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

Sunday, 2 October 2016

Mental Health as a social movement

As you come out of the metro - Il Duomo
Shops in Milan
Milan is somewhere I have never been before – but I do remember being told, a few years ago, that when you go to the north of Italy (I took that to mean further up than Florence or Bologna) you need to dress in a smart, stylish and rather formal way. Not exactly my usual modus operandi. And I was invited to this occasion about a year ago by the organisers of the annual conference of the Italian association of therapeutic communities‘Mito e Realta’ – with the flights and hotel booked in the spring, and several reminders to send my talk for translation at least four weeks in advance. So I had a long time to get anxious about it.

As I understood it (which, admittedly, wasn’t very well) this was the first ‘Annual Forum’ of the whole-Italian equivalent of our British ‘Community of Communities’.
Logo of the Italian association of TCs
They had already invited us (usually meaning Jan Lees and myself from the British TC movement, but also some others sometimes – particularly in the months when Jan was having her bionic surgery done), to the first three of the equivalent Sicilian events – which, by being in southern Italy (and even more so by being Sicilian), were necessarily friendly, informal and relaxed affairs. So I was expecting these two days to be a rather familiar type of event, with a day of leisurely talks, and a day of celebrating the success of the TCs who had managed to go through all the processes to be accredited. And all in Armani suits (except me) and with immaculate northern Italian style (maybe).

But I was wrong. The friendly informality was the same as I was used to – and there were at least a few people who were less dressed up than I was. The relative simplicity of the Sicilian ‘visiting project’ was blown out of the water by the innumerable different levels, processes, methodologies, clinical and geographical considerations – all with a perplexing array of different permutations which were presented to us. Simone Bruschetta – who I have always considered a reasonable and straightforward sort of guy – had become the mysterious mastermind of a web of inter-related projects, stretching across Italy.
Simone Bruschetta - aka Bond
Like a true Bond film, the different cells all had their own secret language – like ‘VIVACOM’ and ‘SCAF’ and numerous other coded messages for the eyes of the initiated. Acronyms are often hard enough to follow in English – but when they are in Italian, I have to give up hope of understanding them at all. But everybody there understood them well enough, and the business was done.

But then there was the conference programme – which I should have studied before – as it had included several spaces on the programme for me, as the UK supervisor and ‘esteemed visitor’, to fill with my erudite thoughts and utterances. If only…! There were three or four occasion on which the people on the platform turned to me and said ‘over to you, Rex’ in Italian, sometimes when I was least expecting it. But, in the lovely Italian tradition of kindness to visitors and to those who don’t speak the language, it seemed to go reasonably well. Whatever rambling and disconnected thoughts I managed to put into the microphone which was then put under my nose, which were then translated into Italian, seemed to be well-received. I think it was more important to smile and say friendly things, than try to say anything seriously meaningful!
Marta Mingharelli, M&R Presidente

The pre-arranged part of the proceedings were on the first day, and seemed to go quite well. John Turberville, one of the leading figures at the Mulberry Bush School in Oxfordshire and current chair of the Community of Communities advisory group, gave a talk about how the London-based Community of Communities project currently works. Then I gave an edited version of the current bee in my bonnet - about what TCs need to do to cope with modernisation, globalisation, terminal fragmentation and inevitable eco-meltdown (see previous blog entries). The questions and discussion points ranged between the ‘evidence-based practice is killing everything of value’, ‘thank goodness that a proper RCT has been done’ and ‘all you need is love’ (relationships) extremes. I felt a pang of guilt and sense of betrayal to a couple of elderly and distinguished Italian psychoanalysts, who I had met years ago, by proposing that we need to ‘get modern’. But no voices were raised, tempers lost, or friendships hurt in the process.

There was then, despite IT problems, the presentation of a one hour video film which has been commissioned by Mito e Realta, and produced by professional film-makers. It was a remarkable exercise which took (only) three months to film – including dozens of Italian TCs, showing the depth and intensity of their work. Group members were clearly enthusiastic about appearing, including in their therapy groups – which is sadly inconceivable (and probably illegal) in the UK – at least for those in the NHS. The whole process of their ‘Community of Communities’ process was explained step-by-step, and in a way that was both intimate and authoritative. The film-makers said that they hope to produce a version with English sub-titles before long, and I hope they do. It would be an excellent introduction to the work of therapeutic communities for a wider audience – but also one which we in the British TC movement should be doing for ourselves.

The second day was altogether different: the first part was easy to understand, when three TCs had about a quarter of an hour each to introduce themselves to us. It started with the external auditor giving a report about how they did in trying to meet the standards – qualitatively as well as quantitatively –then a presentation by people from the community, with pictures and more of an impression of ‘what its really like’. Congratulations to ‘Gnosis TC’ near Rome for getting top marks in everything – but also for coming across as lovely people doing a brilliant job, in ways we’d hope all TCs to be.

The next session was led by Raffaele Barone, the Sicilian public health psychiatrist who I think has worked tirelessly to do as much as anybody anywhere to humanise mainstream state-provided mental health services – and demonstrate the intellectual poverty at the core of biomedical-only psychiatry.
Raffaele Barone
Several of the questions seemed to be rather disbelieving of how such an approach was possible, and perhaps envious that their own commissioners, managers and political opinion-formers were not as sympathetic as they were in Raffaele’s patch (Caltagirone in Sicily). But I have often met Raffaele over the past few years, and have seen how hard and continuously he works at building the understanding in the institutions of power, and public opinion, that psychologically sophisticated approaches need.

After this session, I was called up for one of my impromptu opinions – and, struggling for something sensible to add, remembered the conversation that Geoff and I have been having in Slough. We are starting to think of ‘health as a social movement’ – so I linked that to Basaglia and the late 20th century Italian psychiatric reforms, along with the 1950s social psychiatry revolution in the UK, and said that we need another mental health uprising, led by service users and focussing on ‘mental health as a social movement’. The time is ripe.


And although the rest of the day went into complex details about how different communities in different networks had managed to audit themselves, that conversation, started by Raffaele, is what stayed with me – and what I think it’s all about. Not just in Italy, but also in Slough, and the British TC movement, and anywhere else people are oppressed by state-run organisations that make people’s mental health worse by stripping them of their power and dignity.

Saturday, 18 June 2016

Embracing the ASSiST team

ASSIST is East Berkshire’s antidote to harmful, degrading and dehumainsing hospital admission – see the recent blog with one of our members telling how the process of being admitted to the mental health services made him feel like nothing more than a number.

EMBRACE is a novel ‘micro’ therapeutic community that meets together for only 2½ hours per week but ties together a whole week of individually tailored and co-created therapeutic services – in all the relevant sectors – NHS, social services, voluntary, social enterprises and charities.

Just coming up to our second birthday for the two projects we were delighted to be shortlisted for the BHFT (the NHS hospital and community provider organisation that manages us) ‘best patient initiative’ award …and even more delighted to win it!

So while I was trying to get to sleep after an evening of Italian food, music and fun (see the previous blog), texts and WhatsApps kept pinging me awake.

The team looked fabulous – well done them. A great deal of hard ‘governance’ work behind the scenes is needed to keep a project like this on track – ensuring all the tedious risk documentation and excruciatingly pedantic policies and procedures are followed, for example – to make it look calm and easy!

Maybe this means the ugly duckling (of a disfavoured TC) has become a swan – but it’s still paddling furiously under the water…

Thursday, 16 June 2016

Living and Learning in a haunted monastery

Imagine setting up a therapeutic community for business entrepreneurs, experts by experience, family and friends, and a few mental health staff. The entrepreneurs were from a supportive society in Rome. We had a financier, a travel business executive, a high level head-hunter in telecoms, a previous national queen of salsa who is now a retail d├ęcor retail entrepreneur, and a barrister – as well as a boy scout leader, a couple of pianists and guitarists plus a singer with a beautiful

This was our first attempt to try therapeutic community principles out on people from entirely non-clinical backgrounds, by offering them three days of immersion in a carefully planned and designed ‘Enabling Environment’.

It has worked for many years as a useful training course for practitioners in TCs, then more generally for multidisciplinary staff in mental health services, and more recently as a ‘taster’ of what enabling environments feel like ‘from the inside’. This was the first time we have tried out the format on a mixed collection of people from completely ‘normal’ backgrounds.

The setting was spectacular – a converted Franciscan monastery in the hills about 50km out of Rome, with a sheer drop of 100m to the rapids below. I Also think l it was haunted – not only the site of an ancient Roman aqueduct (which we walked through), but it also had eerie dark corners, unexplained walled-off areas and quite a few bumps in the night. And – oddest of all – although the outside temperature was in the mid 20s, we were all shivering when we went into the staff room, and needed far more layers of clothes than you expect in Italy in the summer.

The Italy v Sweden football match threatened to derail the first small groups, but – with the importance of structure in mind – plans for a vote on the matter were abandoned when the four staff walked out of the first community meeting exactly on time. Everybody turned up for the small groups and the football was never mentioned again (Italy won 1-0).
The course went unexpectedly well – by the end, many of the participant expressed genuine surprise and gratitude for what they had learned, and felt, and experienced together, and everybody joyfully joined in with the more playful fun and games we all had together. At least two or three of them said that they had gained transformational insights over the three days.Perhaps the most interesting observation – which can only be qualitative and impressionistic at the moment – is that the entrepreneurs ‘jumped in’ more willingly than most of the non-TC clinicians, and were considerably helped by the openness and authenticity of the experts by experience. It is as if normal mental health training makes staff more ‘defended’ and unable to be in touch with their own emotions – unless they work in TCs.

That is quite a hypothesis to test – but Aldo and I are on the case. Aldo has devised questionnaires to demonstrate that the workshop closely reflects the Royal College of Psychiatrists ‘Enabling Environments’ quality standards, and we also hope to show that this sort of experiential workshop trains people in a way that no other learning experience does …and is ultimately justifiable in terms of efficiency and cost-effectiveness.

Please feel free to post any ideas that might help us to do this!

Wednesday, 15 June 2016

The new Animal Farm and the House of Lords

Ideas for therapy centre at animal farm launched at the Lords
The Cholmondeley Room is a rather graciously decorated, Victorian-feeling, reception area which opens out into the red-striped marquee and terrace on the Thames – where we were entertained by the battle of the Brexit boats, shouting at each other, flying provocative flags, and playing extremely loud rock and hip-hop music.

But inside, it seemed that everybody agreed what a good idea it was for people to be helped by animals as they themselves were helping the animals. And everybody included a lot of people with power, budgets and influence in Windsor, Maidenhead and Slough.  The eastern side of the Royal County of Berkshire, indeed. I imagine at the horses and horticulture for mental health might well be something that would appeal to the family who sometimes live just over the river from us!

The ones I managed to talk to included:
  • ·        Derek Bishop – Mayor of Eton. derek@etonplace.com. Very interested, said to get back to him if we need. Says Wooldridge Trust (?) may be able to help.
  • ·        Bob Jones – Slough Business Community Partnership. bob@sbcp.co.uk . Knows us through our greencare horticultural project at Iver, keen to hear more.
  • ·        Paula Greves – Trustee and treasurer of TASUK.  paula@grevett.co.uk. Very keen on the idea of collaboration, knows the local system.
  • ·        Adam Afriyie – Windsor MP (Con). adam.afriyie.mp@parliament.uk. Fairly interested (more in his speech than in person), and suggested to get onto councillors, CCGs etc.
  • ·        Phil Bicknell - WAM Councillor (Park Ward, Con and deputy council leader) cllr.bicknell@rbwm.gov.uk, interested, but clearly very ‘political’ and suggested we need to involve David Coppinger.
  • ·        David Coppinger -  WAM Councillor (Bray Ward, Con) cllr.coppinger@rbwm.gov.uk who knows the mechanics of the CCG and where we should start 
  • ·        Diana Coad – SBC Councillor (Langley, UKIP) siana.coad@slough.gov.uk – very keen, was on CCG, and is also on TASUK board of trustees, wants to help.
  • ·        Wayne Strutton – SBC Councillor (Haymill and Lynch Hill, Con) wayne.strutton@slough.gov.uk – didn’t seem to be directly interested himself, but supportively suggested we get Gus O’Donnell on board (GP commissioner lead MH)

… and a few others I can’t remember!


And here’s what I wrote:
Dear supporters and friends of Sara and The Animal Sanctuary UK
It was good to meet and talk to some of you at the House of Lords reception today - about the idea of an NHS collaboration with The Animal Sanctuary UK to develop a ground-breaking Ecotherapy centre at Bell Farm (to include animals, horticulture and other nature-based activities).
 I didn’t get to mention to some of you that I come from a very old mental health tradition of ‘therapeutic communities’ – where services are co-created with service users and peer mentors, to tackle stigma and generate real empowerment.
It would even be possible for a well organised therapeutic community to be thoroughly involved in designing and building cutting-edge eco buildings, if we get the funding right.
So we could have a fantastic opportunity here to build on some of the great work that has been happening in East Berks – particularly in Slough CMHT and Hope Recovery College – and really take mental health ‘out of the institution’ and ‘into the real community’. I really believe it could be a model for others to follow, if we do it properly.
I’m writing to remind you of the potential for the idea, and put us all in touch with each other. Please feel free to copy it to anybody else who might be interested.
The key person who unfortunately couldn’t come today was Geoff Dennis (Head of Slough Mental Health for SBC and BHFT), who some of you know – so I will copy him in too.
I hope this will help to get the ball rolling, and I look forward to helping in any way I can.
Rex
So watch this space.

If you know how to get funding for things like this, please reply – or if you know some eco-architects who might be interested, we’d be very interested to meet.