the ‘hierarchy of evidence’ is ‘Type 1 evidence’. That means a meta-analysis of high quality randomised controlled trials (RCTs). This is why somebody who is now a very senior government psychiatrist once called therapeutic communities an ‘evidence-free zone’.

RCTs are difficult in TCs, because there are so many ethical problems and methodological difficulties in doing a meaningful experimental study on therapeutic communities – as well as the bluntness and coarseness of the polar ‘yes or no’ results that they give. But without these experimental studies, influential individuals and organisations can promote the idea that we are an ‘evidence-free zone’. This specific requirement for experimental studies is at the heart of the government’s National Institute for Clinical Excellence’s (NICE) work, and it is a very powerful process in the British health system. Although its stated are intentions are to provide ‘guidance’, this is often interpreted to mean ‘instructions’. Its methods are also being adopted internationally.

In my work on the committee for drawing up guidelines for Borderline Personality Disorder, I soon saw that no equivocal evidence, or doubt, or shades of grey are tolerated in what the committee see as satisfactory evidence. The process adheres very strictly to the hierarchy of evidence. To me, this represents a ‘zero tolerance’ of uncertainty. In this specific guideline I was involved with, there was little ‘high quality evidence’ for treatment of Borderline Personality Disorder, so a useful and ‘common sense’ guideline emerged which was not too prescriptive. That was because it was based on a good consensus between the experts by experience, the clinicians and the researchers on the panel. But this is called ‘clinical consensus’, which is very low-rating in the ‘hierarchy of evidence’.  Perhaps this shows that ‘no high quality evidence’ can be quite a good thing for common sense and thoughtful clinical practice! (NICE, 2009)

However, the volume of ‘acceptable’ research is growing – particularly for psychotherapy treatments for borderline PD, and therapeutic communities would have soon become invisible unless we had started to produce our own acceptable evidence. We used to say that ‘no evidence of effectiveness does not mean evidence of no effectiveness’, the only fact being that the research has not been done. Unfortunately, nobody who manages or commissions services takes much heed of this. 

My own response to this has been to think that the whole ‘evidence-based practice’ principle is based on absolutely sound principles, but the spirit of the whole evidence initiative has been lost to an unrealistic quest for absolute certainty. As a result, the whole process is reduced to an arcane and annoying game, with rules too complex for everybody except those whose careers depend on it. Such meticulousness and precision might be understood for cancer chemotherapy, but it seems out of place in disciplines like psychiatry – where diagnosis and psychopathology are based on no equivalent basic science. However, we must play the game, with all the complex rules, in order to communicate the ‘scientific fact’ that therapeutic communities are an effective treatment, to the important officers and organisations they depend upon for their continued existence.

Many colleagues with long clinical careers in TCs are convinced that people benefit from time in them. This makes equipoise difficult when randomising subjects to treatment as usual. Also, most clinicians believe that the small proportion of people who might be harmed by them can be helped to get out, with due clinical sensitivity, before they are done any damage. However, many clinicians and service users remain unconvinced that RCTs and standardised questionnaires and protocols will pick ‘outcome’ up in a way that is meaningful or sufficient. Perhaps, in a digital world where the only possible answers are ‘yes’ or ‘no’, this is asking for more than experimental methods can achieve. At the very least we need to undertake good qualitative research alongside the data from RCTs. In this way, we might start to understand what the numbers do not tell us.

In the last year, the first ever RCT of non-residential democratic therapeutic communities has been completed and published - to the standards required of the medical research establishment (Pearce et al., 2017; Haigh, 2017a). The results are generally positive, and longer-term follow up results are expected in the next few years. However, others in TCs now need to become involved in serious research and to follow this up by undertaking whatever data collection or research they can (Lees et al., 2004). There are at least two reasons for this.

The first is that there will need to be more trials in the next few years to back up the first one. Research is never finished – there is always more to know, as well as needing to test out the first results, and gather enough data to do a meta-analysis of several studies. Therapeutic communities need to get together to plan this, so that the data can make a real impact by doing large and multi-centre clinical trials.

And the second reason applies to all therapeutic community: unless you can justify the existence of your therapeutic community, with data in hard-line objective and numerical terms, you may not be able to survive. It means collecting, analysing and communicating outcome data. It could start as service evaluation (such as an annual report to demonstrate what you are doing and how it helps) but it does need to develop into, and join with, substantive and formal research programmes. Therapeutic communities as we know them will not survive in the long-term unless they show that they are doing something that works, in the format and language that the international health field demands.

In a very different frame of reference, Nick Manning, a prominent medical sociologist, asks difficult questions about what he calls ‘the Politics of Data’: where the real power is, how funding decisions are made, and what are the unstated assumptions and biases in the process (Manning, 2014). If TCs are to keep to their principles of challenging authority and holding it to account, they will need to become involved in these matters.

3          TRAINING: the only way is experiential: 
the “Living-Learning experience”

There is something about the ‘atmosphere’ or ‘culture’ of a therapeutic community that is very difficult to put into words, in any language. It is about the quality of relationships – the way people are with each other – that is experienced in a preverbal or non-verbal way. Some describe these qualities as ‘ineffable’ or ‘numinous’. Any number of books, academic papers or lectures of can try to explain what it is – but can never recreate the experience itself. Personal therapy might give some idea, perhaps more so if it is in a group format, but this will still not give a realistic experience of what it is like in a therapeutic community. People who are trained in group analysis, psychoanalysis or existential psychotherapy will probably have some idea of it – but not the continuous ‘edginess’ of it, or the ‘hurly burly’ that it often feels like. Manualised and directive therapies have reasonably high levels of predictability: this is not so in therapeutic communities, where tolerance of not knowing what might happen in the next hour, day or week is an important therapeutic factor. The spontaneous and creative solutions that the group needs to find very often mark a turning point in how people relate to each other, and to themselves.

For staff, it is very useful training to experience this, but away from the heat of day-to-day clinical work. Hence the development of the ‘Living-Learning Experience’ workshops over the past thirty-odd years (Lees et al., 2016). These are three-day residential transient therapeutic communities for staff to attend as residents, which are conducted by senior TC staff and ‘experts by experience’ (people who have been through therapeutic communities themselves, as client members, and had relevant subsequent experience and training). The format is for 15-25 strangers (most of whom are staff from different therapeutic communities) and 3-5 workshop staff to conduct it. In England, it is run it several times per year in a large manor house in Kent, which is part of an organic farm study centre. Exactly the same workshops also take place regularly in Italy (Sicily, Rome and occasionally elsewhere), India (near Bengaluru), and irregularly in other countries (which include Australia, Northern Ireland and Portugal).

It is managed by a not-for-profit organisation called ‘Living and Learning’. The organisation draws on fifteen suitably qualified and experienced staff members of different nationalities. The international group is called ‘International Network of Living-Learning Experiences’ (Living and Learning, 2017). Basic information about the events, and brief staff biographies are kept on the website.

By attending these events, and maybe only by doing so, TC staff can really come to understand what their patients and clients and service users feel like when they start in a therapeutic community, and have to deal with the process of forming numerous new relationships in a short period of time. Participants need to make decisions about what to do together, to have small stranger groups (90 minutes each, five times – regular group analytic format) with other members with whom they live with in the same house, and make meals for each other. Usually it is also quite playful, and people generally have fun together as well as experiencing intense and sometimes difficult emotions. Music is often enjoyed: one of the staff team regularly takes a guitar, and another musician on the staff team took a ‘cello once – and he sat in the kitchen playing Vivaldi while the rest of us made lunch. Various other domestic and rural activities take place, in the building, grounds and surrounding landscape. All decisions about the activities are made in the morning and evening community meetings. On the third day, everybody tidies up after lunch, says goodbye and leaves - and might never see each other again.

Experience of the group over many years indicates an extraordinary intensity, scope and level of emotional and interpersonal work that many participants do: how far the individuals and the group come in such a small period of time.

Courses are always evaluated with questionnaires at the beginning and the end, and then for follow-up a few weeks later. With this, we hope to be able to understand how people feel that they benefit or not, and we can adjust the programme accordingly. As well as receiving predominantly positive comments, we have done some basic quantitative analysis. This has shown high and increasing level of satisfaction. More recently, formal qualitative research has been undertaken using ethnographic methods. This has already shown that the courses meet the ‘Community of Communities’ standards (Rawlings, 2005), and the results are now starting to show interesting differences from other types of group relations events. Data is also being collected to demonstrate how LLE courses need to adapt to local cultures – such as the difference between (superficially) identical courses run in urban Sicily and rural India, for example. We hope this work will develop and grow into something that can be published in the scientific literature to help understand the theoretical basis of therapeutic communities, and the acceptability of the method across different cultures.

4          INNOVATION: Using therapeutic community ideas in new ways

As a result of external pressure, as much ideological as economic, much has changed in the type of democratic therapeutic communities in mental health services. We have lost all the seven day ‘total immersion’ residential therapeutic communities – no more now exist in the UK. The Cassel Hospital continues to offer medium to long term inpatient intensive psychoanalytic psychotherapy, but it no longer defines itself as a therapeutic community per se. The Henderson closed in 2010, and Francis Dixon Lodge has become a 3-day per week unit since then.

There are a few, including new types, growing up as charities and cooperatives. The state sector – the NHS in the UK – is very highly regulated and risk-managed, and is becoming an increasingly difficult context for therapeutic communities to flourish, or even survive. But these charitable or social enterprises, or sometimes commercial, therapeutic communities now sell their places to the state system when the local services have no suitable facilities to help. A more flexible range of facilities, with varying degrees of ‘TC-ness’ is a possible future development: different places for those who need a therapeutic environment with specified levels of physical containment, with types of therapy programmes suited to their particular circumstances. Not all like traditional therapeutic communities, but with some or many of the features and qualities – and the underlying values.

As well as closing the beds, non-residential therapeutic communities have also ‘reduced the dose’ over the last ten years – and TCs have evolved from 5 days per week to three, to one, or even less. A ‘micro-TC’ started in 2013 gives even less time together – it only meets together for two and a half hours per week, but is connected to numerous other therapeutic and social activities that are available in the town (Haigh, 2017b). Some are run by health services, others by social services and some are in the charitable and voluntary sector. Members of the ‘micro-TC’ make their own ‘pick-and-mix’ therapeutic programme. In this way, various therapeutic elements (psychotherapy, sociotherapy as well as the traditional psychiatric treatment) are distributed across the whole town, but with the continuity established between them - through people feeling that the whole system is joined together. This gives ‘continuity of care’ rather than ‘fragments of services’ which is otherwise so often the case. There is an interesting debate about what to call it – is it a ‘micro therapeutic community’ because it only meets for 2½ hours a week, or ‘macro therapeutic community’ as it is like it is a therapeutic community without walls, that involves elements from across the whole town?

Perhaps this is a ‘post-post-modern’ therapeutic community, and it shares some features with a faith community on the south coast. This is a church-based therapeutic community without buildings or even staff: members meet in various places in the town, and sometimes live in each other’s houses. What seems to matter most, and is the common factor with long-established TCs, is ‘the therapeutic community in the head’. That means experiencing the nature and quality of relationships around you that make you feel safe enough to be able to do the work you need, even if they are only physically present for part of the time and are with different people.

An important consideration for the future of TCs is perhaps to better recognise this ‘therapeutic community in the head’ (Haigh, 2013). In this way, the experience of being with each other is the essential element, and not the timetable or buildings. The physical space and regular timing become less prominent. This could also lead to the development of virtual, or partially virtual, therapeutic communities. Most crucially, members feel they have a sense of belonging in the community for 24 hours a day and seven days a week.

A different innovation has arisen from the work of the Community of Communities (see ‘quality’, above). In 2007, a set of ‘core standards’ was defined – the specific factors that exist in all therapeutic communities, but are not generally present in other types of service. From these, a set of ‘core values’ was established. These were the values that underlay the core standards – you did not need to be a formal ‘therapeutic community’ to hold those values, but all therapeutic communities did– as did many other places that looked and felt like therapeutic environments (Haigh et al., 2012).

Here are ten the values which are thus defined for ‘Enabling Environments’: recognizing the importance of RELATIONSHIPS is always a central requirement;  BOUNDARIES are what keeps a space safe; all behaviour can be seen as COMMUNICATION; DEVELOPMENT needs spontaneity for creativity and growth; INVOLVEMENT means everybody is responsible for the place, and each other as well as themselves; SAFETY is created through support; STRUCTURE gives a purpose to people; EMPOWERMENT comes through authority being open to question and discussion; the LEADERSHIP is responsible for making sure the environment is enabling; and external relationships are sought and valued in a culture of OPENNESS.

Standards were then written to embody these values, with several flexible criteria for each. The criteria show how to demonstrate that a unit or service is meeting the value-based standards. To work towards the award itself, there is a process of compiling a portfolio, which is often done with great pride and energy, and submitting it. As we might expect in a therapeutic type of activity, the process of doing this preparation work is more important, and enjoyable, and meaningful, than simply getting the award at the end (Royal College of Psychiatrists, 2016).

The Enabling Environments project now has nearly two hundred units as part of it network. It has been particularly successful in the criminal justice world – where prison staff are finding a new sense of purpose in their jobs, there is much less violence on prison wings, reoffending is reduced, and morale of prisoners as well as staff is demonstrably higher. Because of its success, the head of the UK Prison Service has publicly supported the project, setting it as an aim for all probation hostels, and as an aspiration of values across the prison estate.  This is at a time when British prisons are under great pressure and strain, where this project and its outcomes are seen as an area of hope in a grim landscape. Wider scope for enabling environments, particularly in the health and social care systems, is now being planned.

These examples illustrate some examples of how TCs can be adapted to fit well within modern highly-specified services - by modifications to the traditional TC programme, and using the longstanding therapeutic community ideas as the fundamental principles behind all services where relationships are important. It is likely that there are many other people, projects and organisations doing similar things, and we all need to draw support from each other.


Global managerial processes - particularly through ‘New Public Management’ (Gruening, 2001)  have led to health and social care systems being more standardised, risk-averse and regulated. While this is undoubtedly of benefit in terms of efficiency and effectiveness in areas such as cancer care or ischaemic heart disease, it produces a mechanical and technological framework for mental health services which allows little recognition of the importance of creativity, spontaneity or playfulness. It can also support care that is devoid of meaningful human interaction, compassion or kindness (Ballatt and Campling, 2011). Well-functioning therapeutic communities thrive on such elements, and cannot function well without them. Most significantly, they prize relational practice – where every individual is treated as an individual with their own personality, talents and problems recognised and respected - above procedural practice, with performance-managed adherence to closely-defined policies, targets and goals (Hoggett, 2004).

It is often a natural reaction of any team, in times of staff reduction, service cuts and efficiency savings, to ‘batten down the hatches’ and protect what they have, rather than try to change it. However, in therapeutic communities this has led to a climate of fear which has brought about rigidity, inflexibility and an inability to grasp the size and scale of changes needed – simply to survive. Therefore, many TCs have not survived: there are now less than twenty residential therapeutic community beds in the National Health Service, and nearly all the non-residential day-TCs have reduce from five-day programmes to three, two or one days per week.

But this could be seen as not so much a decline, as an accommodation – with its own distinctive clinical advantages (Haigh, 2007). Although, while we in a state of apprehension and uncertainty about survival, it is natural to fight to continue what we are doing, that is unlikely to increase the probability of that survival. The TC ‘movement’ needs to be more willing to adapt and change – while keeping to the therapeutic philosophy described above – in order to keep the underlying emancipatory ideal alive. It is not helpful to fight for the detailed structures, programmes, buildings and guidelines that worked fifty – or even five – years ago. The individual elements that are worth preserving include experiences that are difficult to isolate or enumerate: such as emotional safety, interpersonal conduct, continuity, feeling empowered, allowed to act authentically – and, dare I say – about having fun. Therapeutic communities value the playful aspects of the work, although there seems to be little corporate recognition of its value in any public services.

Modernisation may also be a reaction to some fundamental fear of ‘other’ in a very diverse and globalised world: with lack of trust in relationships is growing with the global tensions and responses we see around us, we retreat into technical solutions, certainty and individualism. In contrast, Foulkes, the founder of group analytic psychotherapy, noted that “each individual is an abstraction, determined by the world, the community and the group we live in” (Foulkes, 1946). This idea of fundamental human experience being more about our relationships than about us as individuals can be used to draw an analogy with the well-known phenomenon of wave-particle duality in physics. Although the two seem incompatible, both are valid, and electrons can only be understood if we understand their nature as both a probability wave function and a particle with uncertain position or momentum. Particles could represent the individual view of human existence, and wave the relational aspect. We need to accept both. Reflecting on the recent discovery of the Higg’s Boson: if Higg’s Bosons are the things that gives matter its mass, then relationships could be seen as the things that give humans their meaning.

Perhaps TCs can leapfrog over ‘modernisation’ – and get to a more holistic, wholesome and complex way of organising our services (Haigh, 2005a). This is beyond modernism as we know it: not minimalist, sterile and automated, but human, complex, uncertain and authentic. We can incorporate some of the ‘efficiency benefits’ of modernisation (such as flexible use of new technology), but the new focus will be relational, not performative, transactional or procedural. In that way, it could be seen as post-modern. This has a close parallel with Bracken and Thomas’s coinage of ‘post-psychiatry’ (Bracken and Thomas, 2001).  Because the therapeutic community field has been working progressively for many years, in ways such as transparency, democracy and service user partnership, it is familiar territory. Using these principles, along with the underlying emancipatory philosophy, could be even more exciting and worthwhile than being part of traditional therapeutic communities, and trying to maintain what they have always done. The placing of relationships at the centre perhaps moves even further – beyond the post-modern dogma of relativism, ‘anything goes’ and ‘no grand narratives’. The relational framework itself could be described as a new ‘grand narrative’.

However, leadership to promote such ideas is not common in state-commissioned services, and an accommodation must be found to ‘keep the flame alive’ while getting on with the business of doing effective clinical work - in an increasingly regulated and managed system. Manning (2013) clearly articulated this in ‘Charisma and Routinisation’: having a powerful charismatic leader is not a stable or sustainable position, while becoming routinized and bureaucratic is no better. It is a fine line to tread, and I have previously argued that the ideas behind therapeutic communities carry plenty of their own charisma – and that the key is to place relationships (at every level) at the centre of the work and the development of the field, rather than have celebrity-type individuals as its powerful leaders (Haigh, 2005a), or to turn to bureaucratic and administrative solutions (Haigh, 2005b).

We who work in mental health know that we can only ever work in uncertainty and probability, but the world in which we now exist increasingly demands certainty. A current example in the UK is the ‘zero tolerance of suicide’. In the digital tyranny that computers demand of us all, only zeroes and ones are allowed, and no fuzzy indeterminacy is permitted. This ‘untrusting performativity’ characterises the ‘New Public Management’ and now permeates everything we do in health services and universities – and other public sector organisations. It is also becoming dominant in the voluntary sector, for charities and social enterprises. Unless one shows corporate understanding of the layers of governance, risk management and compliance checks, funding is unlikely to be granted.

This process fundamentally does not trust relationships: this is not acceptable as the core foundation for human services, particularly mental health. Mental Health needs to be seen again as a social movement as it was in the 1790s (with moral treatment) and again in the 1950s (with antipsychiatry) – with the challenge to authority and oppression which that needs. The work and thinking of therapeutic communities needs to be a part of it. With much of the current culture based on mistrust and fear, therapeutic communities, and other relational approaches, need to work hard to demonstrate that there is a different way to live our lives, and a better way to be with each other.


Ballatt, J., Campling, P., 2011. Intelligent kindness: reforming the culture of healthcare. RCPsych publications.
Baron, C., 1987. Asylum to anarchy. Free Association Books.
Bion, W.R., 1961. Experiences in groups: And other papers. Tavistock Publishers, London.
Bracken, P., Thomas, P., 2001. Postpsychiatry: a new direction for mental health. Br. Med. J. 322, 724.
Cooper, D., 1968. The Dialectics of Liberation. Penguin, Harmondsworth.
Foucault, M., 1965. Madness and Civilization: A History of Insanity in the Age of Reason. Pantheon, New York.
Foulkes, S.H., 1946. On group analysis. Int. J. Psychoanal. 27, 46–51.
Goffman, E., 1968. Asylums: Essays on the social situation of mental patients and other inmates. AldineTransaction.
Gruening, G., 2001. Origin and theoretical basis of New Public Management. Int. Public Manag. J. 4, 1–25.
Haigh, R., 2017a. Therapeutic communities enter the world of evidence-based practice. Br. J. Psychiatry 210, 313–314.
Haigh, R., 2017b. A New Biopsychosocial Programme for Emotional Instability: the Slough Model. The Psychotherapist 66, 27–29.
Haigh, R., 2013. The quintessence of a therapeutic environment. Ther. Communities Int. J. Ther. Communities 34, 6–15.
Haigh, R., 2007. The New Day TCs: Five Radical Features. Ther. Communities 28, 111–126.
Haigh, R., 2005a. Charismatic Ideas--Coming or Going? Ther. Communities.
Haigh, R., 2005b. The trouble with modernisation: we need better relationships, not policies and procedures. Ment. Health Rev. J. 10, 3–7.
Haigh, R., Harrison, T., Johnson, R., Paget, S., Williams, S., 2012. Psychologically informed environments and the “Enabling Environments” initiative. Hous. Care Support 15, 34–42.
Haigh, R., Lees, J., 2008. Fusion TCs: Divergent histories, converging challenges. Ther. Communities 29, 347–374.
Haigh, R., Tucker, S., 2004. Democratic development of standards: the community of communities—a quality network of therapeutic communities. Psychiatr. Q. 75, 263–277.
Harrison, T., 1999. A momentous experiment. 1999“Therapeutic Communities Past Present Futur. Lond. Jessica Kingsley.
Hoggett, P., 2004. Shame and performativity: Thoughts on the psychology of neoliberalism. Psychoanal. Cult. Soc. 1–19.
Jones, M., 1979. The therapeutic community, social learning and social change., in: Hinshelwood, R.D., Manning, N. (Eds.), Therapeutic Community – Reflections and Progress. Routledge & Kegan Paul, London.
Jones, M., 1956. The concept of a therapeutic community. Am. J. Psychiatry 112, 647–650.
Laing, R.D., 1967. The Politics of Experience. Penguin UK, Harmondsworth.
Lees, J., Haigh, R., Lombardo, A., Rawlings, B., Pearce, S., 2016. Transient therapeutic communities: the’living-learning experience’trainings. Ther. Communities Int. J. Ther. Communities 37.
Lees, J., Manning, N., Rawlings, B., 2004. A culture of enquiry: Research evidence and the therapeutic community. Psychiatr. Q. 75, 279–294.
Living and Learning, 2017. The International Network of Living Learning Experiences.
Manning, N., 2013. The therapeutic community movement: Charisma and routinisation. Routledge.
Manning, Nick, 2014. Politics of data (personal correspondence).
NICE, 2009. Borderline Personality Disorder: Treatment and Management. National Institute for Health and Clinical Excellence: Guidance.
Pearce, S., Scott, L., Attwood, G., Saunders, K., Dean, M., De Ridder, R., Galea, D., Konstantinidou, H., Crawford, M., 2017. Democratic therapeutic community treatment for personality disorder: randomised controlled trial. Br. J. Psychiatry 210, 149–156.
Rapoport, R., 1960. Community as Doctor: New Perspectives on a Therapeutic Community. Tavistock Publications, London.
Rawlings, B., 2005. The Temporary Therapeutic Community: a qualitative evaluation of an ATC Training Weekend. Ther. Communities 26, 6–18.
Royal College of Psychiatrists, 2016. What is the Enabling Environments award?
Royal College of Psychiatrists, E.P., S...Thorne, J.,.Das,A, 2015. Service Standards for Therapeutic Communities, 9th edition.
Spandler, H., 2009. Spaces of psychiatric contention: a case study of a therapeutic community. Health Place 15, 672–678.
Spandler, H., 2006. Asylum to action: Paddington day hospital, therapeutic communities and beyond. Jessica Kingsley Publishers.
Tuke, S., 1813. Description of The Retreat, an institution near York, for Insane Persons of the Society of Friends. The Retreat, York.