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...

Sunday, 27 May 2018

Stiamo ancora imparando da Basaglia


Titolo: Il Post modernismo

Autori: Rex Haigh
Traduttore: Laura Liverotti

Luogo: Forum di Catania - 25.05.2018



Il Postmodernismo

In una comunita’ terapeutica, affinche’ si possa lavorare in modo efficace, c’e’ bisogno di usare modalita’ che differiscono da quelle adottate per esempio nell’istituzione della Psichiatria Biomedica.

Recentemente, ho letto un libro che parla in modo molto approfondito di Franco Basaglia, scritto da uno storico Britannico di nome John Foot. Devo dire che la sua storia offre molto di piu’ di quello che pensavo e, l’esperienza italiana di cio’ che viene definito l’antipsychiatry’ (l’anti-psichiatria), continua ad avere ancora una certa rilevanza nel contesto attuale, a differenza dei lavori di Laing, per i quali non e’ piu’ cosi’ in Gran Bretagna.

Quando ho letto di Mario Tomassini di Parma e di Giovanni Jervis di Reggio Emilia ho pensato ‘questo e’proprio quello che stiamo cercando di fare al momento in Slough ed Oxford. Siamo forse piu’ vicini ai principi che provengono da Gorizia che a quelli proposti dalla Kingsley Hall.

Percio’ in questo mio internvento, usufruendo del pensiero critico del Postmodernismo, provero’ a raggruppare insieme alcune di quelle tematiche che riguardano il lavoro di comunita’ terapeutiche e degli ambienti abilitanti.

Attualmente, viviamo in sistemi che sono altamente gestiti da politiche, procedure e protocolli. Al contrario, le comunita’ terapeutiche hanno bisogno di flessibilita’ e di spontanieta’ (e di creativita’). Questo pero’ e’ difficile da mantenere nella scia di richieste sempre piu’ esigenti di protocolli standardizzati e manualizzati. Uno dei modi che attualmente viene utilizzato in Gran Bretagna e’ chiamato ‘relational practice’ (pratica delle relazioni) piuttosto che ‘procedural practice’ (pratica della procedura). In un mondo dove le persone si aspettano soluzioni mediali per ogni problema, numerose regolamentazioni ed una tolleranza ‘zero’ riguardo al rischio, cio’ che e’ umano ed ordinario e’ stato perso. E quello che che e’ stato perso ha un ruolo centrale nella relazione terapeutica, e qui non parlo necessariamente della conoscenza dell’analista, bensi’ mi riferisco all’aspetto umano ed all’ordinarieta’ del convivere l’uno con l’altro. O, come per esempio, le persone non trovino facile rilassarsi ed essere informali l’uno con l’altro sul posto di lavoro. Il personale clinico e’ spesso reso ansioso dal dover applicare ed aderire correttamente alle ‘prescrizioni del manuale’, o se il ‘livello di rischio’ e’ stato annotato sul computer dell’ospedale. Una parola che usiamo per descrivere cio’ che manca e’ la “therapeutic ordinariness” (ordinarieta’ terapeutica) - ed il progetto ‘Enabling Environment’ si basa prorio sui principi di questa ‘’relational practice’ (pratica delle relazioni).

La prima volta che ne ho sentito parlare fu nel 1978, quando, all’epoca studente di medicina, attendevo le lezioni di Science Sociali condotte da David Ingleby. Lui era uno scienziato sociale radicale all’Universita’ di Cambridge, e quello era proprio l’anno in cui la Legge 180 fu passata qui in Italia. A quel tempo, Ingleby stava scrivendo un libro dove spiegava come la malattia mentale fosse primariamente un problema politico e getto’ dubbi riguardo le affermazioni fatte circa l’oggettivita’ scentifica, proponendo metodi qualitativi piu’ precisi con l’obiettivo di ottenere un maggiore livello di significato dai punti di vista fenomenologico ed interpretativo (David Ingleby usa il termine ‘depth hermeneutics’ e lo relaziona alla comprensione psicoanalitica). In questo modo ci propone una visione della sofferenza mentale che e’ piu’ vicina all’esperienza del paziente e meno contaminata dall’ineguaglianza e dal divario di potere intrinsechi alla pratica clinica. Nonostante al tempo non ne fossi a conoscenza, cio’ e’ molto vicino a quello che Basaglia promuoveva in Italia. Il libro fu pubblicato nel 1980 e si intitola “Critical Psychiatry”. L’importanza di questa esperienza soggettiva del paziente e’ diventata un aspetto centrale nel movimento dei ‘service users empowerment’ (responsabilizzazione degli utenti), ed e’ stato uno dei principi fondamentali delle comunita’ terapeutiche sin dai suoi albori: un modo che ha ri-bilanciato il concetto di potere. Negli ultimi 15 anni, nel movimento britannico c’e’ di forte tendenza a “ri-definire” i servizi pubblici, sia nel settore sanitario che forensico, per coloro che hanno una diagnosi di Disturbo di Personalita’.

In Gran Bretagna, intorno agli anni ’70, Ronald Laing era visto come il trascinatore del movimento dell’ ‘antipsychiatry’, ma come Franco Basaglia, anche lui negava di vuolersi sbarazzare della Psichiatria, anche se la vuoleva cambiare. L’obbiettivo di Laing era quello di voler capire piu’ approfonditamente le esperienze del paziente: per quanto ho capito, il proposito principale di Basaglia ed la sua equipe era, prima di tutto, di sviluppare una comunita’ terapeutica a Gorizia cosiche’ da offrire ai pazienti condizioni piu’ umane, e susseguentemente di smantellare le grandi istituzioni. Tuttocio’ avveniva nel contesto della rivoluzione giovanile degli anni ’60, che rese tutto molto piu’ intenso e politico e confuso. Comunque entrambi, Laing e Basaglia, ci stavano mostrando come le realta’ sociali, politiche e culturali svolgono un ruole vitale in aiutarci a comprendere la sofferenza e l’esperienza della pazzia, e di come allo stesso tempo dovremmo e non dovremmo rispondergli. 

Nonostante le grandi istituzioni siano ormai chiuse da anni, in Italia come nella Gran Bretagna, il problema legato all’ ‘institutional thinking’ (pensiero istituzionale) continua a manifestarsi in modi diversi. Nessuno e’piu’ legato con catene o trattato come un animale, ma continua a soffrire della degradazione, della mancanza di emancipazione/responsabilizzazione e di rispetto, sentendosi cosi’, oppresso, alienato e come un cittadino di seconda categoria. Non sono necessari vecchi edifici per avere relazioni deleterie con coloro che si trovano in uno stato di bisogno. Io chiamo cio’ ‘institutionalisation in the head’ (l’istituzionalizzazione nella testa). I procedimenti che sostengono questo sono quelli  moderni delle regolamentazioni, della standardizzazione e del controllo sociale che rendono l’assistenza sociale simile ad una procedura industriale invece di essere umana e basata sulla speranza, la fiducia e le relazioni vere. Il lavoro attuale della Psichiatria, nel peggiore delle ipotesi, e’ quello di diagnosticare e prescrivere i farmaci necessari, e di evitare rischi. Purtroppo l’idea che il miglior modo per limitare i rischi sia quello di sviluppare e mantenere rapporti terapeutici, non e’ riconosciuta come valida. Questa e’ una delle idee alla base della ‘Critical Psychiatry’ (Psichiatria Critica), che a sua volta segue la scia dell’ antipsychiatry (anti-psichiatria) di 50 anni fa.



Alla fine dello scorso millennio, nel 1999, Greenhalgh e Hurwitz scrivevano proprio riguardo a quello che e’ stato perso:

“All’apice piu’ arido, la medicina moderna scarseggia di una metrica per misurare le qualita’ esistenziali come il dolore interiore, e che certamente costituiscono le malattie di cui le persone soffrono. Durante la formazione medica, la continua sostituzione di quelle abilita’ considerate “scientifiche” - quelle che sono eminentemente misurabili ma inevitabilmente riduzionistiche - con quelle che sono fondamentalmente linguistiche, empatiche ed interpretative, dovrebbero essere viste come aspetti vittoriosi del curriculum moderno.



Bradley Lewis, uno psichiatra americano, promouove il metodo narrativo nella Psichiatria (Lewis, 2011):

“Questo e’ il momento della ricerca dell’anima per la Psichiatria. Nonostante gli investimenti che la Psichiatria ha fatto in creare classificazioni rigorose e nella Neuroscienza, il campo attualmente sta riscontrando opposizione e critiche reminescenti quelli degli anni sessanta e settanta. Il giornalismo investigativo, i consumatori ed gli attivisti della riabilitazione, gli accademici nelle Scienze Umanistiche, Scienze Sociali e gli studi sulla disabilita’, ed i networks della ‘Critical Psychiatry’, esperimono tutti  una crescente preoccupazione sul fatto che questo dsciplina abbia smarrito la sua strada.”



La maggior parte del lavoro all’interno della nostra comunita’ terapeutica riguarda i costrutti narrativi , sia per ragioni storiche, che guardano alle ragioni per cui i suoi membri sono ‘finiti li’, sia per la storia del loro percorso come membri di comunita’ e di come cio’ abbia un impatto sia su loro stessi che su coloro a cui vivono insieme. Il gruppo di ammissione (che e’ parte del nostro processo di ammissione all’interno della comunita’) e’ il momento in cui la narrativa circa il “perche’ ho bisogno di essere qui” diviene cristallizata in una sessione di mezz’ora con il resto della comunita’.  Cio’ ha una profonda valenza terapeutica, e cioe’ quella di creare il senso di appartenenza  e di attaccamento, insieme a quello di comunicare informazioni importanti. Obbiettivi simili sono ottenuti anche quando, usando una modalita’ simile a quella descritta, si vanno a valutare i progressi raggiunti dai residenti della comunita’; cio’ infatti non deve essere vista soltanto come un ostacol o una formalita’ amministrativa, bensi’ un’ esposizione inevitabile, difronte al resto del gruppo, di quei sentimenti legati ai propri miglioramenti ottenuti all’interno della comunita’ terapeutica; nonche’ un’opportunita’ per i nuovi arrivati di vedere il tipo di narrativa che potrebbero essere in grado di generare per loro stessi.

Questo problema ontologico puo’ essere osservato da un angolo diverso e cioe’ come il ruolo del dubbio, di una narrativa complessa ed il graduale sviluppo delle conclusioni ed azioni siano oscurate da una visione digitale - 0/1, si’-o-no - di cio’ che e’ corretto. E’ come se ci fosse una tolleranza zero riguardo all’incertezza. I metodi ermeneutici e qualitativi, i fattori relazionali, le variabili contestuali ed altre distrazioni che permettono all’incertezza di emergere, sono viste come un’interferenza nell’algoritmo, e percio’ negate di ogni rilevanza significativa. Questo bisogno di certezza si nasconde dietro ai paradigmi dominanti della ricerca, e piu’ chiaramente nella gerarchia delle evidenze.

Al fine di trovare quelle prove che siano accettabili cosiche’ da influenzare le direttive nazionali sui trattamenti, una terapia deve far si’ che le sue evidenze trovino un posto, il piu’ alto possibile, all’interno di questo ordine gerarchico.  L’evidenza ‘gold standard’ e’ una meta-analisi dei randomised control trials di alta qualita’. Tra una vasta gamma di trattamenti psicologici che competono affinche’ vengano riconosciuti e finanziati, la richiesta di evidenze accettabili porta ad una mentalita’ tipo quella dei concorsi di bellezza, dove i trattamenti sono definiti, attuati, pubblicizzati e messi sul mercato come prodotti facili da replicare. Queste terapie, allo stesso modo,  possono essere cosi’ trascritte sottoforma di manuali ed essere passate attraverso il processo piu’ adatto di raccolta di dati. Steve Pearce, un collega di Oxford, che e’ anche uno Psicoterapeuta medico che lavora in comunita’ terapeutiche, ha intrapreso questa sfida e, nel 2016 ha pubblicato nel British Journal of Psychiatry, i risultati del suo studio sui gruppi randomizzati all’interno di comunita’ terapeutiche non-residenziali. In un certo senso penso che abbia fatto l’impossibile, ed allo stesso tempo forse ha anche aiutato la sopravvivenza delle comunita’ terapeutiche britanniche. Penso che gli organizzatori di questo incontro, lo vorrebbero invitare a Roma l’anno prossimo, cosiche’ possa parlare del suo studio.

Ho comunque delle riserve circa questo processo di ricerca; la prima riguarda la stretta somiglianza con gli studi sui farmaci condotti dalle industrie farmaceutiche; la seconda riguarda l’inadeguatezza di questo modello cosi’ rigido ed inflessibile. Inoltre lo vedo come parte di un progetto commerciale neoliberale con l’intento di confezionare e promuovere i trattamenti di psicoterapia come se fossero comodita’ che possono essere acquistate in un negozio. Penso che questo sia un esempio di economia di mercato usata in un ambito nel quale non dovrebbero, e vengono sostenute da un tipo di scienza positivista che, a sua volta, e’ usata in contesti in cui non e’ adeguata. 

Comunque, segnali di un metodo piu’ sofisticato e flessibile stanno emergendo, in cui la ‘qualita’ della prova’ sta divenendo un concetto piu’ complesso. Nel 2016, Steenkamp sostiene che le scelte di trattamento, in linea con i principi fondamentali della pratica clinica basata sulle evidenze, dovrebbe essere basata su tre principi:

·        La prova migliore
·         
·        La scelta del paziente, e
·         
·        L’espereinza clinica
·         
Inoltre, sostiene che, a parte il facilitare una processo decisionale condiviso, una sceta piu’ adatta e’ possibile; per esempio quella tra i fattori specifici legati ai pazienti ed i trattamenti disponibili. Cio’ sta a simbolizzare uno spostamento significativo da quella che e’ l’inflessibilita’ delle scelte del trattamento algoritmico, basate solamente sui trattamenti standardizzati ed ‘pazienti uniformati’.

Un fattore che limita ulteriormente il valore degli studi competitivi e’ la scoperta di come terapie specifiche diverse possono essere ugualmente efficaci e che la loro efficacia dipenda maggiormente da ‘fattori terapeutici non-specifici’ che sul tipo di terapia in se stesso. Questo e’ stato dimostrato molte volte, e risale al verdetto del ‘Dodo-Bird’ (dove tutti hanno vinto ed ognuno dove avere un premio). Questo fu sostenuto per la prima volta nel 1936 da Rosenweig, poi  dimostrato con la ricerca di Luborsky nel 1975, e da allora continua ad essere elaborato in modi diversi. Per esempio Lambert, nel 1992, mostra le percentuali relative ai diversi fattori presenti nei trattamenti psicosociali:

·        La relazione terapeutica 30%
·         
·        I fattori esterni 40 %, e
·         
·        L’aspettative di/l’effetto placebo 15%, lasciando
·         
·        alle specifiche tecniche terapeutiche il rimanente 15% di impatto sull’efficacia
·         


La mia preoccupazione e’ che questo e’ un po’ come la questione degli angeli che danzano sulla capocchia di uno spillo. Sappiamo che la salute e la felicita’ dell’ individuo consiste nella capacita’ di relazionarsi agli altri, e la ricerca moderna non da’ a questo aspetto - l’ ‘a priori’ - la priorita’ necessaria.

La considerevole e contestata letteratura che critica la ‘evidence-based practice’ va aldila’ dello scopo di questo intervento, comunque voglio dire che la tendenza verso l’accettare solo ricerche standardizzate ed aggregate di campioni sempre piu’ grandi sta dirigendosi nella direzione sbagliata, in quanto si sta allontanando da quella che e’ la comprensione dell’importanza delle relazioni umane. E sono proprio le comunita’ terapeutiche che rischiano di soffrirne di piu’ di questo. Al contrario di poter essere applicabili in modo uniforme su una vasta popolazione, le comunita’ terapeutiche sono fondamentalmente complesse e, in un certo senso, hanno anche in che di caotico. Questo pero’, nel vero senso della parola, e’ dove la sua complessita’ porta allo sviluppo di ‘fenomeni emergenti’ (spesso non intezionali) e di un sistema ‘caotico’ che, come il tempo, non puo’ essere previsto da statistiche deterministiche, aldila’ del loro grado di sofisticazione. In questo sistema, ogni individuo e’ riconosciuto per le sue differenze - la sua unicita’ e specificita’ per esempio - e non per la sua diagnosi. Cosi’ come, ad un livello successivo, ogni comunita’ terapeutica e’ orgogliosamente diversa l’una dall’altra, rendendo la specificita’ della ricerca uniformata quasi impossibile. Per questo motivo abbiamo bisogno di un tipo di ricerca diverso, ed anche se credo che ancora non sappiamo esattamente di come questo sia, al momento ci sono progetti di ricerca non-biomedica molto interessanti.

Una ricerca piu’ co-ordinata richiede un maggiore sforzo in quanto ha bisogno di sostegno sia organizzativo che di quello finanziario. In questo campo, il sociologo Nick Manning ha evidenziato una ‘politics of data’ (politica dei dati), il cui risultato e’ stato quello di non prendere le comunita’ terapeutiche come oggetto di studio di ricerca e, che di consequenza non hanno ricevuto finanziamenti da parte di quelle ‘istituzioni di ricerca’ appartenenti al campo biomedio o psicologico. Questo tipo di ricerca, siccome non raccoglie i dati secondo le modalita’ previste, non ottiene finanziamenti governativi; e senza tenere in considerazione coloro che revisionano articoli per riviste scientifiche, i quali probabilmente non accetterebbero articoli considerati ‘dissidenti’. Per questo motivo, la visibilita’ delle comunita’ terapeutiche nella letteratura di ricerca convenzionale e’ scarsa.

Comunque, c’e’ da dire che grazie ai recenti progetti di ricerca portati avanti dagli utenti (service users led research) forse c’e’ spazio per un po’ di ottimismo. Questi studi, seguendo metodi rigorosi e sistematici, pongono una notevole attenzione all’esperienza di coloro che si trovano in posizioni svantaggiose, e fanno fronte a quei temi che, sia i clinici che gli accademici, hanno in precedenza evitato. Questo va di paripasso con la ricerca in psicoterapia e gli studi sulla sua efficacia, secondo cui i risultati sono validi solo in certe condizioni che non esistono nel mondo reale. Questo e’ un buon momento per le comunita’ terapeutiche ed e’ cosi’ da un po’ di tempo. Qui, tutto cio’ che avviene - i nostri colleghi di ‘Open Dialogue’ chiamano cio’ ‘polyphony’ (polifonia) - e’ visto come un’opportunita’ per dialoghi che offrono spiegazioni molteplici ma dove nessuna di queste ha lo stato di verita’ assoluta; e dove, le opinioni di ogni individuo offrono esperienze differenti che a loro volta possono poi essere usate cone spunto di lavoro in terapia; e dove, le scelte e le decisioni sono prese secondo una specie di ‘emotional democracy’ (democrazia emotiva).

Tutto cio’per dire che le relazioni umane, ed in particolare quelle che si formano all’interno delle comunita’ terapeutiche, non possono essere “modernised” (modernizzate) secondo protocolli precisi, regole e controlli di conformita’. Queste rimarranno inevocabilmente complicate, difficili ed incerte, ma allo stesso tempo variopinte, emozionanti e divertenti. Questa e’ sicuramente una delle ragioni per cui non vorrei mai lavorare in ambienti clinici tradizionali dopo aver lavorato una vita all’interno di comunita’ terapeutiche.

Questo e’ tutto sulla Postmodernita’. Adesso invece, per la parte conclusiva di questo mio intervento, vorrei proporre l’idea che le comunita’ terapeutiche sono un esempio eccellente di pratica clinica post-moderna e dovremmo essere in grado di usarlo a nostro favore. In un certo senso, la miglior definizione della postmodernita’ che conosco e’ quella di Jean-Francois Lyotard: “NO GRAND NARRATIVES” (Lyotard, 2001). Sia il tradizionalismo che la modernita’ hanno le loro “grand narrative”, fatte di spiegazioni onnicomprensive che hanno l’obbiettivo di giustificare il tutto, predire cio’ che accadra’ ed avere tutto chiaro ed ordinato – igenizzato, contenuto e senza stati anziosi. Il Post-modernismo riconosce che cio’ e’ impossibile.

Da un punto di vista clinico, questo produce paradossi come quello del fenomeno della ‘overconfidence’ (presunzione/eccessiva sicurezza). Per esempio, come quando un membro del personale, e’ sicuro di fare la cosa giusta, probabilmente ‘sta sbagliando’! E forse, cio’ che accade secondo un meccanismo relazionale, e’ che lo stesso membro del personale appare agli altri come se non fosse intenzionato ad aprirsi emotivamente (perche’ cosi’ sicuro di essere nel giusto). Cio’ comunque conduce alla inevitabile conclusione che forse non e’possibile ‘essere sempre nel giusto’.

Un altro aspetto clinico del “no grand narratives” e’ come i membri delle nostre comunita’, specialmente coloro che hanno ottenuto un certo grado di autonomia, non sono molto propensi ad ascoltare quando gli viene detto che cos’e’ meglio per loro o che tipo di sentimenti stanno provando. Queste persone possono farsi idee da una vasta gamma di stimoli che, per esempio, includono le loro esperienze personali, l’internet, i libri di auto-aiuto, l’arte, i racconti dettagliati e profondi degli amici ed infine gli esperti. Comunque c’e’ da dire che adesso gli esperti non hanno piu’ l’ultima parola.

In un’era caratterizzata dalla ‘New Public Management’ (Nuova Gestione Pubblica), viviamo in un mondo dominato dalla modernita’. Tutte quelle organizzazioni finanziate dal pubblico, dai servizi sanitari alle universita’ ai servizi sociali, devono dimostrare sia responsabilita’ che transparenza rispetto alle specifiche strutture e sistemi di regolamentazione governativi. Questo e’ una modalita’ monotona che manca di creativita’, e spero che le comunita’ terapeutiche possano offrire qualcosa di diverso ai nostri membri, al personale ed all’organizzazione in cui lavoriamo.

Allora, proviamo a dividere i vari approcci verso la salute mentale in tre categorie:  tradizionali, moderni e post-moderni. L’approccio ‘Tradizionale’ che e’ il vecchio sistema del manicomio e delle grandi istituzioni con gerarchie rigide e dove il potere e’ tutto nelle mani dei professionisti, di solito i dottori. L’approccio ‘Moderno’ e’ quello del ‘New Public Management’ o, come alcuni lo chiamano, ‘performativity’ (la migliore performance), dove tutto e’ stabilito e controllato con esattezza, dove ci sono protocolli scritti per ogni variazione/divergenza od eccezione fatta o per qualsiasi inadempienza, e dove l’efficacia, la performance ed i risultati possono essere esattamente misurati e verificati. Qui il potere e’ nel sistema che e’ democraticamente responsabile. Infine, l’approccio ‘Post-moderno’ che e’ molto piu’ difficile e critico, e molto piu’ simile alle caratteristiche delle comunita’ terapeutiche che ho descritto. Ma siccome e’ basato sulle relazioni umane, nonstante la sua creativita’, spontaneita’ ed anche forse un po’ di anarchia, e’ in un certo senso il piu’ difficile da gestire. Ma forse sono proprio questi gli aspetti che rendono la vita degna di essere vissuta o un lavoro degno di essere fatto. Qui, il potere e’ fluido anche se deve essere contenuto all’interno di una struttura contenitiva.

Per concludere, vorrei che tutti noi celebrassimo questo modo di lavorare che segue il ‘Moral Treatment’ (il trattamento morale) del 18esimo secolo quando pochi illuminati riconobbero che le persone con disturbi di salute mentale avevano bisogno di essere trattati come esseri umani. Questo stesso pensiero fu ancora una volta rivisitato negli anni ’60 con il movimento italiano ed inglese dell’antipsychiatry.

Oggi, 50 anni piu’ tardi, cerchiamo di fare la stessa cosa. Lo stiamo ancora facendo nelle comunita’ terapeutiche e negli Enabling Environments (ambienti abilitanti), ed anche qui in Sicilia con il Visiting Project. Credo che adesso sappiamo come costruire la struttura contenitiva all’interno della quale, il potere dello Psichiatra puo’ essere esercitato con compassione ed umanita’.



Still Learning from Basaglia


So, back to Italy - Catania this time - while our bags got stuck in Rome and didn't catch up with us till after the conference. This was for the fifth Annual Forum of the Sicilian Visiting Project - where therapeutic communities, group living apartments and therapeutic housing projects visit each other and demonstrate that they are following the therapeutic model and deserve to be accredited - then all get awarded grand certificates, clapped, and have many smiling photographs taken. 
But before all that were the talks. It was with not a little apprehension that I had prepared mine this time to include some of my own thoughts about Italian (and British) psychiatry since Basaglia and Law 180. Coals, and eggs, and Newcastle, and sucking grandmothers, come to mind. But I was armed and enthusiastic, having just finished John Foot's gripping tale of 'The Man who Closed the Asylums'. And amongst friends, so unlikely to be mauled and publicly humiliated as in the not particularly fond memories from the academic psychiatry meetings of my junior doctor days. 
Amelia and Laura - students of Jervis
And indeed, it was to be. The reception to the talk, and the discussion, was friendly and stimulating - and it was quite exciting to ind that Laura (our translator) and Ameila (one of the main organisers) had both been taught by Giovanni Jervis when they were psychology students in Rome. He was a key member - and ultimately dissident - from Basaglia's equipe; they remember him as rather austere and laconic, and not much fun - as well as being quite old by then. Maybe that's the delayed effect of playing second fiddle in one of history's major psychiatric revolutions... 
Another interesting revelation was the different nature of the soil in which the Italian and British 'antipsychiatry' and therapeutic community movements grew. The Italian one in the post-resistance communism of day-to-day officialdom - and the British one (for TCs, at least) from the wartime group therapy experiments, largely isolated from the explosion of 1960s youthful rebellion. The Italian TC work over the last decade or so suddenly made sense. Why the main TC problem in Italy is that hundreds or thousands of places call themselves TCs - when very few really are; and the main problem in the UK is that there is almost no support in health or adult social services - and often vigorous opposition - to funding TCs, and almost nobody wants to claim to be one. 
Worth some more thought.    Anyway, here is the talk:
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TCs and Critical Psychiatry

Rex Haigh

Interpreted by Laura Liverotti

Catania, 25 May 2018


In democratic therapeutic communities, we need to work in ways that are not the same as the institution of biomedical psychiatry. I have recently read a detailed book about Franco Basaglia – by a British historian called John Foot. There is so much more to the story than I thought – and the Italian experience of what they call ‘antipsychiatry’ continues to have modern relevance in a way that the work of Laing does not any more, in the UK. When I read about Mario Tomassini in Parma and Giovanni Jervis in Reggio Emilia, I thought ‘that is like we are now trying to do in Slough, and in Oxford'. We are closer to the principles coming from Gorizia than those from Kingsley Hall. So in this talk, I am going to try and draw some themes together about what we do in therapeutic communities – and enabling environments – using some of the critical thinking of postmodernism. But also, why postmodernism is not enough to explain what we do.


We all now live in systems that are highly managed, with many policies and procedures and protocols. But in therapeutic communities we need flexibility and spontaneity and creativity. That is hard to maintain in the face of requirements for manualised and standardised protocols. One way we are currently describing this in  the UK is as ‘relational practice’ rather than ‘procedural practice’. In the modern world, where people expect technical solutions to all problems, many regulations, and zero tolerance of risk, something very human and ordinary has been lost. And we are saying that what has been lost is central importance of the relationship in therapy – not necessarily the expertise of a psychoanalyst, but the ordinary and human way people are with each other. Or how it is not now possible for people to be relaxed and informal with each other at work. Clinicians are often made to be anxious about whether they are ‘following the manual’ correctly, or whether they have ‘recorded the risk level’ on the hospital computer system. One word we use for what is missing is ‘therapeutic ordinariness’ – and the Enabling Environments project, which I have described here before, is based on these ideas of relational practice.

The first time I came across this was when I was taught social sciences as a medical student by David Ingleby, in 1978. He was a radical social scientist at Cambridge University, and that was the year, of course, that Law 180 was passed here in Italy. Ingleby was writing a book at the time explaining how mental illness is primarily a political issue: he threw doubts on claims made for scientific objectivity, and uses detailed qualitative methods to reach a more phenomenological and interpretative level of meaning (he uses the term ‘depth hermeneutics’ and relates it to psychoanalytic understanding). In this way, he provided a view of mental suffering that is closer to the patient’s experience, and less contaminated by the inequality and power imbalance inherent in normal clinical practice. Although I did not know it at the time, it closely reflected what Basaglia was saying here in Italy. The book appeared in 1980 – and is called Critical Psychiatry. That importance of the subjective experience of ‘the patient’ is now a very strong feature of the ‘service user empowerment’ movement – which has been a major theme in therapeutic communities since the very beginning: a way the power balance is changed. In the last 15 years, it has also been a significant force in the British movement to re-design state services for those diagnosed with ‘personality disorders’ – in both heath and criminal justice services.

In the UK in the 1970s, Ronald Laing was seen as the champion of the British ‘antipsychiatry’ movement. But, like Franco Basaglia, he denied that he wanted to get rid of psychiatry – but he did want to change it. Laing’s focus was wanting to see deeper into the meaning of patients’ experiences; as I understand it, Basaglia and his equipé had their major purpose as, first, making a therapeutic community in Gorizia to humanise conditions for the patients there – and, later, to dismantle all the large institutions. This was all in the context of the 1960s youth revolution, which made everything much more intense, and political, and confusing. But both Laing and Basaglia were showing us how social, political and cultural realities play a vital role in helping us to understand the suffering and experience of madness, and how we should and should not response to it.

Although all the large institutions have been closed for many years, in Italy as well as the UK, the problem of ‘institutional thinking’ has now come out in different ways. Nobody is now tied up with chains or treated as animals, but they still suffer from degradation, disempowement and disrespect – and feel oppressed, alienated and as second-class citizens. It does not need large old buildings to have unhelpful and destructive relationships with those in need. I call this ‘institutionalisation in the head’. The processes that support this are the modern ones of regulation, standardisation, and social control – which make the process of care more like an industrial procedure, than a human one based on hope, and trust, and real relationships. The modern job of psychiatry, at worst, is to make a diagnosis and prescribe the correct medication, and avoid any risks. There is no real recognition that the best way reduce risk is to develop and maintain a therapeutic relationship.  

This is one of the ideas at the heart of ‘Critical Psychiatry’ – following on from the ‘antipsychiatry’ of fifty years ago.

At the end of the last millennium, in 1999, Greenhalgh and Hurwitz wrote about what was being lost:

At its most arid, modern medicine lacks a metric for existential qualities such as the inner hurt, and indeed constitute, the illnesses from which people suffer. The relentless substitution during the course of medical training of skills deemed “scientific”—those that are eminently measurable but unavoidably reductionist—for those that are fundamentally linguistic, empathic, and interpretive should be seen as anything but a successful feature of the modern curriculum.

Bradley Lewis, an American psychiatrist, makes the case for greater prominence of narrative methods in psychiatry (Lewis 2011):
This is a time of soul searching for psychiatry. Despite the investment psychiatry has made in rigorous classification and neuroscience, the field is currently meeting resistance and critique reminiscent of the 1960s and 1970s. Investigative journalists, consumer and recovery activists, academics in the humanities, social sciences and disability studies, and critical psychiatry networks all express increasing concern that the field has lost its way.

Much of the therapeutic work in our TC is concerned with constructing narratives, both of the historical reasons why members have ended up there, and the story of their time as a member of the community - and how it affects and changes them and those around them. The admission group (which is part of our TC’s joining process) is the point at which the ‘why I need to be here’ narrative is crystallised into a half hour session with the whole community. This has a profound therapeutic purpose – of establishing belongingness and attachment – as well as the communicating important information. The periodic reviews of progress, with a similar format, work in the same way: they are not merely hurdles to jump or administrative formalities, but an unavoidable exposure of feelings about one’s progress in the TC, to everybody there – as well as an opportunity of other newer members to see what sort of narrative they may be able to make for themselves.
(ironic)

A different angle on this ontological problem is how the role of doubt, complex narrative and the gradual development of conclusions and action is now eclipsed by a digital, 0/1, yes-or-no, view of what is correct. It is as if there is zero tolerance of uncertainty. Hermeneutic and qualitative methods, relational factors, contextual variables and other distractions which allow uncertainty are seen as noise in the algorithm, and denied serious relevance. This quest for certainty lies behind the dominant research paradigm, most clearly seen in the hierarchy of evidence.

In order to demonstrate evidence that is acceptable in making national treatment guidelines, a therapy requires the best evidence, meaning that it has a place that is as high as possible in the hierarchy. The ‘gold standard’ evidence is a meta-analysis of high quality randomised controlled trials. Amongst competing psychological treatments vying for recognition and funding, the quest for acceptable evidence leads to a ‘beauty contest’ mentality - where treatments are defined, operationalised, advertised and marketed as easily replicable ‘products’. These therapies can then be manualised and put through the process of gathering suitable evidence.

Steve Pearce, a colleague in Oxford, who is also a medical psychotherapist working in TCs, has taken up this challenge and published the results of his randomised controlled trial of non-residential TCs in the British Journal of Psychiatry in 2016. In a way, I think he has done the impossible – and perhaps helped the survival of British TCs. I think the organisers of this meeting are wanting to invite him to Rome next year, to explain his study.

Some of my reservations about this research process are about how closely analogous it is to drug trials in the pharmaceutical industry, and how inappropriate that fixed and inflexible model is. I also see it as part of a neoliberal commercial project to package and market psychotherapy treatments as if they were commodities that can be purchased from a store. I think this is market economics being used in a place they should not be, and are supported by a positivist type of science which is being used in places where it is not appropriate.

However, there are signs of a more sophisticated and flexible approach emerging, with the ‘quality of evidence’ becoming a more complex concept. In 2016, Steenkamp argued that treatment choices, in line with the founding principles of evidence-based practice, should be based on the three principles of
·         best evidence,
·         patient choice, and
·         clinical experience
As well as facilitating shared decision-making, she argues that a better fit is possible - between specific patient factors and available treatments. This represents a significant departure from the inflexibility of algorithmic treatment choices, based only on standardised treatments and ‘standardised patients’.

Another factor limiting the value of competitive studies is the finding that many different specific therapies can be successful, and the effectiveness is more dependent on ‘non-specific therapeutic factors’ than on the type of therapy itself. This has been demonstrated many times, and goes back to the ‘Dodo-Bird verdict’ (‘everybody has won and everybody should have prizes’). This was first claimed in 1936 by Rosenzweig, then demonstrated by Luborsky’s research in 1975, and elaborated in several ways since then.  For example, Lambert gave proportions for the relative importance of different factors in psychosocial treatments in 1992:
·         therapeutic relationship 30%,
·         external factors 40%, and
·         expectancy/placebo effect 15%, leaving
·         specific therapy techniques accounting for the remaining 15% of effectiveness 

My main contention is that this is a matter of angels dancing on the head of a pin. We all know that human health and happiness involves how we relate to other people, and modern research does not give this simple a-priori fact enough priority.

The considerable and contested literature critiquing ‘evidence based practice’ is beyond the scope of this discussion, but the trend towards accepting only larger and larger standardised and aggregated research is one that is moving in the wrong direction, away from understanding the importance of relationships. Therapeutic communities themselves are likely to suffer from this. Instead of being uniformly applicable across a wide population, TCs are fundamentally complex, and possibly chaotic. This is in the strict sense of the terms where ‘complexity’ leads to the development of ‘emergent phenomena’ (which were not intended) - and a chaotic system is like the weather, which cannot be predicted by deterministic statistics, however sophisticated they might be. In this system, every individual is recognised for their differences – their uniqueness and specialness -  rather their diagnosis. And at the next level, every therapeutic community is necessarily, and proudly, different from every other, making uniform research specifications almost impossible. We therefore need a different type of research – and I don’t think we know exactly what that is, although there are certainly some interesting non-biomedical research projects going on.

A more coordinated research effort would of course require organisational support and serious funding. The sociologist Nick Manning has pointed to a ‘politics of data’ in this field, which has resulted in TCs not having been researched or funded by those in the biomedical or psychological ‘research establishment’. Because the data is not collected in the approved format, this research does not receive government funding – and those who review ‘dissident’ papers for scientific journals are unlikely to accept them. So there is very poor visibility of therapeutic communities in the mainstream research literature.

However, there may be some room for optimism in recent service-user led research. This can pay serious attention, in rigorous and systematic ways, to the experiences of those in disempowered positions, and tackle subjects that clinicians and academics have previously avoided. This is alongside disillusionment in psychotherapy research with efficacy trials, because their results are only valid under conditions that don’t exist in the real world. TCs are well-placed here – and have been for some time. Multiple explanations of everything that happens are discussed (our colleagues in Open Dialogue call this ‘polyphony’) with none of them having the status of ‘absolutely truth’; individuals’ different perspectives give different experiences which can be worked in to the therapy; choices and decisions are made by some sort of ‘emotional democracy’.

So I have asserted that relationships, particularly the sort we have in TCs, can’t be “modernised” into precise manuals, regulations or compliance checks. They will remain irrevocably messy, difficult and uncertain – and perhaps colourful, exciting and fun as well. That is certainly one of the reasons that I would not want to work in ordinary clinical settings after a working life in therapeutic communities.

This is all about postmodernity. So for the last part of this dicussion, I want to propose that TCs are an excellent example of thoroughly postmodern practice, and we should be able to use that to our benefit. The best sort definition I know of postmodernity is Jean-Francois Lyotard’s: “NO GRAND NARRATIVES” (Lyotard, 2001). Traditionalism and modernity both have their own grand narratives: overarching explanations that intend to explain everything, predict all that will happen, and have everything neat and orderly - sanitised, contained and anxiety-free. Postmodernism acknowledges that this is impossible.

Clinically, it produces paradoxes such as the ‘overconfidence’ phenomenon: if, as a member of staff, you are quite sure that you are ‘doing it right’ – you are probably ‘doing it wrong’! Perhaps this is through a relational mechanism where you appear to others as ‘not willing to be open’ (because you’re so sure that you are correct). But it leads to the uncomfortable realisation that ‘it is not right to always be right’.

Another clinical aspect of “no grand narratives” is how members of our communities, particularly those who have gained a degree of self-empowerment, are just not willing to be told what is good for them, or how they feel. These people can now make up their own minds from a vast range of inputs – including their own experience, the internet, self-help books, the arts, intimate and detailed accounts from friends, and from experts. But experts don’t have the only say, or the last say, any more.

In an era of ‘the New Public Management’ we live in a world dominated by modernity. All publicly funded organisations – from health services to universities and social care – now need to have demonstrable accountability and transparency with particular governance structures, and systems of regulation. This is a very dull and uncreative world – and I hope that therapeutic communities can offer something different, to our members, our staff and the organisations we work in.

Let us divide mental health care approaches into traditional, modern and post-modern. ‘Traditional’ is the old-fashioned world of asylums and institutions, with strict hierarchies and the power all being in the hands of the professionals – usually doctors. ‘Modern’ is like this ‘New Public Management’ – some call it ‘performativity’ -  where everything is exactly specified and controlled, there are written protocols for any variation or exception or non-compliance. The effectiveness, performance and results can be exactly measured and audited. The power is in the system, which is democratically accountable. ‘Post-modern’ is much more awkward and critical – very much like the features of therapeutic communities I have described. But, being relationship-based, it is also to some extent unmanageable, creative and spontaneous: with a little anarchy in it. Perhaps the sort of characteristics that make life worth living, or a job worth doing. Power here is fluid – but needs to be held within a containing framework.

Finally, I want us to celebrate this way of working. It follows the ‘moral treatment’ of the 18th century – when a few enlightened people recognised that mental health patients needed to be treated as human beings. That returned in the 1960s, with the Italian and English ‘antipsychiatry’ movements.

Now, here we are fifty years later, trying to do the same thing. In modern therapeutic communities and enabling environments – and the Visiting Project here in Sicily -  we are still doing it. I believe that we know how to construct that ‘containing framework’, within which psychiatric power can be exercised with compassion and humanity.  







Friday, 30 March 2018

Piantine italiane per crescere?

Quick train from Cardiff to Heathrow terminal 4, a bit bog-eyed from late-night BIGSPD scheming, to learn that the three of us (Jan, Laura and myself) had been booked on AlItalia’s ‘minimum economy’ to Rome and business class for the return. Minimum economy means no bags, and we had one each: £117 lighter, we got to our hotel to find only one room available for the three of us. Thank goodness we had Laura with us as our translator – and I think after a bit of female sharing, everything was OK for the second and third nights.


This was the LegaCoop annual meeting of several different groups of visiting projects – the principle of which is ultimately derived from the Italian modifications of the RCPsych ‘Community of Communities’ – and we are the link between the two, and called ‘supervisors’. It is always a tutti Italian mixture of talks, heavy duty numbers, and celebrations with jolly team photos.

But this time we learned some interesting new things about the latest developments. First is the difference between the ways it is being done in Northern Italy with Mito e Realta (the national Italian TC organisation) – where it is much more like the British CofC membership, which any organisation can join for the visits, events and general collaboration. In contrast, the Sicilian network is much more like the British TC Accreditation process – where great trouble is taken by TCs and the auditors to ensure that the quality standards are precisely met: they have now been doing it for six years, and there is a great deal of detail in the exact process. I suspect, though did not directly ask, that the communities who were here in Rome for the day are closer to the Sicilian model – but either in the first or second year of it. But their hard work was recognised at the afternoon awards ceremony as all the certificates were awarded, amidst applause and many photos – thankfully not too many selfies!


The second interesting revelation was about the link to LegaCoop – which is the longstanding socialist organisation that promotes cooperative across Italy. Some of the organisation’s leaders were there, welcoming the work, and (now we have perfect translation!) it was explained to us how they are planning to use the principles outside the mental health field. They are particularly interested in Enabling Environments – as they can see the use of it in any setting. I slightly fear that, in Italy, these ideas might have just the sort of backing they needs to grow – that we don’t have in the UK. One to watch…

And business class home was quite a revelation – metal cutlery, china plates and real glasses of grappa behind the green curtain!


Monday, 26 March 2018

What we're all up against (part 2)


The Critical Psychiatry Network always surprises me for the firepower it has, and yet how it always seems to be in curmudgeonly despair about the state of mental health services, and the way the world has inevitably made it like that. And this conference did much the same – an extremely lucid and persuasive set of arguments from five speakers all of whom came from different angles on the same central proposition: we’re going to hell in a handcart. And the only thing we can do about it is to argue p-values, point out loopholes in pharmaceutical regulation, or bask in the comfort of seeing how Foucault said it all years ago. No, I’m sorry, that’s a cheap jibe – these were serious academic contributions to a major modern critique of our current system.

Maybe what I’m fed up with is how little impact ‘serious academic contributions’ have in the world’s current – deplorable and frightening – state of epistemology and ontology. I read about it from ‘real intellectuals’ in the London Review of Books, I hear it from our group members’ fight to have their profound disabilities recognised by the ‘welfare state’, I learn all about it from my wife in how her job, managing the operating theatres in a large teaching hospital trust, attempts at humanity are constantly undermined by ‘the machine’, I see it in the mechanistic way young doctors are now taught their skills and knowledge, and I feel it impinging everywhere around us. And others describe far better than I how the two major political events of the west, in 2016, are now playing it out…

But here’s a quick roundup of what I was excited by at the annual gathering of the Critical Psychiatry Network:
  •  Phil Thomas opened the batting by making us all feel we were in it together – and it’s pretty obvious what we’re really up against (neoliberalisism, loss of meaning, commercialisation of all aspects of life, growing inequality, reducing support for the most needy). Particularly pithy pints included the phrase ‘malignant individualism’ and how ‘the government are turning unemployment into an individual psychological problem’
    Phil Thomas excoriates happy pappy claptrappery
  • Neil Armstrong followed with a rich and thick ethnography which told the tale of how a man diagnosed bipolar, in a ‘major teaching hospital’ nearby, was treated by the mainstream mental health system. It so well described the system’s power dynamics in how any subtelty of understanding his distress was boxed into computer-friendly progress notes – and how his wife had a much deeper understanding of why he had his difficulties, than the psychiatrist did. The real title of his talk was “why feeding the beast might be more than just a waste of time”.
    Neil Thomas tells it like it is
  • John Crombie descried an anatomy (maybe physiology?) of emotions, and introduced the concepts that underlay the ‘Power, Threat and Meaning Framework’, which was led by Lucy Johnson and has been mentioned here before. Lucy herself was present, although not giving a talk, and by the end of the day it was clear that some collaboration between the critical psychiatrists and the critical psychologists is on the cards. I’m keen to also involve the critical psychotherapists – and will aim to do so before the Totnes Limbus conference in November, which has a very similar anguished plea behind it. http://www.limbus.org.uk/toxicorganizations/
    What makes John Cronbie feel sick
  • Helen Spandler – a properly radical academic from UCLAN who has been the longtime editor of ‘ASYLUMS: the journal of democratic psychiatry’ explained how the current scene has two major groupings: the ‘mad studies’ and the ‘psychopolitics’ people, both of whose founders have committed suicide (…). The former, at their most extreme, want to break all links with mainstream state-funded ‘psy professions’; the latter want to change the direction of travel by degrees. The answer was music to the ears of those of us in ‘relational practice’ work – raise consciousness by talking to each other and to those who ‘don’t get it’ until we get to a shared understanding. Oh, to have been old enough to have enjoyed the sixties!
    Helen Spandler does a great Patti Smith look
  • James Davies took us through some of the detailed venalities of the big beast we have so little chance of taming: the pharmaceutical industry, and how Hayek/Friedman/Thatcher economics have influenced it. But, with modern challenges to over-lenient regulation, at least the ropes might be tied round it to make it obey the rules, now that it has been so clearly identified how they are breaking them. Although obviously very worthy and worthwhile, I could not help picturing Gulliver being pinned down by the Lilliputians – and deciding to get up because he didn’t want to be.
    James Davies tell us of the even more evil empire