5 different community meetings: Christmas Quiz

What an odd week - five days and five different community meetings in four different TCs.
See if you can work out where each one is...

		type	sector	purpose	no.	feel
Mon		Residential trauma clinic	Private	Monthly information sharing	8+7	Quiet and reserved (except staff)
Tue		Alternative to admission non-residential	NHS	Weekly support and coordination	13+8	Raucous and festive (with Christmas jumpers)
Thurs am		Environmental / ecotherapy	Third	Intensive support: check-in	4+2+2	Warm, welcoming of visitors, and emotionally intense
Thurs pm		Environmental / ecotherapy	Third	Intensive support: check-out	4+2	Appreciative, mindful and settled
Fri		Offender PD tratment	HMP	One of 2x weekly wing meeting	38+4+1	Boundaried, highly organised, with vivid emotional content

Something else is brewing

Peter Cockersell has produced a book (and written most of it himself), called 'Social Exclusion, Compound Trauma and Recovery. Applying psychology, psychotherapy and PIE to homelessness and social exclusion'. Most interesting I think is a lovely clear account of 'compound trauma' - which seems to be a considerable improvement on the much-overused 'complex trauma'.

Here's my blurb for the back cover:

By drawing on modern psychoanalytic thinking, developmental neurobiology and current ideas of therapeutic environments, Cockersell presents the most complex problems in an accessible and engaging way.

And here's a lengthier piece I have written about his work at CHT:

Many things about the new world of social media, artificial intelligence and compliance metrics are a bit bewildering to digital dinosaurs like myself – but there is something else brewing as well. In the midst of all the turmoil that surrounds us, I am hearing different voices from all sorts of directions saying something new. I hear it at professional conferences, at policy meetings, during clinical discussions, in the newspapers and on the radio. There are also many places where people are talking about it – and feeling that it is what is missing – but can’t quite clearly pin down or articulate just what it is. It is the whole area of needing to make relationships the priority. Inspectors and regulators are starting to see that numbers cannot describe some of the most important things about schools, prisons or care homes; commissioners are recognising that complex systems cannot be purchased like cans of beans; professionals are starting to understand that their work is ultimately a bit empty and meaningless unless they consider the relationship that they are working with. Perhaps even politicians and policy-makers will soon realise that top-down command-and-control systems will not get the best out of people. As resources dwindle, and there seems to be little hope for funders to pay for anything more than the bare minimum. But CHT is now forging a new direction, which will not only be more therapeutic and humane than the ‘industrialised’ alternatives, but will be at the cutting edge of the emerging realisation that genuinely therapeutic care is not a luxury, but a necessity. Unless ‘relational practice’ is in place, outcomes will be worse, more people will complain, and the eventual costs will be much higher. From the work we are now doing with our commissioners, perhaps along with the wider crisis in social care provision, things are looking up. The fees we can ask are no longer dropping, and there seems to be increased recognition of the quality of our services, and the way in which we can provide a ‘value-added’ which is significantly more than the similarly-funded routine care services. In the world of therapeutic communities, a similar process is under way. Although few of the traditional residential TCs have survived, the newer adaptations and modified TCs are now bringing the TC philosophy into new areas. Again, CHT is at the forefront of this: the organisation is pioneering relational practice, based on the therapeutic philosophy of TCs, in developing CHT as a provider of a new intensive form of Psychologically Informed Environments (PIEs). It is widely acknowledged, through evaluation and research in the homelessness sector, that this will help us to engage people who would not normally be able to be helped, and provide a therapeutic environment for treatment that would otherwise not be possible.

This work is built on decades of what has been central at CHT. The broad-based understanding of mental distress, including biopsychosocial understanding, the importance of trauma, and the need for a wider frame of reference than either psychiatry or social care can offer, is something that CHT has always proudly asserted and disseminated. We are now entering the next phase of that, and I am confident that we can look forward to a future at the forefront of progressive practice in mental health.

An unexpectedly helpful conference - the start of something?

When I was asked a few months ago to chair a conference on personality disorder and doing an opening talk, I thought it might be worth doing - and agreed. The first draft of the programme they sent me looked quite interesting - not the normal decontextualised and competitive datafest - and I had a few email conversations with a person I didn't know, called Romy, to bring a bit more of a policy / systems / 'relational' angle to it. It was being run by a commercial conference company called Forums and Events, who were a new outfit to me. With the venue overlooking Lord's cricket ground, and its expensive delegate fee, my expectation was that it would be fairly low key and probably mostly appeal to people in grey suits from private hospital groups, who were wanting to set up slick and profitable PD services for their shareholders. In a way, although that's not a milieu that I enjoy, I didn't mind the idea too much - as my intention for the conference was to show that a purely evidence-based and commercial approach misses more than half the point. And maybe the faceless corporates would start to understand that...

But, in fact, I was altogether wrong - and the delegates included a wide range of people from all sorts of organisations, professions and sectors. I counted about 90 of them, including an actor who introduced herself to me afterwards, to wonder how a highly articulate and intelligent friend of hers - who had been badly let down by the NHS system - could 'help the cause'.

But even more than the mixed, enthusiastic and appreciative audience, the almost randomly thrown-together speaker list - with five half hour presentations in the morning and another five in the afternoon - worked like a dream. The morning started with a short explanation of my usual 20-year project timeline for 'PD World' - ending with an exhortation that 'the golden thread' to make it all hang together is 'relational practice'. Here's the prezi: https://tinyurl.com/DanubiusPD. The rest of the morning included four presentations, and discussion slots, all of which made different cases for relational ways of thinking and working. The high point for me was when somebody, during the final discussion panel, so powerfully said "this isn't really just about PD, is it"...

The afternoon - chaired by a good friend and former warden of the PD movement, Conor Duggan - was similarly collaborative and inspiring. I chatted to the person next to me at tea time - and was surprised by how unreservedly positive they were about the whole experience. But this is what normal conferences (in the PD and TC and EE worlds) are like - though they were expecting it to be more like a 'boring old psychiatry one', as they were used to.

The most interesting bit of discussion - which might be a bit arcane for those who don't know the history of people and problems involved - was how the newly appointed commissioner for the NHSE specialist 'Severe Tier 4 PD services', Sarah Skett, is determined to get things done differently. She will be working with Steve Pearce (clinical chair of the reference group) who seems to have been banging his head against a brick wall for several years now. Under her commissioning of NHS England's half of the Offender PD Pathway, following Nick Benefield's diversion of the DSPD funding in that direction, great things have already happened in the criminal justice sector. The recognition of the importance of relational practice - and the underlying principles and values from Enabling Environments - has made over 200 prison and probation units less violent, with prison officers finding meaning in their work and prisoners being recognised as human. They have set up effective and progressive pathways, with research backing, that are lauded by Michael Storr, the head of English Prisons and Probation. Now that Sarah has the brief to look at non-forensic severe PD services which are commissioned in the NHS, let's hope that we can expect to see a similar light-bulb moment in those policy circles. She will have plenty of support from those who have been trying to do the same, with varying levels of learned helplessness, in our various fortresses of locally industrialised and walled-off health services. It could even fit very well with the aspirations for STPs, ACSs and the 5YFV - if we could get rid of the almost meaningless six-tier system.

What more could we ask? ...Lavoriamo Cantando ('we work singing')

The programme of the day

Trabia is about 20km east of Palermo, and was once home to a Mafia leader who lived in a large and beautiful house with wide views to the Mediterranean in front, and to the mountains just behind.

It is now owned by Cooperativa Sociale "Nuovo Generazione", which is a substantial social enterprise involved in mental health care with numerous other projects. But this is their first like this - which is not surprising as I don't think there are any others like this!.

The founder and leader of Lavoriamo Cantando, Rosaria Turturici, has quietly pulled of the start of what could be the most interesting new therapeutic community on the planet.

I was delighted to be asked along to give a talk about greencare at their official opening - and what amazing promise it holds.

Here is the link to my presentation: http://bit.ly/2j0lEV8

A few quick facts about the project:

View from one of the balconies

• it is in a stylish and high quality refurbished building - with features like balconies overlooking the sea and mountains
• it will be residential, long stay, for 20 people
• it has several acres of newly turned over rich red soil
• they are intending to grow mostly herbs, and sell them commercially
• the multidisciplinary team including a singing therapist, which will be part of the daily work activities
• they have been trained by having Living-Learning Experiences, including one on the premises in 2016
• the group-based therapeutic programme has democratic and co-creation principles
• it will have its quality assured by participation in the Sicilian 'Visiting Project' (equivalent of the UK 'Community of Communities'
• it is founded and built on extensive collaboration with various agencies across all the relevant sectors, with several years in gestation - which a triumph of relational organisation work

Imagining a world without psychiatric drugs

As a 'critical psychiatrist' who has survived a twenty five year career as a senior doctor who has barely ever prescribed any medication, I sometimes feel rather guilty that I have not been 'a real doctor' - or have been doing something seriously wrong for many years - and they will soon find me out!

But really, I know that as a medical psychotherapist - and keen member of the Critical Psychiatry Network - that my work needs to be like this. The feeling of constantly swimming against the tide, being seen as weird / offbeat / alternative, and never quite fitting in with the systems we live by, is actually a completely normal part of being in this territory. There are probably thousands of state-employed psychiatrists with similar thoughts and feelings - but I have the luxury of being in a position where I can make that conflict my life's work. But - although it's often invigorating and quite fun, it is more often rather lonely and disconnected.

By finding a niche in the minuscule field of 'democratic therapeutic communities for personality disorder', I managed to find, and almost hide away, in a cosy world where everything we do is based in therapy, and we can justifiably split ourselves off from the 'real world' of statutory services struggling with insatiable demand and increasing regulation, austerity, and performance management.

Until a few years ago, I lived in that bubble - and our team did good work with a small number of people who were very disabled by their past trauma, abuse, neglect, deprivation and loss. We were recognised as a 'good practice site' for personality disorder treatment - but we were only treating a few dozen people per year, out of a population of over half a million. How many struggled on, in silent desperation, without any help: and how fair is that?

Since joining local mainstream services about eight years ago, I have a different view of it all. Although we can still only do genuinely 'therapeutic things' with a small number of people, we cannot lose sight of how the vast majority of people with mental health problems have only the 'mainstream' services to help them. All too often, this means that they do not ever have the sort of discussion and interview to help them to understand where their problems might come from - and think about what is needed to make their lives different. It also, rather sadly, nowadays means that they do not usually have much of an opportunity to make a therapeutic relationship - with continuity of care - with a suitably attuned clinician. And perhaps, worst of all, it means that the state machinery has the power to coerce them into taking chemical substances that might well do people more harm than good especially in the long term.

With the best will in the world, people with underlying emotional instability end up taking all sorts of medications which can, at best, help to mask their troublesome symptoms. Sometimes I liken it to taking aspirin for a headache - and the doctors involved not having any time or process for finding out about the brain tumour that is really causing the headache. I remember one of my mentors telling me that there are only three disorders in psychiatry, and four medicines. The three disorders were of mood, thinking and consciousness (for example, depression, psychosis and dementia) - and the drugs were 'anti-depressants' and 'mood stabilisers'; 'anti-psychotics' and 'anti-anxiety'. Otherwise called uppers, downers (major and minor tranquillisers), and lithium (and the anti-epileptics). And so many of the people who come into our services are on all four - at high dose -with no good reason, and no noticeable benefit - and without thought to the long-term consequences, as most people are advised to stay on them for may years. If I were visiting from another planet, or in a time machine, I would really wonder why so many people are being systematically and slowly poisoned, sometimes to death but nearly always to passivity and acceptance. But I think we all know that the road to hell is paved with good intentions.

Then I met with like-minced colleagues - mostly online, but also at the conferences of the 'Critical Psychiatry Network'. I was not alone and isolated in my beliefs, and there was some very strong scientific evidence that all was not as the pharmaceutical companies would have us believe. A little later, the announcement of the 'International Institute for Psychiatric Drug Withdrawal' came along, with its Gothenburg workshops.

Although I have been working in non-pharmacological psychiatry for over 30 years, the course gave me the impetus to do something more directly about the over-use of medication (to put it politely). So, hearing about the different projects going on - particularly like the Northampton MA 'alternative town' with its Icarus Project and 'Freedom Centre' - later sanitised for public funding with a meaningless Recovery title - I thought that I should do something locally.

One of the phrases that we mentioned in Gothenburg a few times was 'Pills Anonymous'. So my intention, in the next couple of years, is to introduce 'Pills Anonymous' groups for two of the non-NHS services in which I do clinical work. The principles will be:

• group and relationship based (ie collaborative, democratic, non-paternalistic)
• no coercion to reduce medication doasge, nor for it to remain unchanged, nor increase it
• based on fully informed consent
• to draw up agreed long-term plan, and agree that with prescribers and the group
• include expertise on technicalities of withdrawal (eg from pharmacists)
• monthly follow-up over as long as necessary (maybe years)
• close recording of dosages over time, and aggegated results
• with evaluation and research - to be written up as at least case studies (anonymised)

An early draft of the medication diary (to be kept in an Excel spreadsheet)

I have started to prepare the stationery and spreadsheet for keeping the long-term medication plans, and diary of use of all common psychotropic medication. It will be based on the British National Formulary, which gives low, normal and maximum doses for all medications. Each 'low' dose will score 1 point; 'normal' will score 2; and 'maximum' will score 3. Therefore, somebody on high doses of all four categories of psychiatric medication will score 12. It can be more if people are taking more than one preparation of in any category (for example, being on two neuroleptics). 

The overall graph, for each group member, will show how this total changes over time. I imagine there will be some interesting discussions, and a bit of friendly rivalry, between group members when they dicuss each other's scores!

Watch this space - and get in touch if you want to know more.

World Mental Health Day, Slough, 10 October 2017

In a closed session for an invited audience at 'The Curve', Slough's new and curvaceous library, between 10am and 11am on Tuesday 10 October,  this is what was happening.

Eric Broekaert RIP

Eric was the man who held the whole of the TC movement in one breath and sentence: we were planning a 2017 festschrift on his retirement as Professor of Orthopedagogy to the University of Ghent. But sadly, he died before it happened - so his senior lieutenants there, Wouter and Stejn, organised it as an evening conference, memorial and celebration.

Steve Pearce and I were regular visitors to his department, and here is a video clip of one of his last conversations with us - beer in hand!

A very thick and erudite issue of the International Journal of Therapeutic Communities was published in his honour, and I was invited to present it to the audience. Here is the Prezi: http://bit.ly/2i1vQfr

Dear Eric - we miss you very much. I only hope that there is somebody with your breadth of vision and intellect to break through our increasingly territorial divisions, in the world of democratic mental health, therapeutic communities and enabling environments...

INDTC 2.0 - coming soon

In his last years before retirement from CHT, John Gale worked hard to establish and grow the 'International Network of Democratic Therapeutic Communities' (INDTC). It was based on a simple website and various LinkedIn groups, and flourished under his leadership: last year, it had over a thousand members in dozens of countries. Not all the members were actively engaged in TCs, but they were interested in the field - and they could join without any cost, wherever in the world they lived. Several areas set up their own local groups, which included conferences and other events.

All was going well ...until John retired in the middle of 2016. The financial effects of public sector austerity were forcing CHT to be more prudent, and the network had been built on input from the CHT office and its multicultural and international staff group. This support was no longer possible, and the central coordination of the network looked as if it went to sleep.

However, many of the members recognised the value of the network and started to ask for its resurrection - albeit without the charismatic control of its founder and resources from his organisation. There was a request from TC people across Italy, and an offer to share the practical administration of the network.

Hence this meeting, hosted by Growing Better Lives at Iver Environment Centre.
The outcome was agreement to set up a small steering group of enthusiasts to take it forward:

• Raffaele Barone
• Peter Cockersell
• Rex Haigh
• Laura Liverotti
• Luca Mingarelli
• Angelita Volpe
• Zsolt Zalka

With a task to look into the following:

• Does INDTC need a formal structure with bank account - charity, co-op, company etc?
• Where will the first conference and officer elections take place?
• How should we develop the website?
• Should we have types of membership and fees?
• What are INDTC's aims? Does it include 'applied' TC and allied areas?
• How should we relate to other like-minded organisations?
• How should local groups relate to 'the centre'?

Watch this space to see how things progress:
www.indtc.org

...and we thought it was easy in Italy

This was going to be a different sort of LLE - instead of supervising the clinical work, or doing quality assurance, or having a research group - we were bringing a whole DEVELOPMENT TEAM to see just what it was they did. Why we could go back to England, tell of what they were doing in Caltagirone mental health services and Terra Nostra social farm, and have us all wondering 'why can't we do that here?'.

I remember a talk in the last year or so, when - despite the erratic translation - Raffaele Barone and I came to a cosmic agreement about what is needed. And here it is in diagram form:

So off four of us went - once we had got our passports in the right place at the right time - to do some detailed interviews with the key people behind the Sicilian magic. And what did we find? 

...that it is just as hard there as it is here, and to make a thing like that work, it needs a great deal of energy, enthusiasm, willingness to work way beyond the call of duty for a pittance, and taking risks with your capital all the while. A bigger scale maybe, but not unlike what we're doing in GBL after all.

Here's Trevor's notes on it:

The first reaction when I announced at home that I was going to do some work in Sicily was that I was very lucky, but it wasn’t expressed in quite such polite terms. No amount of explanation and protestation that this is not a holiday entirely changes the perception, but of course the reality was somewhat different, with the usual early start, punishing travel conditions and herding around at airports with many other sleep deprived travellers. The programme for the three days of training were also busy enough and structured enough to preclude much leisure time.  However, the company was very good and the journey through from Catania relaxing and the venue when we reached it, a social farm called Terra Nostra, was a haven of seclusion, with beautiful plants and trees, delightful animals and perfect weather.

The development group in their den

From past experience, I have learned to expect the unexpected on working trips to Italy, but I hoped to get an Italian perspective on the therapeutic community and an insight into the somewhat different approach to, and perceptions of, autonomy and recovery for members of this kind of mental health facility. I am also interested in how the relationship between professionals and members is perceived and how much real democracy is possible, partly because some of my colleagues in Italy are suspicious of any discussion of “therapy” in the context of social integration, because of the connotations of the sort of unequal relationships and medicalisation which is prevalent in the psychiatric establishment.

This visit also provided an opportunity to compare how this kind of setting and the way it is set up might affect the experience of members, particularly in relation to the principles of green care. Differences in opportunities for setting up and funding green care facilities were obviously of great interest.

In terms of my own subjective experience, I did expect, because it is a consistent pattern or progression, to have initial doubts about my own role and a perceived need to have my own space. This can easily lead to projections onto others which take a while to unravel and could have been amplified by our rather ambiguous role as observers. However, such feelings were soon dissipated by the openness and warmth of the other participants and the transition to a more secure feeling and sense of belonging wasn’t long in coming.

It was remarked that this was a group of professionals, reasonable people in similar jobs, and it was therefore unsurprising that communal living of short duration caused few stresses or disputes. However, I was surprised by just how open and good humoured the participants were as a group. This must have made the ambiguities of the democratic approach, for example within work tasks, easier to resolve, although there were discussions about the difficulties inherent in an arrangement where nobody was responsible for decision making, or rather, everyone was. There was a tongue in cheek comment that this was anarchic rather than democratic therapy.

It was interesting to see how the community meeting was arranged. Although it was quite structured on paper, with a business-like agenda, the leaders merely stipulated that it should start and end on time and that the chairperson should be whoever ended up sitting in the seat on which the agenda had been placed. Little guidance was given before or during the meeting as to the approach of the chairperson, which resulted in meetings that seemed more like a large group than a community meeting.

One of the most interesting aspects of the trip was the chance to see the set up at Terra Nostra. The challenges faced by anyone wanting to set up a democratic Therapeutic community within a rather inflexible psychiatric system with chronic funding problems are very familiar. Although there are now small grants available from the EU for starting social farms, the aim is to promote traditional farming, and they aren’t targeted at mental health projects. This may have some advantages, but in any case, this particular project was developed by the investment of the personal funds of a dedicated and resourceful professional who realised that seeking funding from the psychiatric and political establishment was just too problematic and involved unacceptable compromises.  However we think the world ideally should be, his success with Terra Nostra is something from which we should derive real inspiration.             

Gloucestershire stakeholders day

Somehow or other, the commissioners and others in Gloucestershire cottoned on to the idea that good services for people with personality disorder-type problems need more than just a couple of interventions 'off the shelf', with a lot of inclusion and exclusion criteria, and some tight compliance monitoring.

So they decided to invite a little gang of from Slough up the M4 to their multi-agency stakeholders day, in a big modern church hall. We gathered at Calcot Sainburys, where about 100 small packets of sweets needed to be bought - after a slight administrative muddle and having them in the wrong place at the right time. These were to be the symbolic lunch for our audience. When we arrived, we were warmly welcomed and plied with coffee and cookies by very attentive organisers. We were first off, and it was our job to give them some background to the field, and tell them about how we do an 'Enabling Environment' and 'relational practice' in the modified 'whole town TC' we do every Tuesday. We wanted to do a role play of the group, but there were only four of us - three senior group members and myself. So we had to invite some audience participation, and had about eight variably willing volunteers up onto the stage with us. They were very good! The symbolic lunch (fresh from Sainsurys) was vigorously distributed at the appropriate point of the role play. Good fun was had by all, and I think we got our point across quite colourfully. Here's a link to the prezi presentation... http://bit.ly/2Ah28Lw

The Slough gang relaxes with their lunch

The other presentations were really rather inspiring too - some very good work in which the police implemented the mental health act in truly compassionate and helpful ways, and some very imaginative and innovative voluntary sector services. And some women and men in suits sounding as if they really did want to do things differently.
Sadly, it felt like we were visiting an oasis from our own desert. If only ideas like this could come into the home counties (apart from SLough, where we are doing a small scale effort rather under the radar).
The afternoon finished with sausages and burgers from the barbeque, run by service users. I can't imagine that getting past health and safety risk assessment at another big modern church a bit closer to home...

Catania Visiting Project Forum, Terra Nostra LLE and REMS

The energetic, creative and slightly chaotic growth of the Sicilian Visiting Project marches on - this year in Catania. Which, oddly, has a tube map in the car park underneath the conference venue...

Then another of the lovely LLEs on the social farm at Terra Nostra: including donkey care and waste recycling as part of the greencare activities, along with egg collection, vegetable watering and harvesting. Here's everybody getting their certificates at the end

And here's the group photo - donkey and all!

One of our activities, it must be said not one that was approved by all the staff team, was a 15 minute drive to the local REMS. 

REMS are the new non-state run forensic units - and this one is a full-blown TC. We had coffee and ice creams with the inpatient group - who were clearly working relationally, and pretty democratic in the way the impromptu group worked. Some of its residents were Sicily's most difficult offenders - and one, who was extremely attentive to us, previously had to have numerous attendants and no furniture or plumbing, as he would have destroyed it all - and had a history of ripping sinks from the wall and toilets from the floor. His settling in over the last year or so is seen as an absolute triumph of TC methodology. And so it is...

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!

The book of PIPEs

This is the foreword from 'Transforming environments and offender rehabilitation: understanding and harnessing contextual factors in the rehabilitation of offenders', which contains what I hear is the first definitive published account of what PIPEs are. It is chapter 9, pages 179-197, by Nick Benefield, Kirk Turner, Lucinder Bolger and Claire Bainbridge. But the rest of the book is well worthwhile too, and this is what I wrote about it:  

Therapeutic environments have almost certainly existed since time immemorial, but it is a struggle to recognise their importance in a modern world where individualistic enumeration of all our activities has become paramount. In his grand sweep of anthropology and history, Harari persuasively argues that our forebears, as hunter-gatherers, and even Neanderthals, were more socially cooperative and community-minded than we are[1]. Perhaps we have lost something that we need to rediscover – or reinvent - in order to improve our lives today.

 The earliest documented accounts of a deliberately constructed therapeutic community, or enabling environment, is usually given as the village of Geel in thirteenth century Flanders – where those with ‘mental afflictions’ came as pilgrims to worship at the holy shrine of St Dymphna. Most of the pilgrims would probably be diagnosed with learning disability or epilepsy nowadays. When they arrived in Geel, they were taken into the care of the villagers, who were all engaged in working on the land. The success of their care was measured by an annual weighing ceremony, where those who had gained the most weight were the ones thought to be doing the best. An environment was constructed in which people with severe disabilities could be treated as human, and have their basic physical and social needs met.

 Other notable events in history show the same interest in the ‘psychosocial environment’ – such as the implementation of ‘moral treatment’ by the Quakers in York at the end of the eighteenth century, progressive education and democratic schooling for troubled children since the end of the nineteenth century, the rehabilitation of battle-shocked soldiers at Northfield and Mill Hill in the Second World War, and R D Laing’s rather chaotic experiments with ‘unlabelled living’ in the sixties. Perhaps one day historians will add the current reform of penal institutions, with the realisation that attention to the same factors can make twenty-first century prisons more effective and humane.

 The British criminal justice sector has been important at several points in devising the structure for ‘Enabling Environments’, on which most of this work is based. In 1998, the ‘Kennard and Lees Audit Checklist’ (‘KLAC’) was produced in order to be able to audit the prison therapeutic communities (TCs) as part of the Offending Behaviour Programmes Unit. The prison TCs were at that time seen as the only area for therapeutic communities which seemed to have a positive future, as all other sectors seemed to be closing them down or reducing their size. The KLAC formed one of the most important documents in setting the standards for all therapeutic communities when the ‘Community of Communities’ quality network was started at the Royal College of Psychiatrists in 2002. After the network had gathered much data over five or six years, the ‘core values’ were extracted and used to define the requirements for the ‘Enabling Environments’ (‘EE’) award. With this, the essential relational qualities of therapeutic communities could be used in any setting, without needing the whole apparatus of particular groups, specific staffing and suitable buildings – or the need to formally consider oneself as a ‘therapeutic community’. Therapeutic Communities remained the specialist and ‘pure’ implementation of a highly structured psychosocial therapeutic programme, but the ‘quality of relationships’ upon which they were built could now be replicated elsewhere.

 This facilitated the development of ‘Psychologically Informed Planned Environments’  (‘PIPEs’) – which had a particular structure, defined by the National Offender Management Service – as part of the response to the Bradley Report on the management of Mentally Disordered Offenders. By this time the concept of ‘relational security’ was also becoming well known in high secure NHS settings. At the core of the PIPEs was a process which trained and supported staff to establish their prison wings or other units as Enabling Environments, and to work towards achieving the Royal College of Psychiatrists award to recognise that.

 A parallel process, started in the government’s Department for Communities and Local Government, but without the continuing support or funding, established ‘Psychologically Informed Environments’ (‘PIEs’) for the homelessness sector. PIEs are more loosely defined than PIPEs, and do not require participating services to meet EE standards, but they have a clearly articulated structure which is based on the same relational values.

 Once non-participating prison units saw the value of PIPEs, many of them decided to apply to become Enabling Environments, independently of the PIPEs programme. This has raised wider awareness of healthy psychosocial environments throughout the criminal justice sector, and at the time of writing two whole prison establishments are working towards becoming ‘whole prison EEs’, rather than just specific wings and units. At a conference in early 2016, the head of the National Offender Management Service affirmed the priority which is now being given to this work.

 However, it is not easy. As well as the institutional inertia and the staff’s personal feelings of resistance to change and loss, there are major structural obstacles. The task for us in penal settings is to accommodate the very exacting and precise demands of policies and procedures, which allow no flexibility and very little individual discretion, alongside the recognition that basic humanity in relationships is required, in order to stop prisons having persistent negative effects on prisoners.

 This book offers hope that it is possible to do both: to recognise the profound importance of the social matrix and milieu, while measuring, regulating and risk-managing all the necessary aspects of participants’ behaviour. Prisons and forensic settings are amongst the most socially controlled settings, where operational details of security must always trump therapeutic principles - and all the work must demonstrate metrics of outcome such as reduced probability of future offending. Yet this collection of chapters shows that it is possible to find space for humanity, in the way people relate to each other, in these difficult settings. If there is hope here, maybe there is hope for us all!

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[1] Yuval Noah Harari (2014) Sapiens: A Brief History of Humankind. Harper Collins, New York

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.