Monday, 17 December 2018

Seven reasons why psychiatric medication is wrong in therapeutic communities

I'm off to a formal meeting on Wednesday to discuss the prison policy on psychiatric medication in the democratic TCs. So here's some notes I have made to help me think it through...

1    'Medical' or 'psychiatric' treatment should not necessarily have to have to include, or even consider including, any pharmacological component. TCs are such a treatment: they arose from a different therapeutic philosophy in contexts where medication was not relevant or not invented. There is no evidence that their effectiveness has been enhanced by allowing psychotropic medication to be used for their members, except perhaps to increase staff sense of 'knowing better' and social control. TCs are a safe place in which the effects of no medication can be carefully monitored and responded to by psychotherapeutic means

2  Psychiatric drugs directly hamper TC treatment. All groups of psychiatric medication have effects on mental functions that hinder the therapeutic process, or block it: minor and major tranquillisers cause drowsiness and lack of full attention; drugs used for depression and other stimulants can give a false sense of elevated mood; lithium is often reported to leave people 'feeling like a zombie', and most people on it recognise the emotional blunting it causes.

3  Psychiatric drugs indirectly hamper TC treatment. The other way medication hampers TC treatment is that it takes away responsibility for how one is feeling, thinking and behaving - and allows swallowers to think that a pill can cure one's woes. Taking a pill is much easier than making a decision to pursue a more the more difficult option - which involves allowing oneself to trust the holding, containing and transforming effects of therapeutic belongingness. The symbolic meaning of medication also prevents the relational equality needed in a TC: the relationship between the prescriber and the swallower is necessarily unequal.

4  No psychiatric drugs are licensed for the specific treatment of 'Personality Disorder', for which therapeutic communities are a definitive treatment. The diagnosis of 'co-morbidity' usually covers this - but the co-morbid conditions are only symptoms (such as depression, anxiety, agitation, insomnia, voices) of the underlying condition. Medication can doubtless help symptoms, but that is all it does. Diagnosing co-morbid conditions can be seen as an exercise of professional power, which is not subject to the enquiry and scrutiny of other decisions made about members of a therapeutic community. 

5  Medication is less effective than advertised. The general trajectory of many psychiatric medications is enthusiastic optimism, followed by extensive routine use, followed by problems and questions - examples include barbiturates, amphetamines, benzodiazepines and most recently SSRIs. Advocates of new medications often include influential clinicians, guideline-issuing bodies, professional organisations as well as the pharmaceutical industry. The recent challenge of the 2017 NICE depression guideline by numerous experts and fourteen professional organisations opens the question of possible pharmaceutical bias - at the highest levels.

6  Long-term use of medication is harmful. Detailed work by Joanna Moncreiff in the UK and Peter Gotzsche in Denmark have made a strong cases against the way in which psychiatric drugs are currently used. Moncreiff argues that drugs do not specifically target any 'diseases', but have specific effects that may ameliorate symptoms; thee neuroleptics cause brain atrophy, tardive dyskinesia and poorer long-tern outcomes than no medication. Gotzsche goes further and presents evidence to show how psychiatric drugs kill half a million people every year in the USA and Europe.

7  There is a wider movement going on for a more relational and democratic type of psychiatric care. Therapeutic communities and their progeny have always had these core principles, but many other organisations and movements are now espousing similar values: Open Dialogue, Soteria Houses, Multifamily Therapy, Greencare, Hearing Voices Network - as well as numerous small service-user led groups and networks.

In the wider sweep of the history of psychiatry, I believe that many of our current medications will look as archaic as chaining people up and beating them, or putting them into a coma with insulin. But the same may be true of current psychotherapies. Not so sure about psychedelics, though - they seem to have been used fairly well for many centuries...

Thursday, 29 November 2018

Measuring what matters: ReQoL

This is ReQoL day, in a grey and rainy Sheffield.

I'm not usually somebody who gets at all excited about psychometric 'instruments' (as their manufacturers rather grandly call them sometimes) - but ReQoL feels a bit special. In the same way that CORE did three decades ago - something that can really let us and our service users know how we're doing. And this one is based on a value set that comes from research showing what matters to service users themselves - not by clever academics in a university, or powerful doctors in the clinic, saying what should matter. And even more fun was meeting a mystery man on the way into the conference room, who knew me,  but wouldn't tell me who he was (though I recognised him, despite 20+ years since last meeting). When he stood up to speak - about the scientific process behind the new measure - I knew: it was Mike Barkham, one of the main developers of the CORE - and regular in the snooker room at the Raven Hall Hotel at the annual Society for Psychotherapy Research (UK) bashes in the 1990s.

The morning was quite energising, and felt like this was a good new measure that was designed around measuring something that really mattered – and could help us all coordinate across services, research, commissioning and policy.

But then the afternoon came along.
I found Tim Kendall very dispiriting – his vision extending no further than which bits to spend a little bit of extra money on, and a rather nihilistic mood agreeing it’s all bad and won’t get much better (in my working lifetime, at least!)
And as for the best thing Andrew Lansley did was to make the NHS even more hierarchical and driven top-down– I was close to passing out with despair.
It was probably worse because I found the afternoon ‘cafĂ©’ workshop perhaps the dullest event I have ever been to – and annoying in confirming my fear that legions of clever people are running round feeding the machine – and getting quite excited about it.
But where are the service users in it all?
And where were they today? A: not there, because it was all about the experts doing clever and complicated things without them.
And as Tim said, their scores aren’t what really matters, because it’s the measures that show how well that machine is working that he is interested in.

Then he goes and says that an ‘official’ PD measure is being written – probably by people none of us have ever heard of, with a big grant that’s not connected to any of the other work that’s been done in the field over many years, or is currently going on.
And he was extremely lukewarm about ReQoL, which I thought was going to get his backing - as a sensible and robust outcome measure for us all to coordinate ourselves around (and, dare I say, more democratic and meaningful to service users than bureaucratic old warhorses like HoNOS). But no. Aargh.

So NHSE is even more of a disorganised and fragmented mess than I thought – as a personality disorder consultant colkleague, from the Cassel, exactly put her finger on in questioning him. It’s not harder hierarchical management it needs – it relationality at all levels (not performativity) and real service user co-production!
And as for the withering scepticism he expressed in his aside about ‘being human’ (or something like that) …my blood ran cold.

In the old days, like when he was chairing the Borderline NICE group, he used to wear a black polo-neck and tight black jeans – like a baddie out of a Bond film. But I find the new look, with suit and tie, and Robin Day glasses, much more sinister!

Thursday, 19 July 2018

Medication, trauma and psychiatry

As the UN Special Rapporteur announced last year:

 “Mental health policies and services are in crisis - not a crisis of chemical imbalances, but of power imbalances. We need bold political commitments, urgent policy responses and immediate remedial action.” 

“We need little short of a revolution in mental health care to end decades of neglect, abuse and violence.”

However, there is no sign of a revolution around the corner: indeed, with the economic power vested in the pharmaceutical industry and the social power in the medical profession, any UK policy change is likely to be fiercely fought - and very slow.

But there are some signs of an evolution – from the World Health Organisation, from some British professional institutions, the voice of service users, and from a small independent clinic in Oxfordshire – by using the lens of trauma treatment.

·         Historically, the psychiatric profession has defined disorders by their symptom presentation rather than by cause. This is changing with the 2018 publication of ICD-11: see previous blog ‘Thinking about Diagnosis’.

British professional institutions
·         The British Psychological Association has published a detailed critique of biomedical practice in the ‘Power Threat Meaning Framework’. Its central ideas include trauma-informed thinking, formulation rather than diagnosis, and relational practice.
·         Public Health Wales is running a large public education and information campaign about ‘Adverse Childhood Experiences’ and their consequences for individuals and society.
·         ‘Enabling Environments’ and ‘Psychologically Informed Planned Environments’ are becoming well established in the criminal justice sector, with government support.
·         ‘Psychologically Informed Environments’ are becoming similarly established in the voluntary sector, particularly for homelessness, with support from local commissioners, and lottery funding.
·         Several organisations have come together for a parliamentary launch of a consensus statement about ‘personality disorder’, led by Norman Lamb MP.
·         The Royal College of Psychiatrists is working on a parallel position statement.

Service users and other critics of mainstream services
·         Trauma is often not recorded or registered, and rarely taken seriously.
·         Mainstream psychiatric provision often re-traumatises people.
·         Medication only ever offers temporary and partial relief.
·         The most acceptable services are co-designed with experts by experience.

A small Oxfordshire clinic
·         Khiron House is residential trauma treatment service which takes private and NHS referrals
·         It combines a rigorously designed therapeutic environment with intensive individual and interpersonal neurobiological therapies (based on the work of Daniel Siegel, Pat Ogden and Bessel van der Kolk).
·         No other residential units in the UK offer this level of specific trauma expertise.
·         It prioritises psychosocial treatment over biomedical, and aims to work in collaboration with prescribing doctors.
·         It follows a wholly non-paternalistic model, and expects its residents to be able to take day-to-day responsibility for themselves.
·         Its current working practices are not suitable for CQC registration.
·         A higher dependency unit is being planned, with full nursing cover – for those who experience severe dissociative symptoms which require a higher level of psychosocial containment. This is likely to seek CQC registration.
·         Declaration of interest: I work for them as medical director (ie communication channel to the mainstream system), chair of ethics and governance board, and clinical advisor (specifically on therapeutic environments). It is a very part-time role, and does not involve any contact with the residents or involvement in the specific therapies.

Wednesday, 18 July 2018

A real alternative to traditional treatment

There is a wind of change in the air, as evidenced by several formal processes related to mental health policy. This includes the publication of ICD-11, the parliamentary launch of the consensus statement on personality disorder, the Welsh government's public health strategy on adverse childhood experiences (ACEs) and trauma, the serious professional challenge to the NICE revision of depression guideline, emerging evidence of severe long-term adverse consequences of neuroleptics, and a recent report by the UN Special Rapporteur - who called for a revolution in mental health. LINK (also see previous blogs)

The therapy yurt under the apple blossom at Khiron House

Why Khiron is different
A small part of that revolution is what we are doing at Khiron House: delivering an intensive programme in which the primary modes of treatment are psychotherapeutic and psychosocial, and biomedical psychiatry has a secondary role. Many patients and clinicians appreciate that mainstream and traditional approaches can only offer superficial ways of coping with the consequences of severe and complex trauma - without ever truly overcoming it. We believe that our expectations and ambitions should be higher, as the growing body of research evidence indicates. Khiron’s work is based on providing a rigorously planned therapeutic environment in which highly specialised trauma-focussed psychotherapies can be delivered. This field is sometimes called ‘interpersonal neurobiology’, and the definitive interventions are based on the work of Pat Ogden, Daniel Siegel and Bessel van der Kolk. The planned environment work is based on several years' research and development on which the Enabling Environments award at the Royal College of Psychiatrists Centre for Quality Improvement is based.

What we are up against
One of our difficulties is how the whole health system, and its regulation and governance structures, is based on traditional views of disorder, ultimate responsibility and individualism. Our therapeutic philosophy is quite different: we see formulation and understanding as more important than diagnosis, we always try to help people to take responsibility for themselves in the face of paternalistic requirements of the system, and we believe that our residents’ forces of healing come as much from each other as from expert therapists. This means we do not fit very well with regulators’ expectations of zero tolerance of risk, or of staff being wholly responsible for the thoughts, feelings or behaviour of others; nor can our therapeutic and relational methods of promoting and maintaining safety ever meet strictly objective criteria.
However, through our Ethics and Governance Board, we intend to square this circle, and run an extremely safe service which exceeds regulators expectations, without perverse rules or policies, and is in line with our theoretical model, our therapeutic philosophy and our ethical stance.

One specific area of conflict is often that of prescription of psychotropic medication. Unfortunately, for many patients this has become the defining modus operandi of modern psychiatry. We do not deny the power or usefulness of medication, but only when it is used in specific circumstances and as a secondary means of support: the primary treatment with us is always psychosocial. 
All classes of psychotropic medication influence people’s mental state and experience of their own emotions: this is their purpose. However, this often impedes access to the feelings, thoughts and emotions which need to be dealt with by the psychotherapy process. This is why we encourage our residents to understand the medication they are on, be aware of what effects it might be having on them, and be taking as little as they need.
When severe emotional instability or dysregulation inhibits somebody’s capacity to participate in psychotherapy, judicious use of medication does have a role.  This is time-limited and the medication needs to be safely tailed off when the capacity for self-regulation capacity has been established through psychotherapeutic interventions.

We hope that our referrers and fellow-professionals understand and respect the way in which our stance is different to mainstream approaches – and that we all chair the common task of trying to provide the best ways for individuals to get the help they need. To do this, we want to work collaboratively with colleagues working in other settings, by sharing expertise and responsibility.

We do not prescribe medication at Khiron House, and we encourage our residents to keep a diary of their medication - and discuss it with their prescribers. These can be referring private or NHS psychiatrists, or home or local GPs. Our residents are strongly encouraged to understand why they are taking the medication which they are prescribed, and to have an active part in any decisions about it. We recommend that those with trauma-based conditions are on as little psychotropic medication as possible, and on none indefinitely.

Rex Haigh
Medical Director, Khiron House
Professor of Therapeutic Environments and Relational Practice, School of Sociology and Social Policy, University of Nottingham
Clinical Advisor, Enabling Environments, Centre for Quality Improvement, Royal College of Psychiatrists, London

20 July 2018

Wednesday, 11 July 2018

Training for an age of chaos

In therapeutic communities, many of us have always resisted the push to be objectified or reified into ‘things’. I am a wholehearted believer that we are more interested in ‘a way of being with each other’ (aka ‘relational practice’), and a political and emancipatory movement – than in defining a fixed ‘treatment brand’. To me, this also means that the expression of these ideas has to keep up with the world in which they need to exist: TCs need to continually change and modify themselves. IF not, they risk being seen as throwbacks to a past age of radicalism with no contemporary relevance. And I wonder to what extent this is already true. I sometimes get a sense that some “TC hardliners” would rather have TCs die - than that they actively evolved. I fear that some some wallow in wistful sadness, righteous indignation and elemental fury that the ‘pure’ model of TCs has been challenged and found wanting. And that the process has, maybe sadly, killed off some of the best known of them.

But one adaptation I think we are nearly all agreed on is the need to spread the ideas and disseminate the practice beyond the world of ‘pure TCs’ – and to do this in a way that works in the current context. This is the idea behind both EEs (the ‘Enabling Environments’ initiative) and TCEPT (‘Therapeutic Communities and Environments Practitioner Training’). The course is pitched at a level between a short course (such as for EMDR or basic skills) and a full professional qualification (such as a UKCP registered psychotherapy), and it will be suitable for people at all levels of the hierarchy (in true TC fashion), and in all relevant professions (as well as adjacent ones). One of the main pedagogical principles is that we all have much to learn from each other.

That said, it will be rigorous. There will be three residential 3-day blocks to the training: a ‘basic theory module’, followed by an ‘intensive experiential’ one and finishing with the ‘advanced theory module’. They can be completed in just over a year, or participants can take longer if they want. Alongside this, members of the course need to be working in a suitable setting – on which they can reflect in monthly online supervision sessions. This can be anything from a traditional TC to a wide range of places that want to establish more therapeutic ways of working. This includes psychiatric wards, prison wings, voluntary sector projects, or indeed anywhere that wants to become a better therapeutic environment. In addition to this, other course elements include visits to established therapeutic communities, psychologically informed planned environments (PIPEs), psychologically informed environments (PIEs) and enabling environments, and various other ways of learning about them. There is no written work, but participants are encouraged to work in project teams that are linked to their day jobs, and everybody will do a group exercise to rate their ‘before and after’ competencies.

The three residential modules will be held in a beautiful organic farm study centre in Kent, with between twelve and twenty participants, and a staff team of experts in the field. It is starting in October 2018. If you are interested, please contact Sue Pauley through the TCEPT website: