Tuesday, 16 December 2014

The Enabling Society

Having been recently discussing the power of the TC approach with people here and there, I have been making some ideological friends up at UCLAN this week: I was asked to be a speaker on a keynote panel at the inaugural conference of the recently formed Association of Psychosocial Studies, alongside Richard Wilkinson (of ‘Spirit Level’ fame) and a couple of other academic heavyweights. A very different world from psychiatric academia – but the TC ideas went down well – our session title was ‘the Enabling Society’. Lynn Froggett (a very articulate professor from UCLAN) wants to do some fundamental TC research with us in Slough. It might help give us a solid but very different sort of evidence base.

Drinks reception and book series launch with 6 titles
Going there was like a day of deep psychosocial immersion in the strange academic land between psychology and sociology, and I could only be there for the first day. For a bit more than 50% of the time I was fascinated with what they were saying – though the rest was like rocket science to Fred Flintstone.
There’s good number of Lacanians amongst them, and Winnicott is staging an emergence from retirement – and although Bion still plays strong, they haven’t yet got the rhythm of Foulkes’s numbers…

A weirdly compelling day!

Here's the short talk I gave: 

Thank you very much for inviting me to this – I really believe in what this association is trying to do, although I’ve been rather nervous in thinking about what I could write and have to say to real academics and intellectuals in a field that seems so far away from what I know anything about (which gets less as the years go by, I do feel). But then I saw Sasha do a talk at the Institute of Group Analysis a few weeks ago, based on her own research, and had one of those ‘aha’ moments: we’re actually thinking about the same things – that are very difficult to put words on – but are fundamentally about relationships. I felt that she was talking about ‘how we find our place amongst others’ – which is one of the emotional development principles behind a lot of TC work.

The relationships which we’re both talking about are with the world, with our own culture and tribe, with our acquaintances, with our family and intimates, and ultimately with ourselves. As I’m growing into a green and grumpy old psychiatrist, I’d also say relationship with the planet and nature. As I said at a Royal College of Psychiatrists event a couple of weeks ago, the aim of our current work to run therapeutic community programmes in an environment centre is to “connect people to each other and to nature, to help people to see that there is a life worth living, and on a planet that is worth living on.”  But more of that later – that is where we are going; we have to get there first.

So, once I had clicked that we are talking about the same fundamental things, just in different languages as it were - I felt that I could probably say something to this audience and in this discussion with my rather awe-inspiring colleagues on the platform. So I’m aiming to tell you a bit about the forgotten (and I feel neglected) story of therapeutic communities over the last thirty years or so. Somebody said, in a large group at an NHS campaign meeting a few weeks ago that ‘TCs are the last remaining vestige of truly democratic practice in the NHS’. I didn’t know him, but I wanted to rush across the room and kiss him – but that wouldn’t have been within the acceptable boundaries of large group practice, of course! However, I do feel that there is some extraordinary work being done in therapeutic communities, which is very much in the face of increasing regulation, which is very individualistically and rights-driven, and experienced as persecutory. The whole thrust of it denies any importance to interdependence, mutual responsibility, social cohesion, and group process – let alone what we call the dynamic unconscious and the whole irrational realm of how humans operate at their best. Which includes things like spontaneity, holding uncertainty, imagination, and what I call ‘therapeutic ordinariness’ and ‘creative chaos’.

I won’t labour this point, but it does feel like we all now live under a public management tyranny that is based on the ideas of cognitive-behavioural therapy, with an underlying principle of instrumental rationality. I was looking for the right words for this thing, and ‘instrumental rationality’     seemed to capture it best – the definition (Wikipedia, I’m afraid) is "A specific form of rationality focusing on the most efficient or cost-effective means to achieve a specific end, but not in itself reflecting on the value of that end, nor the means of arriving there".  So the way we work in TCs is to some extent an antidote to that way of thinking – although it is becoming increasingly difficult to protect the space within which the TC can happen. And maybe this means that we in the TC field – and perhaps wider therapy world - need to change our tack, rather than keep trying to ‘keep calm and carry on’. And I think that’s what I’m here to talk to you about – TCs, and the philosophy and values behind them, being a radical force for challenging the prevailing view that instrumental rationality is good for your mental health.

My own educational background is relevant, because – in the days when being a medical student was paid for by the state and we received a maintenance grant from the county council – I did an elective third year of two subjects which were at war with each other: experimental psychology and social psychology. In some ways, the experimental psychology was a doddle – we had already done half of it in anatomy and physiology the year before. But in other ways, the critical theory in the social psychology made me doubt that you could believe anything in the experimental psychology, for example IQ testing, because of the political framework it was in. At the very least, what actually mattered more to me (as a rather confused undergraduate) seemed to the reading we did of Laing and Winnicott, than of Skinner and Eysenck. And in a way, I have lived in that polarised professional world ever since – physical sciences versus social sciences, ‘real medicine’ versus psychiatry, CBT versus psychodynamics, diagnosis versus formulation, biomedical versus psychosocial, mental illness versus personality disorder, and perhaps TCs versus the rest!

So, back to TCs. In the 1950s the British social psychiatry movement was storming the world. In 1952 the World Health Organisation published the following advice:
'The most important single factor in the efficacy of the treatment given in a mental hospital appears to the Committee to be an intangible element which can only be described as its atmosphere, and in attempting to describe some of the influences which go to the creation of this atmosphere, it must be said at the outset that the more the psychiatric hospital imitates the general hospital as it at present exists, the less successful it will be in creating the atmosphere it needs. Too many psychiatric hospitals give the impression of being an uneasy compromise between a general hospital and a prison. Whereas, in fact, the role they have to play is different from either; it is that of a therapeutic community.'
And at the forefront of this movement was the Henderson Hospital, where Maxwell Jones was the medical superintendent. Maxwell Jones was a respiratory physiologist who ran a programme for battle-shocked veterans at Mill Hill Hospital in the Second World War, and started to realise that they were better at helping each other to get over what we would now call PTSD, than he was. He was giving them lectures about how their breathing makes them panicky, but – in the time between lectures as it were – they were sharing the emotional meaning of their symptoms with each other. So when he set up the Henderson after the war, that was the principle it was based on. An anthropologist called Robert Rapoport did a detailed ethnography on it, resulting in the book ‘Community as Doctor’ – which boiled it down to four themes: democratisation, permissiveness, reality confrontation and communalism.
·        Democratisation: every member of the community (all patients & staff) should share equally in the exercise of power in decision making about community affairs
·        Permissiveness: all members should tolerate from one another a wide degree of behaviour that might be distressing or seem deviant by ordinary standards
·        Reality confrontation: patients should be continuously presented with interpretations of their behaviour as it is seen by others, in order to counteract their tendency to distort, deny or withdraw from their difficulties in getting on with others.
·        Communalism:  there should be tight-knit, intimate sets of relationships, with sharing of amenities (dining room, etc), use of first names and free communication
Although these made Henderson famous throughout the world, Maxwell Jones didn’t like them – and nor do I. Not because they are wrong, or it wasn’t good research, but because they don’t capture that ‘essence’ that the WHO was talking about. Apart from perhaps communalism, they are very behavioural – and don’t at all capture the quality of experience and particularly the quality of relationships that members of a TC – both staff and service users – actually experience. A more modern version of ‘TC theory’ that is now quite widely used is much more inclusive of different types of TC (apart from just the Henderson model), and is based on five necessary experiences for emotional developmental, and how we recreate them in a TC: attachment and feeling a sense of belonging; containment and experiencing emotional safety; openness of communication in a culture of enquiry; inclusion and interdependence by finding our place amongst others, and empowerment or personal agency through finding an authentic sense of self. But that’s a different talk for another day.

We all know that everything changed in 1979, and I’m sure that most people here can articulate that much more eloquently than I can. But one of the consequences in our corner of the mental health world was that selfish individualism (for want of a better word) made TCs less and less acceptable. I think the same is probably true of group therapy in general. In their heyday, the 50s, 60s and 70s, every psychiatric hospital in the country had a residential TC, some whole hospitals were run on TC principles, and community day centres were run as TCs. Then everything changed as the wind came from a very different direction – and without giving a grizzly account of all the closures – there are now precisely no residential TCs in the NHS, the non-residential day units have been reduced from 5 to 3 to sometimes one day per week and most of them shut altogether; the latest one I have just set up in Slough is just two hours – the rest the ‘patients’ do themselves and elsewhere, and I’ll say more about that later. There was a brief respite during the Department of Health’s National PD Programme between 2002 and 2011, when several new non-residential TCs were set up in the NHS, but most of those are now being closed because they don’t fit into the IAPT programme – which is where PD now sits in the Department of Health policy terms.

Yet we pay seven million pounds for new fences at Broadmoor, and send ‘difficult’ patients to locked wards in the private sector which cost £250,000 per year, where they receive a trivial amount of trivial therapy, and have quite expensive and extremely individualistic mental health services which Sue Bailey, described as a ‘car crash’ as she recently retired from being president of the Royal College of Psychiatrists. Our policy priorities have certainly changed! But I must stop ranting like a grumpy old psychiatrist, and get back to TCs.

It is true that a few of the TC principles from the social psychiatry revolution live on, though in a very attenuated and pale form. Examples include service user involvement, community meetings on some of our ghastly inpatient wards, and maybe some hope and creativity in parts of the contemporary recovery movement. But these are grounded in the soil of marketised and commodified mental health care, and lack the radical roots of people really taking responsibility for themselves and each other and challenging the power base of the system. They are still fundamentally paternalistic.

But I want to turn to where we are right now in 2014. I think a tide is turning and there might be opportunities for a new form of TC value base to have a wider influence – hence the link to the ‘enabling society’ of our title here. We have been doing a lot of work at the Royal College of Psychiatrists since 2002, when UK TCs were probably at about their lowest ebb. With lottery money, formed a quality improvement project called ‘Community of Communities’ – and we’ve had just under a hundred members for the last twelve years. At a formal level, it works just like any other audit or even action research cycle – decide and set the practice standards together – review them – action planning – make changes – start all over again. But where it differs is the fact we insist on communities visiting each other, and being visited, each year – not for an inspection process, but for support and nurturance from like-minded people. And of course, it includes both services users on these visits, as well as staff of all seniorities.

From this, about five years ago we distilled a set of ‘core TC values’ as well as the more prosaic ‘service standards’. The service standards define what TCs need to do, and most other places don’t do, but the core values are not TC-specific at all: they are as close as we have yet got to the ‘essence’ that the WHO directive identified. And with that set of ten values we have established a different sort of quality process – what we call the ‘Enabling Environments Award’ – which is as applicable to a prison or office or school or church or business as it is to a therapy unit. It’s going down very well in the criminal justice sector – and we’ve just had a launch of it for the health sector, with endorsement by RCPsych for it as a potential solution for lack of compassion in the NHS, in the wake of the Mid-Staffordshire crisis.

Finally, a few wilder ideas on the fringes of enabling environments – which are to a wider RCPsych initiative called the ‘Positive Environments Framework’, to our tiny social enterprise called ‘Growing Better Lives’ and the Institute of Mental Health in Nottingham’s ‘Social Futures’ centre. These are just vague threads at the moment – and I have no idea if they will come together or not, but quite a lot of us are trying…

Greencare is the inclusion of nature in therapy programmes – and combined with TC-type groups which our social enterprise runs in a yurt at an environment centre between Slough and Uxbridge, they seem to be very acceptable and effective. We’re also thinking of using permaculture and transition town ideas to give it a more than just ‘group therapy plus horticulture’ by itself.

A psychiatrist colleague in Columbia, Alberto Ferguson, is in his seventies and has run TCs all his life. He has experienced a similar TC trajectory to what has happened in this country: first residential, then day units, then without dedicated premises. To me this shows that ‘the TC in the head’ matters more than the TC in the building – and in his small town near Bogota there is a widespread understanding of TC-type social cohesion. Ex-patients now run groups there to bring together families and individuals involved in the drug conflicts, to make reparation and have the different factions come to some understanding of each other.

So, to finish off, and take these ideas back to our 2-hour per week TC in Slough. The phrase a few of us are putting about – perhaps a bit mischievously, but only half tongue in cheek – is ‘Slough as a Therapeutic Transition Town’. Instead of the ‘TC’ being seen as the two hour group we run every Tuesday, that is just one hub for all the other therapeutic things people can plug into: from mindfulness and psychoeducation groups run by the NHS psychologists, to a very successful mental health choir, to greencare in our yurt, local sports for health groups, a therapeutic digital photography group with Arts Council funding. People’s experience is then of the whole range of activities - delivered by all sorts of different organisation – as being THE therapeutic community. Yes, I am talking about poor old Slough – if you believe that is possible, you’ll believe anything. But we’re going to try!

Wednesday, 10 December 2014

NHS morality and care based on compassionate values

It is difficult to disagree with the main thread of Cox and Gray's argument (1), that the NHS as a whole has lost its grip on being person- centred in any genuine way, amidst the industrialisation and authoritarian managerialism of the modern NHS. However, I would take issue that the College Centre for Quality Improvement (CCQI) is being idle about the matter.
For over twelve years, I have worked with CCQI staff to set up and develop three projects to promote exactly what Cox and Gray are asking for: robust systems of quality assurance and quality maintenance which focus on the emotional experience of the patients in their particular treatment environments. The Community of Communities quality network (2) for therapeutic communities started in 2002; the Enabling Environments award (3) (which is suitable for any setting) was established in 2009; and the National Enabling Environments in Prisons project began to improve relational-based practice in participating British prisons in 2009. All three projects continue to flourish, and more are planned.
The Enabling Environments award is based on a set of ten value statements which define 'relational excellence' in work environments. These value statements have been processed to form ten standards, each with several criteria for demonstrating that they have been met. Naturally, compassion and the quality of relationships are at the centre of the expectations. The standards are measured by submission of a portfolio - for which we have designed a flexible and hopefully enjoyable process, rather than a persecutory inspection. Rather than being part of the regulatory burden that many units nowadays feel, our experience to date is that participants take great pride in the process and receiving the resultant award. It is important to note that the existence of this award was prominently mentioned in OP92: "The Enabling Environments Award recognises that good relationships promote well-being, but that many organisations and groups fail to address this aspect of people's lives". It therefore already forms part of the College's response to the Francis Report.
Unfortunately, the response from NHS organisations (mental health and others) has not been encouraging - and the award is much better used and recognised in the prison service and all sorts of different third sector units. I believe this may be caused by a deeper malaise in the NHS, very much in line with what Cox and Gray are arguing in their paper. In short, the NHS is being run with a competitive business model to such an extreme and aggressive extent, that 'soft' values such as empathy, emotional intelligence and kindness are given no force.
Related to this, it is worth mentioning that the Institute of Group Analysis, alongside other organisations including RCPsych, are running a six-month listening exercise to gather information from staff across the range of NHS professions and specialties (4). When the information is collected and collated, it will be used to negotiate with politicians of all parties in advance of next year's general election. As Cox and Gray argue, this is a moral question - and a profoundly important one for all of us who want the NHS to survive in a form that we can once again be proud of.
1. Cox J and Gray A, The College reply to Francis misses the big question: a commentary on OP92, Psychiatric Bulletin, August 2014 38:152- 153
2. Haigh R., & Tucker S. (2004). Democratic development of standards: the community of communities--a quality network of therapeutic communities.Psychiatric Quarterly, 75(3), 263-277.
3. Johnson R., & Haigh, R. (2011). Social psychiatry and social policy for the 21st century: new concepts for new needs-the 'Enabling Environments' initiative. Mental Health and Social Inclusion, 15(1), 17- 23.

4. http://careers.bmj.com/careers/advice/view- article.html?doi=10.1136/bmj.g5185 (due to appear in BMJ print edition 23 August)