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: 

Friday, 22 June 2018

Thinking about diagnosis

In psychiatry, a diagnosis can only ever be an ‘expert opinion’, because there are no x-rays or blood tests to show what is going wrong in the brain or nervous system. Over the last twenty years, much effort and expertise has been spent on trying to refine psychiatric diagnoses and make the process more ‘scientific’, so detailed questionnaires and structured interview schedules have been produced with sophisticated statistical analyses to show ‘validity’ and ‘reliability’. Although this ‘scientific’ process has helped researchers to define who should be in their research studies and who should not, it has misled public opinion and given the process of diagnosis an importance and authority it does not deserve. It is not coincidental that a great deal of psychiatric research is funded by the pharmaceutical industry, and funding for psychotherapy research is very much lower.

Problems include:
·         The internationally agreed diagnoses are agreed by committees of experts with no objective or incontestable basis (such as radiology or biochemistry).
·         The need for diagnosis, at least in America, is driven by the medical insurance industry.
·         Until recently, diagnostic systems have deliberately excluded anything concerned with the cause of the disorders.
·         The diagnoses all have ‘fuzzy edges’, and often overlap with diagnoses that sound quite different (as Stephen Fry has said, “it is a moot point where bipolar disorder ends and personality disorder ends” )
·         Most people with severe problems have overlapping problems which can be given more than one diagnosis.
·         In mainstream practice, which is usually based on a biomedical model, there is neither time nor expertise to untangle somebody’s symptoms into very tightly defined diagnoses. It is more important to see what somebody’s immediate needs are, and to address them.
·         In psychotherapeutic or trauma-informed practice, a narrative to make sense of the symptoms – a formulation – is produced, ideally in full collaboration with the subject. Although this is normally experienced as helpful in understanding the symptoms and problems, it is opposition to the diagnostic approach. This is because it a formulation is  different for everybody, and not generalisable. Therefore, without a diagnosis, however flawed it may be, it is not possible to be precise or systematically about deciding treatment.

However, things are changing. The new edition of the World Health Organisation’s diagnostic manual (International Classification of Diseases version 11, “ICD-11”) has just been published on their website, and is due to come into full operation in a couple of years. It contains some interesting changes from the previous version.
Here are some of them:
·         There is a new section called ‘Disorders specifically associated with stress’ (6B41) which includes PTSD, Complex PTSD, Prolonged grief and adjustment disorder. The important one here is ‘Complex PTSD’ which requires repeated or prolonged stress – and have many symptoms overlapping with what we previously called ‘Borderline Personality Disorder’. Because of this, it may well now be better-justified – as well as more acceptable to patients/clients/service users - to use the CPTSD diagnosis instead of BPD.
·         Personality Disorder itself has been given a complete make-over in the new classification. All the old categories like paranoid, avoidant, borderline, antisocial, narcissistic and histrionic have gone, to be replaced by a simple measure of severity – severe, moderate and mild. There is also a ‘personality difficulty’ level, which includes a large proportion of the human population – but is not classified as a disorder. For greater descriptive power, each level of severity can be assigned one or more of six ‘flavours’, which are somewhat similar to the old categories: ‘negative affectivity’; ‘detachment’; ‘dissociality’; ‘disinhibition’; ‘anankastia’ or ‘borderline pattern’. This means that each person will only have one diagnosis, not many – although the more severe diagnoses are likely to have more ‘flavours’. The lines between the levels of severity have not been firmly specified yet, but are intended to reflect how many areas of a person’s life are affected, and how persistently.
·         Another new section - much elaborated from the old single condition – is ‘dissociative disorders’. This itself reflects the greater prominence given to internal mental mechanisms – and indicates a less biomedical approach to mental life. The particularly interesting new addition is Dissociative Identity Disorder (DID – previously also known as ‘multiple personality disorder’). This is a diagnosis that has generated much heat and little light amongst psychiatrists in the past, and its addition to ICD-11 might leave some old-school psychiatrists – and their modern followers – rather unhappy. There is also a milder category of the same condition called ‘Partial DID’, which is less continuous and pervasive:
The non-dominant personality states do not recurrently take executive control of the individual’s consciousness and functioning, but there may be occasional, limited and transient episodes in which a distinct personality state assumes executive control to engage in circumscribed behaviours, such as in response to extreme emotional states or during episodes of self-harm or the re-enactment of traumatic memories.

As with Complex PTSD (above), this may well become a popular replacement for the old ‘Borderline PD’ or ‘Emotionally Unstable PD’, or alternative to the new ‘Personality Disorder with Borderline Pattern’.

All in all, this looks to represent a movement away from the biomedical hegemony towards a more open and flexible diagnostic system. It does not answer the critics of westernised psychiatry’s colonisation of the territory, across the world, but it goes some way to acknowledging that ‘what happened to you?’ is more important than ‘what’s wrong with you?’.

Thursday, 31 May 2018

The End of an Era: Greencare moves on

Today was a big day. an ending and loss; and hope for a future of which we know few details.  We knew it was coming, and we were as well organised for it as a royal wedding - with a great deal of work, a good bit of ritual and a fantastic cake.

Here's a video snip of my last walk to the yurt:

There were about twenty of us to do the day's business - group members past and present, staff, ex-staff, peer mentors from Hope Recovery College, and - in the afternoon - out special visitors. Of which, more below.

The event marked the end of our time at Iver Environment Centre, and the dismantling of the yurt -and putting it into storage until Hope Recovery College (which is part of Slough Borough Council's social programme for mental heath) finds a site to continue the Greencare work. And when it continues, it will be run by the recovery college, and its marvellous team of peer mentors - many of whom have been involved with the Greencare project over the last few years.

We have been unable to stay at Iver for several reasons - some of which are sad, and some of which point to a new hope for the future.

The sad ones include the way we have found it increasingly difficult, particularly over the last year or so, to fit with the corporate vision of National Grid, who are the owners of the land. They are moving towards an increasingly commercial use of the site - with little scope or space for small and somewhat unusual social enterprises like us, run and staffed by committed and passionate volunteers.

In some ways, it has never been an ideal site - several miles out of town, across the county boundary, and accessible by public transport only by a slow and circuitous bus journey. But the new hope comes from what we have built together over the last seven years there - the passion and dedication of everybody involved in the group, both members and staff - and the group dynamic methods we have developed by co-creation. The plans mean that the responsibility for, and ownership of, the yurt and greencare project now pass from the directors of Growing Better Lives (who will no longer be involved in the groups) to the peer mentors and staff of Hope Recovery College.

Once a new site is found for the yurt, it will allow a blossoming of the work to include many others who can benefit from its unique therapeutic qualities - in easy reach of town, but with all benefits and joys or working as we have all learned to do. That is our sincere hope, and we know it is shared by those who have leadership roles in Hope Recovery College.

After an extraordinary effort to dismantle the yurt before the anticipated downpour, which was completed by early afternoon (including coffee and pizza breaks), we had the ceremonial 'handing over' at 3pm. And still no rain.
The ceremonial handing over of the yurt

Introduced by music in 'The Garden of Time', members of the group and the staff enjoyed poems and moving testimonies before the formal business. One of four poles from the door section of the yurt was handed over to Geoff Dennis, the head of the Borough's mental health services, and Hope Recovery College. A magnificent yurt-shaped cake - lemon and elderflower flavoured - was cut and enjoyed by all. Just like Harry and Meaghan's, I was told.

Before the yurt is re-erected, the poles will be engraved with the mission statement of Growing Better Lives (in the right hand column of this blog).

So our dear yurt was packed away in a tiny cubicle of the yellow storage company - an extraordinarily alien environment - awaiting its release, and new home.

Watch this space to find out where it will be...