It's just not right.
Grumpy old psychiatrist wonders why - and tries things to escape oppression, institutionalisaton, industrialisation of mental health and digital tyranny.
Hopefully by only bending the rules, but never breaking them.
Well, we'll see.
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…
And here's the text if you don't have access to the BJPsych:
communities enter the world of evidence-based practice
In this edition, Steve Pearce and
colleagueshave 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
(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;
(4) Haigh R. The New Day TCs:
Five Radical Features. Therapeutic
(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
(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
(11) Department of Health. Recognising Complexity: Commissioning Guidance for Personality Disorder
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.