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.
…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.
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
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!
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
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):
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
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.
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 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
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
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:
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: firstname.lastname@example.org .
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!