Wednesday, 18 May 2016

Therapeutic Communities: adapt or die!

This talk was given at the Community of Communities Annual Forum, at the Royal College of  Psychiatrists on 17 May 2016

When I agreed to do this talk my original title was ‘TCs for the future - ‘adapt or die’. But because that was a bit controversial, I changed it to what’s on your programme ‘TCs for the future   …and what we need to do about it’. But I’m afraid to tell you that, although the title on your programme is quite right, I still think that I’m really going to do the original one.

So when I realised that was what I was signed up to - I had a sinking feeling of ‘oh no, how do I try to explain this’ without falling out with everybody. When I looked back at what I had written, at the weekend, I reckoned I’m going to insult and upset all the people who believe in ‘modernisation’ in the first half, and then upset all the people who believe in TCs in the second half.

So maybe I just need to disappear before lunch – but I do hope not!

On one side, when I talk about TCs needing to change I always get some people telling me that I’ve ‘sold out’, we’re throwing away this precious thing that can’t be messed-around with. In the large group at last year’s Windsor conference I remember we had some rousing discussions about what we called ‘the fire in the belly’ – and that is what it needs to be, I think – and we mustn’t let it be put out by the hard things we’ve got to do to survive, at least at the moment.

Then, on the other side, I’ve got powerful and influential people telling me that those of us who work in TCs are dinosaurs / vestiges of a bygone age / old hippies / hopelessly romantic and out of touch / an evidence-free zone. The last comment was in the coffee room, a few years ago, from Tim Kendal, in the old offices of Community of Communities when we were over in Mansell Street. And Tim is now the National Director of Mental Health. A bit worrying, maybe.  Though, as I say later, I do think this is changing.

So we’ve got the might and majesty of NHS England thinking that we’re not serious about evidence on one side, and the therapeutic community radicals and hard-liners saying that we have lost the plot and will all go to hell in a handcart, if we start talking to ‘the enemy’ about things like needing to change the way we work.

The trouble is, I quite like that impossible position – because I believe both points of view. I think that TCs DO need to do something different from what we’ve always been doing (maybe as well as what we’ve always been doing) - and that we’re not very good at that, because we are so committed to preserving the impressive and powerful things we already do.

So I’m saying that that we need to be more willing change AND keep some of the things we do the same. And what we need to keep the same are about some things that are very important to us: like relationships… continuity… emotional safety… not being disempowered or made to be part of a mechanical or industrial-type process… allowed to act authentically …and, dare I say, – about having fun.

Where I’m hoping to get to in this talk is the idea that we need to leapfrog over ‘modernisation’– and get to something better. Something that is much more real and authentic, and human. Most of the so-called reforms we have all been through are sterile, minimalist, and cut-to-the bone things – and we have got so used to them – and we have forgotten that things can be different. This is especially so in the public services, where everything has changed in the last few years.

And it’s not just for us in the NHS, or the prison service, or social service – it is what some people call ‘The New Public Management’, and it has a business and management ethos that has completely changed the nature and experience of being in the public service.

For example, people used to be proud to work in the NHS, but now they are more likely to feel anxious and afraid of ‘doing something wrong’. When I did a national listening exercise for the Institute of Group Analysis with Clare Gerada (from the RCGP) last year, we found that the predominant word people used about their experience of  working in the NHS was ‘fear’, and the predominant word for what they needed – but did not get - was ‘support’. That is a sad state of affairs. And I would say that it is because of the crass way that ‘modernisation’ is usually done in the NHS – and probably in lots of other ‘economically stressed’ public services as well.

So I am proposing that we in TCs have a different answer – that we don’t need to try more and more of the same sort of ‘modernisation’ treatment. Instead of that, we can ‘out-modernise’ (or perhaps post-modernise) even the most ‘progressive’ of our colleagues.

That means to change even more than we had ever envisaged, or thought possible. And because we, in the world of TCs,  have been doing loads of the right things for years – like democracy and service user involvement – we could be really good at it. I think that can be even more fun than being part of traditional TCs, and trying to maintain what we have always done, especially in such hard times

Let me take a short digression – about the language we use. This isn’t really about two sides, one of which says ‘change everything or die’ and the other says ‘no way’. It’s not about a battle between two opposing views, and it’s not even really an argument. What we need to do is to step back and look at what we are really trying to do.

If we just argue between each other, it’s going to take us nowhere. We need to take a step back and look at the whole framework[RH1]  of what we’re doing, I would say that the way we look at it at the moment is too restrictive / too focussed / too much concentrated on what we call ‘mental elf’ / and too directive. We’re working to a business school–type agenda of ‘what are we going to do about it’ – rather than a therapeutic stance of ‘what on earth is going on here?’

In the world of ‘modernisation’ it’s all about what we DO to each other, and how that is all written down in policy and then made to happen by the dreaded managers. What I am saying is what really matters is not that, but how we ARE with each other. I hope you get the drift. Or at least that you do by the end.

So I’m going to start by looking at the idea of ‘modernising’ – then look at what we hold most dearly, and then think about how we DO BOTH – and what that looks like from here, in the Community of Communities project. It means holding on to the valuable bits ….. AND doing what we need to survive. And I think what we are trying to survive is this thing that some people call ‘New Public Management’ – which I fear is another road to hell paved with good intentions.

So first, this idea of ‘Modernising’. Some call it ‘reforming’, ‘service remodelling’ and various other words and phrases – transformational change’ is a fairly recent version, and I’m sure that there are lots of new management buzzwords for it. It also comes out in a rather antagonistic and way when people say to me that you have to ‘get real!’

It seems to come from a business and economic way of thinking that things have got to get more and more efficient, and focussed, and ‘lean and mean’.  I’m not arguing against thoughtful development and all that goes with it – including change and all the loss and trauma that sometimes needs to go with it. But I am arguing against extreme, and continuous, and mindless change imposed from above (ultimately by a mindless government) that leaves the experts (and I mean both service users and professional staff) feeling disempowered. And disempowered because it is only the accountants who make all the real decisions.

I could give so many examples of the way we are all slaves to the machine nowadays – from the digital tyranny of IT to the seventeen levels of permission we need to get to change a light bulb and the irrelevant training courses we are told to go on (I think a better word for most of that would be ‘conditioning’ – like they do with rats – rather than real ‘training’).

Of course this is what happens when we live in a world absolutely intolerant of uncertainty, and governed by thinking only about risk: we all hunker down, act defensively, and do what we can to cover our backs. Not much room for creativity or playfulness, or joy here – perhaps there’s a rather chilling parallel to national and international current affairs.

But in the clinical world, if we reframe risk as something that is best managed and contained by RELATIONSHIPS, rather than by policies and procedures, and locked doors, and a starting place that ‘you can’t trust anybody’ …then things can look different.

That’s often rather difficult to do, and can only happen if we’ve got any time and energy left after we have met the statutory demands that are all around us nowadays. Which usually means filling in something on a computer, so that we ‘are compliant’ with an increasingly vast and complex array of ‘compliance matrices’. As I keep saying, we are slowly but surely getting sucked into the machine.

But we must also be willing to question those demands – when we are told ‘you MUST do this’, we need to think, like we teach members of our TCs to think, ‘why?’ – and then discuss it and understand it. Most things, when discussed, become understandable and when we know why we’re doing something that seems mindless, then we might be willing to do it. Or we might want to ask some more questions. But at least we will be talking to somebody about it, and not just a machine.  But unfortunately, I fear that is a bit of an old-fashioned view – and just isn’t the way the world works nowadays. Conversations with human beings are just too expensive!

An example is the notes on hospital computer systems, which really bug me. There’s often reams and reams of them and they are either so anodyne they’re meaningless, or laden with unconscious bias that they are like toxic waste in somebody’s clinical record, there for evermore. So much for reducing stigma in mental health.

The thing that most of these modernisation processes impose on us is dehumanisation. When clinicians have to go to work and think that they just have to get through the day, and escape without having done anything they they can later be blamed for, we have lost the whole purpose and meaning of being a caring profession. When the only thing we ‘must do’ is to record everything we do, rather than think about what we do, we have lost the plot. We are working for the benefit of the organisation and its own anxieties, rather than for our patients and their needs. We have lost the central importance of relationships.

Image result for "welcome to the machine"
One of our TC members in Slough describes it very graphically as ‘losing your identity as a human being and becoming just a number’ when you enter the system. The system and the modernisation machinery that goes with it just doesn’t DO relationships. It has ever-more complicated ways to increase efficiency and ‘meet the challenges of the financial pressure’ (as the euphemism has it) – but it can’t cope with messy things like the importance of staff-patient relationships, let alone team relationships, and never mind organisational relationships and culture.

‘The experience of the patient’ is meant to be important nowadays – but it is in a rather disconnected and trivial way, where people are meant to score with happy faces on a computer feedback machine when they are on their way out of the building. We have all become consumers or providers nowadays, and the therapeutic relationship is like a commercial transaction; smiley face, neutral face or sad face. Really, what have we come to?? How disrespectful to everybody is that??

Just to think a little bit more about relationships – whether personal, professional, family, romantic or whatever – I sometimes argue that relationships are like waves, and individuals are like particles – it is much easier to think that all matter is just blobs of stuff, like individuals – but modern physics tells us that your theory has to have a wave function as well as these discrete lumps of stuff. And I think that’s a lovely parallel to the group analytic view that it is more the relationships between us that define us, than it is our characteristics as individuals.  I think we all know that realtionships don’t obey the rules of rational processes.

Now Zigmund Bauman (who is like the high priest of post-modern optimism) says: we must value, and cherish, and use, irrational processes – they are one of the things that make us human. And all I’m saying is that we need to accept that relationships are often irrational, and uncertain, and sometimes a bit chaotic – and hold onto or contain the anxiety of that. What all this management and modernism does is try to ‘do something about it’ – make it into a procedure, like increasing somebody’s observations on the ward, or write a new measuring scale, or make a new regulation – rather than reflect and try to understand what’s going on, and why.

I hope most of you think we’re quite good at these things in TCs. And I hope that you think it’s important that we don’t lose them in whatever bit of the system we happen to work. But I want to say something more fundamentally challenging – keeping on the relationships theme. What we are talking about here is prioritising relationships above the written, rational and measurable aspects of life which it says in our job descriptions and we spend most of our working time doing.

This is a rather radical idea – but I hope you’re still with me, because I think it’s at the heart of what we do best in therapeutic communities. It is the way we are with each other – rather than what we do to each other. Issues of power and coercion and inequality fade into the background when we’re in an authentic encounter with each other – whether that’s a community meeting, or a supervision session, or a strategy planning meeting, or a high-level committee.

But trying to describe this ‘way we are with each other’ is always going to be an approximation – and we will never get a logical or scientific definition of what this ‘quality of relationships’ is. Lots of theories have helped us see it. Those of us who work in TCs usually have psychotherapy or clinical backgrounds.  For myself, training in group analysis helped me get close to what it is all about; for many psychotherapists it comes with the core ideas of object relations theory in psychoanalysis; for others more systemic views like the family therapy approach make most sense; and there are many relevant theories in other fields I am sure. But these are all trying to convey it in a language where the words to describe it don’t exist. Poets and artists maybe do it better than scientists. I don’t know if the neurobiology is solid enough yet, but it is like the right brain does relationships and the left brain does the rational and logical communication about it – but it’s always communication about it (like after it has been badly translated) and never the real thing or real experience.

Despite this fundamental impossibility, many people have tried to do something about ‘the quality of relationships’ in mental elf, across the centuries. I’ll just spend a minute on three of them – to hold them up as examples of what I think we are trying to do.

Three people and their influence
The earliest, and simplest, is William Tuke – the Quaker who set up the Retreat in York in the 1790s. It was just by seeing people with mental problems as human beings with human needs, rather than as a race apart: I think Descartes said that people who were mentally afflicted were in the same category as animals, in how we relate to them. I heard a programme on Radio 4 just yesterday about how, in Bethlem or Bedlam – the routine practice before this was to chain these people up and beat them when they behaved in a difficult way.
But the Quakers didn’t agree with all this, and they started relating to these people as fellow human-beings - with an entirely different quality of relationship to what had happened before. It started a worldwide movement that became known as ‘moral treatment’. A good phrase, I think - although my friend Aldo Lombardo here tells me that the history is more controversial than that.

english gentleman who looks just like a psychiatristThe next is a hero of mine from undergraduate days – Ronnie Laing. In The Divided Self, he vividly illustrates how dehumanising medical psychiatry was in the 1950s – and how much of madness can actually be understood, if you have a different sort of relationship with the person who is seen as mad. He advocated being with and tolerating the madness until you could start to understand it – with all the chaos and mess that goes with it, at places like Villa 21 and Kingsley Hall.Having others able to tolerate one’s madness was a new experience (and a new sort of relationship) for people who had been so ‘objectified’ by biomedical psychiatry – and I think things like the ‘Hearing Voices’ network, and the better bits of the recovery movement, or ‘bandwagon’ as I fear it has become, are doing just this.

And the Finnish people developing the Open Dialogue Approach, which comes from the same ‘critical psychiatry’ stable, are on the case too. I’m not sure how well Open Dialogue will survive being translated into a British context, but the British branch are now running a big multicentre clinical trial on it.

And - here’s where we come in – in TCs we also relate to people in a way that tolerates difficult relationships, and – through the wide range of different things we get up to together – come to understand each other. Or at least be able to live a more harmonious life amidst all the struggles and conflicts.

Image result for basaglia francoThe last of my three examples is Franco Basaglia – and I’ve just read a biography of him and what he did in Italy, where he was medical superintendant of Gorizia asylum in the 1960s. It was a huge old-fashioned psychiatric hospital at the north eastern corner of Italy, near Trieste, on the Adriatic Sea and right next to Croatia. He was horrified at what he found there – the inhuman way people were treated.

Clear echoes of Tuke at the Retreat nearly 200 years earlier. What had we learned about moral treatment since then? …we might well wonder. Anyway, with a few years of trying to do something about it, by public awareness-raising and political lobbying he eventually had the Italian Law changed in 1978: Law 180 or Basaglia’s Law – to close all the institutions.

I know that some say his motives were not entirely altruistic, and I’m not trying to say it was an complete success – but it was a real and serious attempt to use the law to change the quality of relationships in the brutal and inhuman parts of the Italian psychiatric system. I’m sure we could have all sorts of arguments and ideas for how it could have been done better, but the point is that the problem was recognised at a level that it never had been before.

And what I want to say is that I think we are at a similar point again, here in the UK – and quite probably elsewhere in the Western world. Okay, we have closed down the toxic institutions that formed the framework for those horribly institutionalising relationships. But, with what we blandly call ‘community care’, we have recreated coercive, disempowering, and downright paternalistic and infantilising relationships. And it has got worse and worse through our more and more desperate attempts to get efficient, save money, avoid conflict, and manage risk.

The old Victorian asylums were founded as a socially progressive and compassionate way to deal with madness – many of them ended up a hundred years later as a public disgrace. But they have suffered from ‘the law of unintended consequences’, if you like – though I prefer to think if it as ‘the road to hell paved with good intentions’.

But it didn’t go wrong because of the bricks and walls and of the institutions, or because of some malevolent government policy. It was because of the nature of relationships they allowed to develop.

There were strict hierarchies, more and more rigid policies were written to cope with problems that came up, and there was nobody with enough power to question what was going wrong.  And we are doing exactly the same thing again.

When our TC member in Slough says that he was stripped of his humanity and treated like a number when he was admitted to the local mental health services, I don’t think he is alone in that. He is saying that the modern system dehumanises people too. Not as violently or as obviously or as physically as in the old asylum days – but in a more subtle way: ‘This is what is best for you. We are the experts. We have the evidence. Do as you are told. Or you will have to.’

It could be called institutional paternalism, or perhaps biomedical hegemony. Let me explain both of those phrases.  ‘Institutional paternalism’ is about the whole system having rules that are imposed by the organisation, ostensibly for everybody’s good – but they actually morph into a rather rigid power structure where things can’t be challenged or questioned. Perhaps they can by rigid and inflexible procedures like for complaints or grievances – but they are administrative processes that deliberately make everything entirely sterile and procedural, and do not seek to find meaning or understanding – just blame and retribution.

‘Biomedical hegemony’ is more to do with the dominant paradigm or discourse which is acceptable to the field in question – ‘hegemony’ is a tricky word and I think ‘biological fundamentalism’ or ‘biological dogmatism’ would mean much the same. Which is that mental health is dominated by a view that there is a brain fault that can most efficiently be rectified by physical means – at the moment, that is mostly drugs – but it has been all sorts of things in the past, and may well be so again in the future.

Very few psychiatrists would say that is the only factor that matters, but I think most now have to work in this way – whether they like it or not. They have little time or scope or support to consider anything apart from diagnosis and prescription. And as the power in the system is mostly lodged with the medical profession, it is unlikely to change very easily.

Along with this goes the huge dark shadow of the pharmaceutical industry, and all the economic and free-market arguments that go with it, and the enormous power it therefore has in the system. I won’t waste your time by ranting about it, as many other do that better than I can.  But suffice to say that what I call the ‘biomedical hegemony’ is very well supported by the pharmaceutical industry.

But, whether it’s the administrative or psychiatric, or world economic, system that is doing it, the effect is to take responsibility away from people and leave them disempowered, and in the hands of the so-called ‘experts’.
By taking this responsibility away from people it is is exactly the opposite of what we try to do in TCs. In TCs, we try to empower people and give them responsibility for themselves, and for each other. And that feels profoundly against the tide, in the world of ‘New Public Management’. But there is a problem with this, when it comes down to the level of individual freedom.

And that is that institutional paternalism, or biomedical hegemony, is getting less and less acceptable in our socially networked times. It is an attitude that is becoming more and more difficult to maintain in our information-rich, transparent, freedom-of-information, accountable world. People expect openness, and to be able to make real choices for themselves - and I think rightly so, and completely in keeping with the democratic principles of TCs.

It ‘goes wrong’ through the way relationships are conducted by ‘the system’– which is often rather mechanically, led by the computer information systems, and almost entirely in the service of risk assessment and management. The fact that the core of ‘care’ is about how one human being helps another human being can be almost entirely lost.

Image result for hello my name is nhs campaignNowadays we have to have notices on the wall to remind staff to say say ‘Hello my name is …so and so’. But what sort of culture have we set up, what sort of road to hell paved with good intentions have we led ourselves into, where staff need to be told to do things like that? Where we have to have notices on the wall to remind staff that they are humans, and that their patients are humans too? 

Enough said. I think you can see what I’m saying is the problem – but what are we doing about it? That’s what I’ll turn to now.

What CofC is doing
So first, let’s identify what are the ‘modernisation’ things are that we do need to do, for TC thinking and approaches to stay alive. I’m going to divide them up into these ‘need to do’s’:
1.      Need to…
Know what we’re doing and doing it well  (quality assurance, what they specialise in here at CCQI)
2.      Need to…
Show it is worth doing, and that it works (Research, despite being called an ‘evidence-free zone’)
3.      Need to…
[RH2]  the ideas beyond TCs (the EE development, mostly) –and join up with others, without being too precious about what we’re doing, or what I think TCs have been doing for years.
4.      Need to…
Give up sacred cows (like ‘this is the only way a TC can be’)

Knowing what we’re doing and doing it well.
This is where we started from with Community of Communities in 2002 – the method we wanted to use was a harking back to the old days at the beginning of ATC in the 1970s. It was to visit each other’s TCs and pick up ideas and share what we were doing ourselves, and generally feel less isolated about the way we were working. As well as that, we incorporated the idea of standards – we were the third network here to do so - so we could be fairly objective about that, with the authority of the College behind us. But the standards were democratically developed, using TC principles of everybody being involved in the discussion, and agreeing and voting if necessary. This meant that we as TCs felt we owned the standards, and that they were meaningful to us – and not that they were some persecutory orders delivered from above, as quality standards so often can be.

Community of CommunitiesSo it became a recognised quality improvement process as well as a way for TCs not to feel isolated or not knowing if ‘they were doing it right’ – and we could be quite comfortable with language like ‘sharing best practice’ and ‘benchmarking’ and ‘action planning’. We had done the modern thing, called ‘quality improvement’ - but in a TC way that we could live with.

I would maintain that – just by being TCs and believing in the central importance of relationships – we had also produced something that was more meaningful than a treatment manual (in a relational way), and brought a bit of a Trojan horse – spreading a message of gentle subversion and quiet revolution - into the dry and technical world of the Royal College of Psychiatrists. I mustn’t say things like that too loudly amongst my psychiatric colleagues, but I expect we’re all friends here today!

Showing it is worth doing, and that it works
This is all about research, and countering that opinion that we’re an evidence-free zone. I’m not going to go into the whole RCT argument here – but just to summarise it by saying that many people only consider that evidence is ‘good enough’ if it ‘Type 1 evidence’ in what is rather grandly called the ‘hierarchy of evidence’. That means a meta-analysis of high quality RCTs. I have always been deeply ambivalent about this one, because I think there are so many ethical problems and methodological difficulties in doing an RCT on TCs – as well as the bluntness and coarseness of the whole ‘yes or no’ results that they give; but I am also aware that without it, influential people can go on saying things like we are an ‘evidence-free zone’. So I have come round to thinking that we need to treat it like an annoying game we must play in order to communicate that TCs work, as a scientific fact, to the funders, commissioners, policy makers and bodies like NICE on whom our existence depends.

I was on the group that wrote the 2009 NICE guidelines for Borderline Personality Disorder, and NICE is very hard-boiled about it all – no shades of grey tolerated in what they call satisfactory evidence. In fact, because there wasn’t much ‘high quality evidence’ for Borderline Personality Disorder, I think we came up with quite a useful and sensible guideline. That’s because it was based on a good consensus between the experts by experience, the clinicians and the researchers on the panel – not very ‘high quality’ evidence in the ‘hierarchy of evidence’.

Turning to TCs, personally, I have no doubt that people benefit from time in TCs – where they are immersed in that ‘different quality of relationships’. But I wasn’t at all confident that RCTs and standardised questionnaires will pick that up in a way that is meaningful. And I’m still not – but maybe that’s because I’m expecting more than the ‘evidence-based research’ methods can achieve.

So, a few years ago, I was worried about what will happen when the NICE guideline gets revised. So many other alphabetti spaghetti treatments have now put themselves through the RCT machine since the 2009 guideline – and TCs were not amongst them.

So reluctantly, kicking and screaming if you like, I have come round to realise that we need to play the game – the evidence-based treatment game – if we are going to have any chance of surviving. And what a game it is. But I’m now less worried about TCs being left out of the next NICE guideline – and I think I was probably right to be worried before recent developments. So let me tell you about the recent developments.

For the last few years I have been watching from a safe distance as my colleague Steve Pearce in Oxford, recently Chair of this Community of Communities here, has been learning the rules of that evidence game - and running the first ever RCT for democratic TCs. He has been learning some of the rules from somebody else we know here,  Mike Crawford, who as well as being a new young professor of mental health research at Imperial College, is also the Director of the CCQI here (within which we as Community of Communities exist), and consultant psychiatrist to the first ever NHS enabling Environment.

It has both amused and alarmed me as to how complicated and rarified those rules get – not just like the statistics you must use, and the boxes you must tick to be considered for a ‘good journal’, but also who can be authors of a paper, and how you have to structure the paragraphs and tables in an exact way. And the weird and arcane ways that academics have to preen themselves and show how big their ‘impact factor’ is – as well as how they suffer quite horrible and career-threatening anxiety about the regular ‘research excellence framework’ audit.

I think that sort of research world would drive me bananas – it reminds me how much we also need the counterpoint of people like Nick Manning, the sociologist, who asks difficult questions about what he calls ‘the Politics of Data’ – and where the real power is, about how funding decisions are made. But, luckily for all of us, Steve has learned the rules and played the game – and we’re expecting his generally positive results to be published in the next few weeks.

But I don’t want to let you all off the hook – we mustn’t think that we can now get away with not needing to do any sort of data collection or research because Steve and the Oxford TC have done it all. That is not true – for at least two reasons.

The first is that there will need to be more trials in the next few years to back up the first one. And the second one applies to absolutely all TCs: unless you can justify the existence of your TC to your local commissioners, managers and referrers, in hard-line objective and numerical terms, you will be on thin ice. This means collecting, analysing and communicating outcome data – at least as service evaluation, if not formal research – like an annual report for your commissioners.Alongside the annual report from CofC, of course!

However, I was rather worried when I came to a meeting here a couple of weeks ago, to learn about ‘POD’, or ‘patient owned database’. I was alarmed because it is a free benefit of Community of Communities membership – which hardly any TCs have signed up for.

Yet it is so sophisticated, and user-friendly, and could save so much work of collecting and scoring questionnaires – that I would have thought we would all be using it. But, sadly, I think that says something about how reluctant TCs are to take on new things – even ones that make our lives easier, that help ensure our survival, and are completely congruent with TC philosophy. Hence the sting in my title’s tail – adapt or die!

Spreading the ideas beyond TCs
I remember when we started Community of Communities that John Cox, who was then President of the College, said to me something like ‘That’s all very well, Rex, but it’s for such a miniscule number of services. It’s too inward looking’. So that was in the back of my mind, and several other people’s, as we went through the first few years of CofC – with a good steady membership just under a hundred.

Then in 2007, we started to look in earnest at what have become our ‘core standards’ – the special things that we as TCs all do, and not many other sorts of service do. And they are still the central part of the annual Community of Communities process, and the TC accreditation. We also developed, with the Association of Therapeutic Communities what we called the ‘core values’ (just when it was starting to change into TCTC when it merged with Charterhouse Group of children’s TCs).

EE logoThese were the values that underlay the core standards – you didn’t have to be a TC to have those values, but all TCs did have them – and many other places that looked and felt and smelt like therapeutic environments did too. This was the starting point for the Enabling Environments project, which is now an award here – and a very successful one which has nearly two hundred units signed up to it. It has been most spectacularly successful in the criminal justice world – where the staff are finding a new purpose in their jobs, there is much less violence on prison wings, we expect reoffending to be reduced, and morale of prisoners as well as staff is demonstrably higher.

Because of its success, we had Michael Spurr, head of the UK Prison Service (now called NOMS) standing on this platform here at the Royal College at an Enabling Environments conference in January, saying that all prisons should be Enabling Environments. Then other people - myself and Simon Wessley the current President of this college and and Sue Bailey who is leader of the Academy of Medical Royal Colleges, saying that the NHS should be doing the same thing. Well, we’re working on it. It might take a while.

The NHS is a bit hard-headed when it comes to spending money on what some people see as ‘fluffy new initiatives’. It wants things like RCTs and NICE approval first – but we’re hoping to get something started using the evidence from the prisons and probation side.

Going back to what I was saying before, it’s a way of sneaking a subversive idea (about how relationships can contain risk) under the radar – and I hope we can show how it has changed the whole culture of prison wings as a result. And if we can introduce a bit of relational thinking and compassion into the brutal and hard-edged world of prisons, surely we can do something useful in the health service?

Throwing away the sacred cows.
I must say I was a bit hurt when John Cox told me that we were too inward looking – we were doing our best to get TCs meeting each other and accept scrutiny by the Community of Communities process, and it seemed like hard work to all of us.

But he was right. If we had stopped there, and just accepted that TCs had to always be as they always had been, because we as a group said ‘that’s the only way to do it’ – I think we would be extinct by now.

But partly from within, and partly from external pressure, a lot has changed. We have lost the ‘total immersion’ residential TCs from the NHS scene (like the Henderson, which has closed, and Francis Dixon Lodge, which has become a 3-day per week unit). But there are a few, including new types, growing up outside the NHS - which often sell their places to the NHS when the local services have run out of facilities to help. And I think that’s probably how it should be: a small number of places for those who really do need 24/7 physical containment with a democratic therapy programme, at least for a while.

This is very different from the old expectation that anybody who might benefit could be referred, and only the ‘most suitable’ would be accepted.

Slough 'Embrace' group at CofC 
In parallel to that, non-residential NHS TCs have ‘reduced the dose’ – and gone from 5 days per week to one, or even less. What we’re up to in Slough is an even more extreme version of that progression – we only meet together for two and a half hours per week, but we join it up with all sorts of other things people can do to make a pick-and-mix therapeutic programme. We’ve an interesting tussle about what to call it – I say it’s a ‘micro TC’ because it only meets for 2½ hours a week, but Geoff our Head of Mental Health for Slough calls it a ‘macro TC’ – it’s like it is a TC without walls, that involves bits and pieces across the whole town. Come to our workshop this afternoon if you want to hear more.

I also think that this ‘post-modern’ TC development has some of the ideas like Christ Church Deal – the TC in Kent that says it doesn’t have buildings or even staff. What really seems to mater is ‘the TC in the head’. That means experiencing the sort of relationships around you that make you feel safe enough to be able to do the work you need, even if they’re not there the whole time - and the relationships aren’t always with the same people. So I think one of the ways for the future is to better recognise ‘the TC in the head’ and maybe to plan for ‘the TC in the whole town’, or at least the whole of a locality’s mental health and social care services.

Something else that has changed is in the children’s TCs. In days gone by, in the times of Finchden Manor and Peper Harow, by they used to be large groups living together in grand houses that had great facilities and intensive TC programmes – with all the dyanamics that sort of group living brings. Now there are only a few of those – and long may they survive because we still do need a few – but most TCs for children that are members of CofC are now in domestic-scale houses for a small group of children.

The same therapeutic philosophy of as much democracy and shared responsibility as possible, and the sort of relationships I keep bashing on about – but not TCs as we always knew them. These are important politically, because the need for more therapeutic care for children living in institutions is well recognised by local authorities, and is probably going to be recognised formally in the commissioning framework. There are often items in the news about serious failures in the care of children whose parents can’t do it – and we are in a very good position to come up with models of best practice.

But to say that these places for children have to be ‘proper TCs’, with all the standards for bigger TCs being met, is likely to mean shooting ourselves in the foot. So the CofC team is working on a new subsection CofC called something like ‘Therapeutic Child Care’ – that will go through the same process of membership of the network and self-review and peer review, and may eventually lead to accreditation.

But they won’t look like TCs as we knew them fifty years ago – or be explicitly called ‘Therapeutic Communities’. But that is something we will have to get used to. TCs indeed, Jim, but not as we know them. And maybe called something quite different.

I was thinking of calling this talk ‘The TC is dead – long live the TC’ – but I think that’s too harsh.

In the same way as a small number of wrap-around fully immersive TCs are necessary for some people, I think ‘traditional’ style TCs are still needed in some places. But looking at how hard it is to survive at the moment, in the face of a risk-obsessed world and continuous financial cuts, ‘being a real TC’ is a very hard job. It is not one for the faint-hearted, or for those who aren’t willing to ‘play the survival game’, as I have described. So good luck to those of you who are on that path – and I hope that Community of Communities can help you with it.

But what it means for many other services, less willing to play the high stakes game and working in a way that is essentially ‘against the system’ - is that I think that there will be a range of different things that all follow the underlying therapeutic philosophy as TCs. Some of them might be quite close to TCs as we know them now, but most of them will look rather different. And some of them will look like nothing we have seen yet. I think that’s quite an exciting prospect.  

But they will all need to have that ‘quality of relationship’ at their core. That probably means being some variety of Enabling Environments, even if they don’t do it exactly by the book, or aren’t signed up to the award here.

However, I’m confident that good and acceptable services of the future will certainly all have a different way for people to be with each other than most of the mainstream mental health, or prison, or children’s, or addictions services are at the moment.

I just don’t think people will put up being treated so badly for much longer – a lot of people know there’s ‘trouble at the mill’ – from the calls for ‘parity of esteem’, to the service user movement, to secretly-filmed Panorama programmes. I come back to the point that we have forgotten how to treat each other as human beings when our world of mental health services becomes so industrialised, and corporate, and institutionalised. We are not numbers, or robots, or badly functioning machines – we are people who are all interdependent on each other. We all need each other – and not just as economic units.

A lot of people know this – but they don’t know that the centuries-old tradition of therapeutic communities has some of the answers to these problems.

We need to get out there and tell them!

1 comment:

  1. Remember the UKCP conference 'Adaption or Extinction' of nearly 30 yrs ago? where Rex muttered 'these people don't know what they're on about' - well they have adapted nd changed beyond expectations - some for the good some not--may be psychiatrists/therapists benefit from a kick up the bum in the form of threats of closures; with -holding of funds - the old TC's were certainly not democratic