Friday, 12 May 2017

When is a therapy?

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…

The vibrant Verona gang!

Wednesday, 3 May 2017

IT'S OFFICIAL: Democratic Therapeutic Communities are now an evidence-based treatment!



And here's the text if you don't have access to the BJPsych:

Therapeutic communities enter the world of evidence-based practice

In this edition, Steve Pearce and colleagues have 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 disorder.
750 words

References
(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; 1960.
(4) Haigh R. The New Day TCs: Five Radical Features. Therapeutic Communities 2007;28(2):111-126.
(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 Quarterly 2004;75(3):263-277.
(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 Communities 2013;34(1):6-15.
(11) Department of Health. Recognising Complexity: Commissioning Guidance for Personality Disorder Services. 2009.
Rex Haigh
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.

Wednesday, 26 April 2017

Three psychologists tell the critical psychiatrists

…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. 



Friday, 7 April 2017

NICE idea from Gothenburg




I was 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 Carina HÃ¥kansson; 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!

There’s too 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 public commitment...
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):
--------------------------
Hello CPN Colleagues
I’m just 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 MEDICATIONS?
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.
Any thoughts?
------------------
Hi Tim
I’m just 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 thanks
------------------
Watch this space to see what comes of it!



Sunday, 2 April 2017

The 'Human Development' consultation

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 they live.

Over-riding 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 our families.

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:
And a link to a higher quality pdf of it https://tinyurl.com/PDtubemap 

  
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: nick.benefield@icloud.com .
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!