Friday, 12 May 2017

When is a therapy?

I have used this blog before to beef on about therapies being branded and packaged and commodified and marketed like drugs – but a couple of days in Verona (which I seem to be coming to more often than any rational reason would suggest) have given me another layer of it to think about. I suppose it is how to ‘monetise’ the therapeutic alliance.
Aldo translates for Renee
My line is always that the ‘nature of the therapeutic relationship’ is always, absolutely always, more important than the type of therapy. And that is backed up by the research going back to the Dodo-Bird verdict, the statistical analyses that show that only 15% of the variance comes from the type of therapy, the PD pilot project showing the crucial role of engagement – and agreement about it with every therapist I have ever talked to (though I don’t talk to pure CBT therapists very often). And it’s at the root of the ‘quintessence’ too: the attachment and containment need to be securely in place before you can get on with the routine bits of therapy, and they’re mostly unconscious anyway.

Yet the ridiculous horse race between the alphabetti spaghetti therapies continues, and more and more horses are bred - and trained, and put through their paces in the RCT hurdle steeplechase. They have to keep entering more races, of course, to keep their form. When everybody knows it doesn’t really matter who wins.

…Except that we have a competitive international research system, run by sharp, smart and competitive research staff. This system demands absolute certainty (well, as much as RCTs can give), a marketised system where celebrity academics and a few others can make a fortune out of it, and a lot of other pedantic and arcane reasons for ultimately stripping the humanity and agency out of the decisions when the needy person actually meets the human representative of the machine.

So I was a bit wary of going to Verona to share a platform with my old friend Aldo (who spoke with dazzlingly animated slides of neurobiology and sociotherapy) and an infrequent acquaintance Renee Harvey (who presented the STEPPS model and her creative Sussex adaptations of it). My worry was that STEPPS is one of the alphabetti spaghetti therapies I have been so rude about in the past, and I didn’t want to fall out with Renee as I do respect the way she works.

Indeed, it shone through how she works – in close partnership with service users, in a very relational way, attending to engagement, using the manual as flexibly as needed, in conflict with the powers that be (about their anti-therapeutic demands), wanting to make partnerships with the third sector, making full use of positive group dynamics, and seeing it as much as a framework for therapy as a definitive intervention. In other words, a therapeutic environment. With that lot in place, it felt quite close to what we do, for example, in the Slough micro/macro TC.

But one tiny thing she said set me on edge: when describing the room, she showed us a picture including ‘the cupboard where we keep all the materials’. As if everything you needed could be bundled up and put in a cupboard – and those materials, I assume, are like lesson plans and detailed handouts for the highly structured sessions. So even though it’s a fairly well-guaranteed way of establishing and maintaining the therapeutic culture where the quality of relationships is paramount, it’s commodified and packaged and marketed. I fear it’s the way of the world – inexorable and inevitable – though I still don’t think it’s a price worth paying. It’s the corporate way, and it moves authentic therapy closer to prostitution…

The vibrant Verona gang!

Wednesday, 3 May 2017

IT'S OFFICIAL: Democratic Therapeutic Communities are now an evidence-based treatment!



And here's the text if you don't have access to the BJPsych:

Therapeutic communities enter the world of evidence-based practice

In this edition, Steve Pearce and colleagues have demonstrated that it is possible to do an experimental study on a complex treatment modality that has been in use for over 50 years. This is an important study, and is a landmark in being the first ever randomised controlled trial on democratic therapeutic communities for personality disorder. In the seven decades since their role in psychiatric services was established, clinicians in therapeutic communities have generally preferred qualitative approaches to research (1). These were seen to have a more congruent epistemological basis, but were a richer vein for anthropological and sociological enquiry than they were for clinical studies. An extensive systematic review in 1999 (2) found few studies were suitable for inclusion in the meta-analysis, and those that were included were too heterogeneous and imprecise to give robust results.

For psychiatrists who remember democratic therapeutic communities in their heyday, they were based on Rapoport’s the four themes (democratisation, permissiveness, reality confrontation and communalism) which he identified at Henderson Hospital in the late 1950s (3). Although the service in this study is based on some of these fundamental principles, they are overlaid with several decades of development and modification. Newer TCs now bear few superficial resemblances to these residential services which were formed in the heat of the social psychiatry revolution of the 1950s and 1960s. No wholly group-based residential therapeutic communities now remain in the NHS, and all of those that still function are day units, as in this study (4,5). The laissez-faire attitude of ‘leave it to the group’ rarely prevails, there is a high level of structure and order, and there is very little opaque psychoanalytic interpretation delivered by remote therapists. Modern therapeutic communities have a strong emphasis on empowerment, openness and ‘ordinariness’, which soon dispel any notions of therapeutic mysteriousness and charismatic leadership. They are tightly managed services with clear admission, review, progression and discharge protocols (6). 

The ‘Community of Communities’ quality network at the Royal College of Psychiatrists Centre for Quality Improvement (CCQI) was one of the first projects there in 2002, and it helped democratic therapeutic communities to agree the nature of best practice and to consistently deliver it (7). Part of this process involved the distillation of ten core values that underlie the measurable standards. These would be entirely familiar to early therapeutic community pioneers: a culture of belongingness, enquiry and empowerment; democratic processes whereby no decisions can be made without due discussion and understanding; and the fundamental importance of establishing and maintaining healthy relationships (which are not always comfortable and are seldom without conflict). This work has also led to the ‘Enabling Environments’ award at the Royal College, and the development of Psychologically Informed Planned Environments (PIPEs) in criminal justice settings, and ‘Psychologically Informed Environments’ (PIEs) in the homelessness sector (8).

The publication of outcome studies for personality disorder treatment have had something of the quality of a ‘horse race’ or ‘beauty contest’ in the last decade. New treatments have been constituted from various old psychological theories, which have been branded and packaged, then manualised and researched with much energy and competitiveness. In this way, they have been suitable for ‘selling’ to mental health commissioners as simple value-free ‘commodities’ or ‘products’ (9). In a way, this study indicates that therapeutic communities have now entered this race. However, it is worth proposing that Pearce et al’s study is not of a simple ‘brand’ of treatment, but of a therapeutic philosophy with a long and distinguished heritage, which has been now adapted to fit into the wider ‘whole system’ of a twenty-first century mental service. Therapeutic communities offer a democratic way of conducting therapeutic business, demand specific attention to the coherent and coordinated use of the different therapeutic approaches, and deliberately provide an overall therapeutic environment (10). These do not often happen in other therapies.

Therapeutic communities also specialise in being able to treat those who have a particular severe presentation of personality disorder, such as in prisons. This severity can be measured by diagnostic criteria, comorbidity, risk, complexity or unmanageability (11). The therapeutic environment, including techniques such as peer mentoring and deliberate informality, facilitates engagement of people who would otherwise be ‘untreatable’. Also, by managing risk primarily through continuing, empathic and intense therapeutic relationships, therapeutic communities can manage levels of risk that would be unacceptable in other services.

This study demonstrates that democratic therapeutic communities have now started to accumulate the evidence to earn a place in the therapeutic pantheon for moderate and severe personality disorder.
750 words

References
(1) Lees J, Manning N, Menzies D, Morant N. A Culture of Enquiry: Research Evidence and the Therapeutic Community. London: JKP; 2004.
(2) Lees J, Manning N, Rawlings B. Therapeutic community effectiveness: a systematic international review of therapeutic community treatment for people with personality disorders and mentally disordered offenders. University of York: Centre for Reviews and Dissemination; 1999.
(3) Rapoport R. Community as Doctor. London: Tavistock; 1960.
(4) Haigh R. The New Day TCs: Five Radical Features. Therapeutic Communities 2007;28(2):111-126.
(5) Pearce S, Haigh R. Mini therapeutic communities: A new development in the United Kingdom. Therapeutic Communities 2008;29(2):111-124.
(6) Pearce S, Haigh R. A Handbook of Democratic Therapeutic Community Theory and Practice. London: JKP; 2017 (in press).
(7) Haigh R, Tucker S. Democratic development of standards: the community of communities - a quality network of therapeutic communities. Psychiatric Quarterly 2004;75(3):263-277.
(8) Haigh R, Harrison T, Johnson R, Paget S, Williams S. Psychologically informed environments and the “Enabling Environments” initiative. Housing, Care and Support 2012;15(1):34-42.
(9) Haigh R. Industrialisation of therapy and the threat to our ethical integrity. Personality and mental health 2014;8(4):251-253.
(10) Haigh R. The quintessence of a therapeutic environment. Therapeutic Communities 2013;34(1):6-15.
(11) Department of Health. Recognising Complexity: Commissioning Guidance for Personality Disorder Services. 2009.
Rex Haigh
Consultant Medical Psychotherapist, Berkshire Healthcare NHS FT
Honorary Professor of Therapeutic Environments and Relational Health, School of Sociology and Social Policy, Nottingham University.

Conflicts of Interest:
RH leads the Enabling Environments project at the Royal College of Psychiatrists Centre for Quality Improvement. No financial conflicts.

Wednesday, 26 April 2017

Three psychologists tell the critical psychiatrists

…and all of them were white and male, and middle class and middle-aged, and 'academic' if you want to add those to the charge sheet.

But this was the annual one-day conference of the Critical Psychiatry Network – a mainly UK-based online group of several hundred psychiatrists. It is held in the School of Sociology and Social Policy at Nottingham University – and a few dozen of the members make it to the conference; this year’s title was ‘Recovery in a Time of Austerity’. And that is indeed what we talked about – although a couple of programme changes needed to be made: Tim Kendal, our Grand Vizier of English Mental Health, had to cancel because of the civil service ‘purdah’ now an election has been called. Just like the clean air act going through parliament. Julie Repper, leading light of the national recovery college razzamatazz, was replaced by an even bigger cheese in the world of ImROC, Mike Shepherd, now retired from his role there. But a good time was had by all – even if the speakers did end up all being white male psychologists. Three kings bearing gifts, maybe.

In which case the first on, Dave Harper from UEL, was the King of the land of rational discourse. He spoke softly and with authority on his subject of ‘Responding to the challenges of austerity, recovery and neoliberalism’ – weaving a web of facts that made it hard to disagree that inequality is the pump that we need to take the handle off. But his critique included subtler points, such as the likely psychological impacts of inequality (from the ‘Psychologists for Social Change’ group) and authentic ‘recovery’ being in danger of being only understood in an individual context and dyadic conversations – and missing the whole ‘the personal is the political’ point. All good stuff: no nonsense, but no fireworks. I particularly liked his BPS daleks screaming ‘formulate’ rather than ‘exterminate’ (ref RitB) though I was a bit troubled by his black polo sweater. It gave me flashbacks to the same kit as worn by Davros, as we used to call the architect of IAPT and all the ghastliness that has followed it. See other blogs for more details…

Next was the King of Recovery Colleges, or at least ImROC – Geoff Shepherd. He gave his talk with the air and authority of a big beast on a day off (although he explained to us that he now has every day off, at least insomuch as that he is retired from his previous commanding role). But he gave a fishy history of ‘recovery’, and he told us it was going to be fishy – because there are so many invisible and inaccessible fish in the sea of facts that incompleteness was inevitable. He did start by going back to The Retreat – but with only scant reference to therapeutic communities, which have been espousing, disseminating and celebrating the same ideas for centuries, not just a few years. Although his delivery was a bit like that of a tired expert, he did have a cracking analogy for the end – which really nailed the problem for me better than his generous welter of words: the poor troubled man, who is carrying us, is exhausted and clapped out despite us doing all we can to help him. Except, that is to get off his back. Geoff really does believe in the stuff – even though he’s clearly an expert.

After lunch, the finale from the King of Recovery Evidence – Mike Slade, the home candidate from Nottingham’s Institute of Mental Health, talking about ‘Recovery – commandeered but rescuable?’. He wasn’t quite political enough to call it ‘colonised’ – and he was keener on lists and declarations of new paradigms, than he was on any deeper analysis of how that commandeering is linked to something bigger, smellier and more rotten than his neatly constructed powerpoints could show. one interesting proposal he made was to pay doubly-qualified clinicians more - those who have lived experience, as well as a professional qualification. And he muttered something like 'you just wait and see' under his breath when a few of the audience didn't quite believe him. But to be fair, I think he had the most fire in his belly of the three – perhaps through youthful exuberance (well, compared to some of us) in the role of a globetrotting messiah of recovery. I suppose what unnerved me is how slavishly he adhered to the hierarchy of evidence in his arguments and conclusions – and although they did seem watertight by the positivistic standards we have all been encouraged to worship, only one type of evidence was worth even considering. I have seen that in other people with fire in their bellies, in the PD world, and it’s not always a Good Thing.

Overall, I felt a bit less at home there than at similar sized and similar format conferences in the therapeutic community, personality disorder and greencare worlds. It is as if those other areas are not just critical of mainstream practice, but are actually doing something different. A different sense of informality, openness and responsibility? Maybe that’s just a problem for psychiatrists – and we need psychologists to tell us. 



Friday, 7 April 2017

NICE idea from Gothenburg




I was expecting to arrive at one of those over-professionalised conferences with a lot of men in suits talking about receptor subpopulations and the latest meta-analyses of different dose regimes.
what I was expecting, and dreading...

Thankfully, how wrong I was! The venue was ‘The Extended Therapy Room’, a conception of the energetic and charming Carina Håkansson; it is a therapy centre for family placements – akin to an adult adoption agency for those with severe mental health problems. However, we did talk about receptors (and how little they matter in real life), and robust evidence (particularly, how little there is that's relevant in clinical practice).

This was the first workshop of the International Institute for Psychiatric Drug Withdrawal, and I was hoping to find practical information about safe withdrawal from all the different psychotropic medications, and to become part of a social movement to swing the pendulum of psychiatry back towards psychosocial means and methods. I was well-satisfied in both – and also found myself part of a warm and welcoming network of people who talk about things like ‘just being human’, 'holistic care', 'relational practice', 'biopsychosocial formulations', 'reductionism of diagnosis' and the importance of the service user voice. Not quite into the realms of ‘democratisation’, but not bad for a start!

There’s too many interesting things to mention them all here, but just to name-check Olga – a fantastically articulate ex-service user who was very nearly poisoned to death by the psychiatric system a few years ago, and Sami Timini, a British psychiatrist who has a powerful presence in the ‘Critical Psychiatry Network’ (fellow psychiatrists – do join up, for some fantastically erudite and challenging online discussions!).

In the final group we all spoke of one thing that we’re going to do before the second and final part of the course in October. I’m going to put mine here, so it’s like a public commitment...
And it is to lobby NICE to produce a guideline on ‘withdrawal from psychiatric medications’. My starting two shots are the following emails, which I have already sent to the Critical Psychiatry Network and to Tim Kendall (who is National Director for Mental Health in NHS England):
--------------------------
Hello CPN Colleagues
I’m just at the training course for psychiatric drug withdrawal run by the International Institute for Psychiatric Drug Withdrawal (IIPDW) including CPN’s own Sami Timini.  It’s very stimulating and interesting – especially to hear of the Norwegian policy directive for each area to have a non-drug mental health facility. The participants in the course are mostly Scandinavian and multidisciplinary, including several carers and experts by experience. So here’s one idea that Sami and I were talking about: Why not lobby NICE to set up a guideline for SAFE WITHDRAWAL FROM PSYCHIATRIC MEDICATIONS?
The reason being that, even amongst experts here, there is little solid evidence for what are the best ways to withdraw psychiatric medications (except perhaps benzos) – despite the generally accepted view that long term use and polypharmacy is a Bad Thing. And the increasing evidence of long-term harm, and the public disquiet.
Could CPN ask Tim Kendall to set one up?
Or is there a formal process we could lobby through?
It would probably need some much better-informed research-savvy people than me, like Joanne and Sami, to make the case.
But NICE guidelines now carry so much (spurious?) authority, that it would certainly create a (useful) stir.
Any thoughts?
------------------
Hi Tim
I’m just at the first workshop of the International Institute for Psychiatric Drug Withdrawal in Gothenburg.
It’s clear from the discussions here that nobody really knows what the protocols should be, and there are no easily available or unbiased guidelines on the subject – despite recommendations about no long term use, increasing evidence of long-term harm, and many unhappy service users and carers.
Any chance of setting up a NICE guideline on it?
Or is there a formal process we should follow?
Many thanks
------------------
Watch this space to see what comes of it!



Sunday, 2 April 2017

The 'Human Development' consultation

Many of the fundamental principles behind the 2002-11 National Community PD Development Programme come from a developmental view of human relations. This is very different from the psychopathological frameworks always used by psychiatrists and psychologists - which are enshrined in policy and law in many ways, with the authority they thus convey.

Here is what Nick Benefield and I wrote about it in 2008, in our editorial for a special edition of  'Mental Health Review Journal':
When human development is disrupted, the psychological, social and economic consequences can reach into every area of an individual’s personal and social world, resulting in alienated and chaotic lives and repercussions throughout their communities.  The causes of this disruption may cover the whole range of physical, environmental, psychological, social and economic factors: from an unlucky genetic inheritance to a difficult birth, child abuse, inadequate parenting, failed attachment, trauma or emotional deprivation. The causes can also be poverty: material poverty, or the poverty of expectation that leaves individuals feeling powerless to have any impact on the world in which they live.

Over-riding differences in class and educational advantage confer some with strong constitutions - or a range of poorly understood protective factors – which may be sufficient to enable them to withstand the impact of these environmental failures and emerge from their early experience to live what appear thriving and healthy lives. However, very many end up in a situation where they are excluded from mainstream society, rejected by those who might be able to help them, and destined to live lives of unremitting frustration, without the happiness and fulfilment that most of us would consider just - and expect for ourselves and our families.

These individuals, and often their families, have little psychological sense of their place amongst others or where they fit into society. School, working lives and almost any pro-social relationships are difficult or impossible to establish and sustain. They experience the world as a hostile, unhelpful, threatening or undermining environment, living in a marginalised underclass with high levels of substance misuse, self harm, criminality, and suffering severe, enduring and disabling mental distress. People in this situation will often use a considerable range of statutory services to little benefit.

A minority will receive a formal diagnosis of personality disorder and so gain access to appropriate PD intervention services. However, the majority will receive an ambiguous and often prejudicial formulation of their difficulties and will more likely to meet a range of unsatisfactory public service responses.  Dependent on the immediate presenting difficulty, this response will often be inconsistent and have little relevance to the core psychosocial problem faced by individuals who are trapped in the experience of a failing relationship with the world around them.

Current government policy on personality disorder is seeking to change this and achieve three objectives: to improve health and social outcomes,  to reduce social exclusion, and to improve public protection. Three separate policy initiatives have broadly begun to address these through the Social Exclusion Action Plan: “Emerging PD in Children and Adolescents”; “PD - No Longer a Diagnosis of Exclusion” and “Managing Dangerous Offenders with a Severe Personality Disorder”. New legislation in the form of the Mental Health Act 2007 also aims to improve access and rights to treatment for those individuals most severely affected by personality disorder.

In all three areas of this work, progress is being made. The papers in this issue of the Mental Health Review give some indication of learning and experience in the field so far. Evidence from DH funded pilots across the country is emerging to demonstrate that that answers do exist, but that they do not lie in a traditional mental health treatment model or straightforward social policy - but rather in sophisticated cross-agency work that takes in the experience and expertise from various sectors: including health, social services, offender management, housing, social security and the voluntary sector. It also involves new forms of partnership with service users themselves – where they can feel themselves as active agents in their own recovery, rather than the passive recipient of technical expertise.


This is the very beginning for a field that is more complex than a disease model or unitary interventions can address. At this stage there is a need to continue to encourage evaluated and researched service innovation, and establish a workforce equipped to meet the demand for skilled and specialist intervention. To be effective, this will require closer collaboration across public services to ensure the relevance of personality disorders is understood and informs policy, strategy and service provision across the fields of health, social care, education and criminal justice.

Since the community programme was closed in 2011, we have continued to work on the 'relational principles' behind this. The 'PD tube map' was an attempt to demonstrate the pervasive and profounf effects of what we diagnose as 'personality disorder'; and the complexity and interrelation between the systems and services we had set up to tackle it. Here is the tube map:
And a link to a higher quality pdf of it https://tinyurl.com/PDtubemap 

  
So, with particularly useful input from the Offender PD team at NHS England and NOMS (National Offender Management Service), we started to design a more 'serious' version. It is likely to be adopted by the criminal justice sector as a useful model, and there is interest that we are pursuing from the health and education sectors. The hope is that it could convey the importance of considering a non-linear and complexity-based framework for policy and commissioning in all public sector areas concerned with the various 'failures' of adaptive human development. 

At the recent Inverness meeting of BIGSPD, we started a consultation about the model - which has so fare been through eleven iterations. Following the very detailed and informative discussions we had about it in Inverness, here is the latest - version 12:

If you have any thoughts about it, please join the consultation and send your thoughts and ideas to Nick: nick.benefield@icloud.com .
But please don't use it or redesign it for your own purposes, as it is only an early draft at this stage. We are the copyright holders and we'll be after you if you do!

Thursday, 30 March 2017

Whatever happened to therapeutic communities?

Following the Community of Communities Annual Forum at the Royal College of Psychiatrists (a hectic and jolly affair, as has become the custom), Steve and I did our first formal launch of our labour of love, ‘The Theory and Practice of Therapeutic Community Treatment’. I say first because we are also planning a couple of others for later in the year (do come to Windsor...)

Young Sophie from JKP came along with a box of fifty, the great majority of which we managed to sell and sign. Steve and I started it all off with a few words – I was the ‘grumpy old psychiatrist’ who didn’t see that TCs should be entering all this business of manuals, and that it’s a textbook anyway. Steve countered that this is the modern way, the only way, and that now we all live in the squeaky-clean world of evidence-based practice, there is no alternative. Then we read a couple of nice passages from the book and cracked open the wine. Signing was great fun – probably the closest I’ll ever get to knowing what the life of a celebrity is like. I often wrote ‘this is not a manual’ inside the front cover, and Steve followed it up with ‘Oh, yes it is!”. Well, famous for fifteen minutes is good enough.

I am so often asked ‘whatever happened to therapeutic communities?’ or some variation of the question – usually in a rather apologetic way indicating that the questioner didn’t know that they actually still existed at all - that I decided to do a fairly short written answer, so I could point people to it. Before they read the book, that is. Here it is:

In the twentieth century, therapeutic communities in the UK established themselves as a radical alternative to mainstream psychiatry. However, some of the philosophical roots can be traced back much further. In the thirteenth century, ‘mentally afflicted pilgrims’ travelled to Geel, where the village community took them in and looked after them. After the Enlightenment, people with mental ill-health were defined as ‘mad’ and incarcerated away from society. The Quaker William Tuke’s response to this in the UK was to open The Retreat in 1796, and argue for the ‘moral treatment’ of people as human beings, rather than as animals to be tethered and caged.
 
There is also a long tradition of progressive residential education for children and young people, dating back to the late nineteenth century with the ‘Boys’ Republic’ in Chicago and the ‘Little Commonwealth’ in Dorset, run by Homer Lane, and Summerhill in Suffolk, set up by AS Neill and still operating today. Community meetings are held, and each child is allowed to choose what they learned and when they learned it. In the field of learning disabilities farming communities such as L’Arche and Camphill were established in the twentieth century, by Jean Vanier and Karl König respectively; both organisations expanded internationally and still exist today.
 
The British ‘democratic therapeutic communities’ emerged from wartime military experiments and the heat of the 1960s and 70s social psychiatry movement: the doors of wards were unlocked, and therapeutic communities were firmly against medical orthodoxy, the power invested in hierarchy and status, and the use of physical treatments, such as newly emerging psychotropic medications. Instead, TCs promoted democracy, empowerment, treatment of equals by equals, and the importance of ‘being with’ rather than ‘doing to’. The main principles include challenge and confrontation in a flattened hierarchy, and culture of enquiry, where people feel emotionally contained and safe to do the necessary psychological work. Risk is contained through relationships, rather than protocols and procedures.

The programmes are group-based, and the community itself is the primary therapeutic intervention: all members of the community are responsible for the day-to-day running of the unit and decisions are made by consensus or voting; members cook, eat and spend social time together. One of the most important TC principles has always been ensuring that patients take the lead in their own treatment, as well as contributing to the treatment of others - in contrast to the paternalistic attitudes taken by mainstream services. TCs have extended this practice so that that ex-service users and experts by experience are encouraged to become involved in teaching, training, research, service commissioning and consultancy. More recently, these practices have been adopted by other services in all areas of health and social care.

Although this discussion mainly concerns democratic therapeutic communities for people with mental health difficulties, there is also a very large worldwide contingent of addiction TCs; although their origins were very different to ‘democratic’ TCs, some commentators have noticed that they are becoming increasingly similar.
 
What TCs do well is to adapt and change in response to challenges: their members are expected to do the same in their own lives. In the last thirty years, TCs have particularly had to adapt and change in response to increasingly austere economic policies and the emphasis on short-termism, as well as the rise of individualism and consumerism.

While the late 1980s and 90s saw the closure of many residential NHS TCs because of financial constraints, creative adaptations were taking place in order to survive. Two new national residential NHS TCs were set up to replicate the work of the flagship Henderson hospital; other NHS residential TCs responded to the challenge by converting to non-residential programmes, and a number of day TCs were established as part of the national personality disorder program in the early 2000s. Four new TC wings were established as part of a new purpose-built private prison; researchers in the TC field were awarded two major grants – one to undertake a systematic review of the evidence base in the TC literature, and the other for a multicentre comparative research study.
 
In response to increasing government regulation and inspection of care provision, TCs again responded creatively by devising an international network of peer review and audit, which was based on TC principles: the ‘Community of Communities’. It sets its core standards by democratic processes, involves current and ex-service users at all levels, and implements its audits in an inclusive and empowering way.
 
More recently, although British TCs continue to struggle to survive in the current political and economic climate, there are still some new and interesting developments in the TC field. One is the establishment of regular experiential training communities – the ‘Living-Learning Experience’ workshops. These were originally set up to give TC staff the experience of what it is like to be a member of a therapeutic community, but they have more recently been adapted for use in training for relational practice in groups, teams and organisations – and, in Italy, for entrepreneurs and business leaders. Although these events have been running in the UK for over twenty years, the programme and structure is being faithfully reproduced and used throughout Italy, increasingly in India and most recently in Portugal. In addition, particularly in Sicily, the government has encouraged the setting up and funding of new TCs. Several Italian centres have also set up networks adapted from the UK’s Community of Communities.
 
In 2007, the Community of Communities started a spin-off project called ‘Enabling Environments’. By distilling the underlying relational values from several years of TC audit data, ten ‘value-based standards’ were set. These represent the ways in which the therapeutic community ethos and atmosphere is established, but without any of the structural requirements of therapeutic communities – such as community meetings or specifially trained staff. They are therefore transposable to a wide range of settings where the quality of relationships is seen as crucial. This work, and the portfolio-based award to which it leads, now underlies new ways of working in the homelessness and prison sectors. Psychologically Informed Environments (PIEs) are transforming homelessness hostels, while Psychologically Informed Planned Environments (PIPEs) are doing the same in prisons and probation premises. Most recently, all UK ‘approved premises’, are being supported to become accredited Enabling Environments, and their use in other public service settings is being explored.
 
An additional extension of TC and EE practices is seen in ‘Greencare’, in all its forms. This entails including nature and the natural world as an integral part of therapeutic programmes: it can include therapeutic horticulture, animal assisted interventions, care farming and wilderness camping.
 
The most recent adaptations by the TC field have been in response to the dogmatic demands for evidence-based practice and manualisation. The first is the publication of the research findings of a modern randomised controlled trial of non-residential therapeutic community treatment for people with personality disorders (Pearce, Scott et al. 2017). The second is publication of the first handbook for democratic therapeutic community practice (Pearce & Haigh 2017).
 
Although the future remains uncertain, basic TC principles will endure - and TC practice will continue to change and adapt in creative and forward-looking ways.

Thanks to Jan Lees, who collaborated on writing this.
And apologies for the incomplete references – I’ll update it when I get a chance!

Friday, 24 March 2017

The Inverness Accord

The annual meeting of the British and Irish Group for the Study of Personality Disorder took place in Inverness this year. It was billed as the seventeenth, although some argued that it was actually the eighteenth. The conference is notable for travelling the length and breadth of the British Isles for its venues, and never having been back to the same place twice. Notable venues have included Jersey, the Isle of Man and, most recently, Inverness.

Many papers were given, interesting main speakers – and we had a presentation on the concept of ‘identity’ from an actor, and a cartoonist who captured the main messages from each of the sessions. One presentation worth mentioning was that of Lucy Johnson – if only for revealing the vipers’ nest in the British Psychological Society who are trying to undermine the whole glorious edifice of ‘psychiatric diagnosis’ (they are Lucy herself, Mary Boyle, John Comber, Jacqui Dillon, Dave Harper, Peter Kinderman, Eleanor Langdon, David Pilgrim and John Read). The trouble is, although she was meant to be a conflict-triggering main act, most of us agreed with her – especially about how degrading the general term ‘personality disorder’ is. It’s a name I wouldn’t want to give even to our mad Dalmatian (though he does suffer from several of them).

But as is often the case, the interesting things happened in huddles over coffees, beers and meals. So I’m going to put down some of our wildest ambitions for the field in the next year or so. I won’t ‘out’ my fellow consipratiors, as I expect they are a bit more careful and less excitable than I am, but here are five ideas we hope to push along:
·        A formal training for therapeutic community practitioners: with theoretical, clinical, experiential and assessed elements.
·        A bringing together of national service user and expert-by-experience efforts under a coordinated and well-funded organisation.
·        The agreement across the national commissioners of public sector services in criminal justice, social care, health and education about a cross-agency, cross-sector and interdisciplinary model of human development and what goes wrong with it.
·        Founding an online peer-reviewed, free, journal – to be called something like ‘Journal of Relational Health’.
·        The establishment of an influential ‘umbrella body’ probably constituted as a charitable learned body, with a name something like ‘Institute of Relational Health’.


Let us wait and see: every the optimist, but deeply pessimistic about the way everything else seems to be going...

Monday, 13 March 2017

What goes around comes around

Roma - La Dolce Vita: well, quite hard work really. But some good developments, and exciting new things on the horizon.

Beers on Termini balcony
So, on Thursday two of us arrived at Fuimicino’s new terminal 5 (extremely curvy and sensuous – but quite a hike to passport control and baggage reclaim) and one at Ciampino (the RyanAir destination). The cost for a third ticket to Fuimicino, ten days in advance, was going to be an unbelievable £800 – so RyanAir it had to be. But everything worked smoothly, and the two talks were polished up over a beer on the Termini station balcony.

The meeting and talk on Friday was for the first all-Italian Annual Forum for their Community of Communities equivalent, and we wrote our paper on ‘The Third Position’ – eventually to be written up and published. Fiona, Jan and Rex presented – Rex was told to keep mostly out of the way - and they had a very good reception. While experts by experience are already widely used in Italian services, the audience seemed to be were very enthusiastic about the progressive and non-paternalistic way we do this work.
Simone and Jan on the platform
Somebody described the cultural (primarily Catholic) social milieu which makes it difficult. In the afternoon, in the usual Italian hurly-burly, Simone the magician and Emelia, his Pre-Raphaelite magician’s assistant, delivered a blizzard of multi-coloured and muli-logo’ed certificate to continuous applause from an appreciative audience. A Italian trattoria, virtually taken over by us – with tables squeezed into impossible corners - ensured a good dinner and much jollity for all.

In working on the Third Position paper, Rex remembered what he had written for the 2004 Maxwell Jones lecture, which seems very apposite to our current struggles – and to the depth and difficulty of doing this work. In some way, it gets to the heart of the necessary ‘creative chaos’ that needs to be contained (and even celebrated) in therapeutic community work.
“So we have a pragmatic argument that the problem of personality disorder may not be a problem as we know it; and the solution anyway is to live together, tolerate and grow from difference and disagreement, and create an environment in which that can happen.”
There is more detail about these theoretical points in the paper: “Charismatic Ideas: coming or going?”  Haigh, R., Therapeutic Communities, (2005), 26, 4:  367-382. It’s a theme I want to develop some more – as it links to the horrors of performativity and ‘New Public Management’. Here’s a link to the pre-publication version of the 2004 lecture: https://www.dropbox.com/s/0wslcu5ttyau8a3/04%20MJL%20rev3.rtf?dl=0

The auditorium
On Saturday Fiona, Jan and Rex presented at the ‘scientific congress’ – and our subject was ‘Enabling Environments and Greencare’ – here’s the link to our Prezi:
https://prezi.com/wfc3k07onzom/enabling-environments-and-greencare/?utm_campaign=share&utm_medium=copy
Many Italian TCs are involved in different sorts of greencare and social farms, and the audience was very enthusiastic – we had a long and rich discussion afterwards. The discussion about how to incorporate greencare into the local community was fascinating, if only for the parallel between what we are trying to do in Slough, and what they have been doing for some time in Caltagirone. With five partners involved in each (no mean feat), what they each give and get is so similar. The five partners are (1) mental health (2) local authority (3) education (all statutory sector); and (4) not-for-profit organisations and (5) local businesses. I can feel a diagram cooking!

Then something we weren’t expecting – we were invited to lunch in an organic social farm a few miles outside Rome, where we had a stunning meal set up by Marino de Crescente (who runs a Rome TC). He also organised a tree-planting ceremony to mark the inauguration of an International Network of Greencare Organisations. Fiona helped with the planting ceremony and watered the tree in. Then she suggested that we also plant a tree in UK – their logo on the plaque for the tree is almost the same as our GBL one. We also agreed to share website links and keep in touch.
Planting the ceremonial tree

Quite a lot of other wheeling and dealing went on during the proceedings – particularly about resurrecting the International Network of Democratic TCs. The provisional plan is to hold an autumn colloquium  in London – and devise a structure where the leadership of it is shared between Italy (Sicily, Rome and Tuscany) and the UK (including TCTC, CofC and the journal). Watch this space.

There were also preliminary discussions about how the Italian TC work might be connected to the group analytic training and the central organisations, and the wider groups like EGATIN and GASI. Although this is a bit rareified, it could link up with the Aarhus discussions last November and the hopes to build a group analytic training presence in Bangalore, especially as Shama is going to the big GASI meeting in Berlin later this year…




Friday, 20 January 2017

It's in the book...



Contents

PART 1: HISTORY


1. A History of Therapeutic Communities 18
Geel and the mentally afflicted pilgrims 18
Moral treatment 19
Therapeutic education and social pedagogy 19
Wartime UK experiments, 1939–45 21
Social psychiatry 22
Criminal justice and offending behaviour 24
Concept Houses, drug-free and addiction TCs 25
Antipsychiatry and ‘unlabelled living’ 26
Personality disorder TCs 26

PART 2: CONCEPTS

2. Why Therapeutic Communities 30
Critical theory 33
Antipsychiatry 34
Critical psychiatry 37
Biomedical domination and the role of the pharmaceutical industry 41
The loss of meaning and context 42
Reductionist research paradigms 44
Postpsychiatry 44
Other relevant ‘movements’ in psychiatry 45
The quintessence of a therapeutic environment 48

3. TC-Specific Theory 53
Specific therapeutic factors in democratic therapeutic communities 53
Therapeutic methods in democratic therapeutic communities 55
The function/structure-based approach – Rapoport 55
The culture of enquiry – Tom Main 57
Flattening of the authority pyramid and the analysis of all events – David Clark 57
A living learning situation – Maxwell Jones 58
The milieu and the use of member expertise 59
Confidentiality and respect/no secrets/openness 59

4. Belongingness 62
Belongingness and Maslow’s hierarchy of needs 62
Belongingness as a therapeutic factor 64
Therapeutic environments in which belongingness operates 65
Therapeutic communities and belongingness 66

5. Responsible Agency 71
The wedge theory of responsibility and choice 72
Self-efficacy 73
Empowerment 73
The nature of responsible agency 73
Willed action and the nature of desire 75
The muscle model of the will 75
Other techniques promoting responsible agency 78
Responsibility without blame 79
Links between blame and shame 82
Implications for DTC practice 82

6. Social Learning 85
Reinforcement 85
Social learning 87
Relevance to TC practice 92

7. Emotional Progression and Narrative 94
Emotional progression in DTC 95
Narrative formation 100
Emotional competence and mentalisation 102

8. The Use of Psychodynamic Theory and Techniques 105
Object relations theory 105
Splitting and borderline functioning 106
Unconscious defence mechanisms, and their relevance to TC practice 107
Paralleling behaviour 110
Interpretation 110
Transference and transference interpretation 111
Boundaries and containment 112
Therapist activity in democratic therapeutic communities 113

9. Group Analytic Influences and Theories 114
The roots of group analysis 114
The basic law of group dynamics 117
Key group analytic concepts relevant in therapeutic communities 118
Transference and countertransference in groups 122
Group analytic interpretation 123
Group-as-a-whole 123
Differences between therapeutic community groups and group analytic groups 124
Interpersonal group psychotherapy and Yalom’s therapeutic factors 125

10. Group Process and Systems 128
The primacy of groups 128
The impact of social psychology research on TC theory and practice 130
Leadership in DTCs 134
Systems theoretical influences 135
Systems theory in non-family groups 138

11. Evidence for Therapeutic Community Effectiveness 139
Concept (drug-free) TC research 139
Democratic TC research 141
TaCIT – a randomised controlled trial of democratic therapeutic community treatment 150
Future research directions 151

12. General Approach and Principles 152
Application of theory 153
Milieu therapy 153
Democratisation 153
Permissiveness 156
Reality confrontation 157
Communalism 157
Social analysis of events 158
Culture of enquiry 159
Freeing of communications 159
Flattened hierarchy 161
The living learning experience 162

PART 3: PRACTICE

13. Phases and Timing 164
Phase 1: Engagement and stabilisation 165
Phase 2: Assessment and preparation 174
Phase 3: Intensive treatment 177
Phase 4: Recovery and rehabilitation 180

14. Assessment and Selection 181
Dimensional approaches and severity 182
The importance of groups 183
Intolerance of groups 185
Members who may adversely affect the culture 185
The possibility of harm from DTC treatment 186
Heterogeneous group formation 187
Selection processes 187
Dropout from DTC treatment 188

15. Democratic Therapeutic Community Structure 189
Assessment and preparation 189
Joining and leaving 192
Therapeutic community size 195
Weekly structure 195
Daily structure 195
Special/crisis meetings 196
Mentoring and peer support 197
Meeting structure 199
Open groups 203
Work groups and activity groups 203
The place of play in DTC 203
Specialist psychotherapeutic approaches 204
Milieu time 205
Therapy breaks 206
Moving on groups 207
Follow-up 208

16. Boundary Maintenance 209
The implementation of boundaries in DTC 209
Time boundaries 210
Disturbances and distractions in groups 210
Hierarchy of consequences of boundary violations 211
Relational risk management and positive risk management 214
Concurrent psychological treatment while a member of DTC 216
Other boundaries 216
Drugs and alcohol in DTC 220
Medication in DTC 222
Abuse of prescribed medication and medicinal substances 227
Somatisation and somatoform disorders 228
Special treatment 228

17. Quality of Relationships and Therapeutic Method 230
A different kind of relationship 230
Flattened hierarchy 230
Authenticity 231
Working alongside 231
Acting ‘as if ’ 232
Uncertainty 232
Safety and transparency 232
Management of personal information for TC staff 233
Making the diagnosis of personality disorder 234
Co-morbidity with mental illness in personality disorder DTC treatment 236

18. The Use of Psychoeducational and Humanistic Methods 238
Mindfulness 238
Descriptions of approaches used in the large group 240
Action methods 241
Approaches derived from transactional analysis 243
Diagnostic personality disorder group 245
Family and Friends (carer’s) programme for personality disorder 245

19. Antitherapeutic Processes 248
The difference between group/peer pressure and TC process 248
Bullying and scapegoating 249
Subgroup formation 250
Persecutory interventions 251
On not ‘trusting the process’ (or group) 252
Summary 252

PART 4: ORGANISATIONAL ASPECTS

20. Organisational Relationships 254
Commissioning 254
Management 256
Governance and regulation 257
Referrers and colleagues 257
Local neighbours 258
Professional network organisations 259

21. Organisational Development 260
Planning a therapeutic community service for personality disorder 260
Formation of the team 262
Premises 264
Induction and initial training 265
Continuous improvement 266
Organic growth 267
Innovation 268

PART 5: TRAINING

22. Training – Introduction 272
Practitioner requirements 272
A curriculum of therapeutic community training 273

23. Experiential Training for Working in Therapeutic Communities 275
The living learning experience 275
Other group relations courses 277
Personal therapy 278

24. Supervised Clinical Practice 279
Pre-briefs and debriefs 279
Formal supervision 280 
Sensitivity groups and staff groups 280
Profession-specific supervision 281

APPENDICES

A1   Definitions 283
A2   Community of Communities 291
A3   Enabling Environments 302
A4   DTC Preparatory Group Documents and Policies 315
A5   DTC Programme Documents 322
A6   Moving On Group 342
A7   Family and Friends Programme 344
A8   Training Resources 346


Further Reading 360
References 361
Subject Index 376
Author Index 382