Thursday, 11 January 2018

Consensus statement ...nearly

After a monumental struggle to herd the cats, Sue Sibbald, Alex Stirzacker and Norman Lamb managed to get eight felines into the bag:
  • Mind
  • Centre for Mental Health
  • Royal College of Nursing
  • British Association of Social Workers
  • Royal College of General Practitioners
  • British Psychological Society 
  • Anna Freud Centre
  • Barnet, Enfield and Haringay Mental Health Trust

One more joined the party, the next day, perhaps after being shamed into doing so - the Royal College of Psychiatrists.

Here are the links to the statement itself and the BBC webpage on it.

The gang of three - plus the Man from Mind - at the parliamentary launch of the Personality Disorder Consensus Statement

Here's the briefing from GBL, some of which is in the Consensus Statement itself, and some of which found its way into the BBC News piece:

Some key facts and figures on ‘personality disorder’
·         Though PD is most visible in forensic settings (ie linked to public safety and dangerousness), the size of the problem in general mental health settings is hardly ever recognised. It affects, at some level of severity:
o    Between a third and two thirds of all psychiatric inpatients
o    92% of homeless people
o    60-80% of prisoners
o    Up to a quarter of GP consultations in inner city London
·         Suicide rate for Borderline PD (= “Emotionally Unstable PD”) = 10%;
o    this means people diagnosed with it are 400 x likelier than the national average;
o    Epidemiology figures indicate that at least half of all suicides ‘have some PD involvement’
o    On average, people with PD live 17 years less than the general population (including other reasons as well as suicide)
·         It costs a fortune, one estimate gives
o    £34bn (yes, not million!) for general management costs across all health services
o    £14½m for inpatient stays
o    Yet only 55 beds are commissioned by NHSE for severe cases

That’s the bad news, here’s something a bit more positive:
·         17% of areas had dedicated community PD (ie non-forensic) services in 2003, now (2016-7) it is 79%
·         Since the launch of the national training programme, over 100,000 frontline staff have received awareness and attitude training

Some opinions on ‘personality disorder’
·         Although most public interest is in forensic PD, that is relatively well-resourced
·         The lack of understanding of PD in general mental health services is a public health scandal
o    That lack of understanding is at least as significant as the lack of NHS resources (especially beds)
o    Many private hospital providers make their profits by providing bed-based services which rely on this lack of understanding
·         The vast majority of people with these problems do not get help from NHS – they suffer loneliness, isolation, social exclusion and desperation without knowing that help is possible. Many kill themselves without anybody else ever knowing. Many others manage to cope with help from voluntary organisations, churches and other religious groups, and random kind people.
o    The NHS is very wary of taking people with these complex problems onto its lists – partly because they are so short of resources – but also because these conditions are often seen as ‘untreatable’ and potentially a waste of what resources they do have.
o    Also, suicides are increasingly seen as unacceptable in mental health services (eg ‘zero tolerance’ programmes), and people with these conditions are at high risk. So, without deliberate direct intent, it is ‘convenient’ to find them untreatable, so that the suicides of those unregistered people with ‘PD’ are not counted as mental health failures by the NHS.
·         Cross-departmental work is needed to address this at policy level: the National Personality Disorder Development Programme did this (across DH, MoJ, DCLG and DfE) but was stopped in 2011.
·         The only national coordination is now through the IAPT programme, which is does not have sufficient scope to be fit for the task.

Please contact me if you would like more information, or would like to be put in contact with other experts.
Dr Rex Haigh, NHS Consultant Psychiatrist in Medical Psychotherapy; Clinical Advisor to National PD Development Programme, 2002-2011.

These opinions are not necessarily those of organisations for whom I work.

Overall, a lot of work and conflict contained in many struggly months - and a worthwhile day at the end of it. Maybe it's a new start for doing something meaningful about the ghastly industrialisation and corporate fascism of public service mental health. But it's a shame...
  • That RCPsych wasn't enthusiastically in there from the beginning
  • The BBC piece used a rather frightening forensic case to open it
  • More journalists were not at the launch - to write more about it in broadsheets etc
  • The statement itself is not more slickly produced (not something I usually complain about!)
  • Paul Farmer from Mind couldn't be there
  • NHS England were only there in disguise - when Simon Stevens should have been
  • It doesn't link up with anything else going on in the field (eg BIGSPD, specialist commissioning, innovative services, relational practice and enabling environments, great progress in the homelessness and justice sectors).
  • Nothing is on the horizon for joined-up leadership of the field - and the kerfuffle with the RCPsych being left out didn't help. But thereby lie dragons.
  • It was the greyest, darkest, drizzliest January day in lining memory. London at its most iconic.

Saturday, 6 January 2018

The modern psychotherapies

Out of a book, a course is born

The book of the non-modern psychotherapy
One of the advantages for modern psychotherapies is that they are in keeping with the times: they are easy to understand, generally positive, low risk and populist. The processes that clone, replicate and implement them ‘at scale’ are industrialised and commercialised for maximum market penetration and efficiency. An individual or team of individuals can conjure up a ‘new’ therapy out of elements that most psychotherapists have known for years, simplify it as much as possible, define it exactly, research it, write a manual and – if they have done it well enough – hit the jackpot and become celebrity academics. A neoliberal success story – rock on!

One of the problems with the world of therapeutic communities is that they don’t fit this modern way of doing things. They have been around for decades, if not centuries, and nobody could or should claim any sort of ownership of them. They are fundamentally counter-cultural, anti-individualistic and strongly communal. Therefore, the corporate and industrial processes that work for modern psychotherapies will never be acceptable to their members or champions. These processes don’t allow for democratically incremental and reflexive change and development of the field, don’t recognise the inherent complexity and uncertainty of depth approaches, and deny the need for a critical or whole-system approach. The modern psychotherapies are managed into a state of fixed and reified sterility. Which means, since the late 1980s, therapeutic communities have been left out in the cold: in a state of moderate decline and all but forgotten by all but a few aficionados.

However, a few have adapted and modernised themselves to survive – hopefully without ‘selling out’ – although the rest have gone to the wall, and Empire is now Striking Back – with three prequels. The first has been to gather up all the therapeutic communities into a ‘Community of Communities’ and have a process to agree together what they are all doing, help each other with it, and make it accreditable. The second is to grit one’s teeth, screw one’s courage to the sticking place, and finish a research project which has been declared well-nigh impossible by anybody who has thought about it in the past. The third is to get together with everyone’s favourite friendly independent publisher, and publish a book about it all. The two people responsible for the first and second prequels are the co-authors.
The course of the book of the therapy

So now the book is there, it needs to earn its living – by making therapeutic communities, and therapeutic environments, spring up in new places, and bring the whole therapeutic communities movement back to life and rude health. It was a powerful social force in the heyday of social and emancipatory psychiatry in the middle of the twentieth century, and many feel the need for a twenty-first century version: mental health as a social movement.

One way we are starting this do this is by stealing a trick from the ‘modern therapies’ by mounting a practitioner training course. It is based on the book, and includes as many therapeutic goodies as it is possible to get into a course little over a year long. But those who complete the course will be able to call themselves ‘therapeutic community practitioners’, have confidence that they are doing something that is both age-old and evidence-based, as well as being thoroughly human. They will bring the quiet revolution to a mental health service near you. 

May the force be with them!

Friday, 15 December 2017

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...


Residential trauma clinic
Monthly information sharing
Quiet and reserved (except staff)
Alternative to admission non-residential
Weekly support and coordination
Raucous and festive (with Christmas jumpers)
Environmental / ecotherapy
Intensive support: check-in
Warm, welcoming of visitors, and emotionally intense
Environmental / ecotherapy
Intensive support: check-out
Appreciative, mindful and settled
Offender PD tratment
One of 2x weekly wing meeting
Boundaried, highly organised, with vivid emotional content

Friday, 1 December 2017

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: 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.

Friday, 3 November 2017

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:

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