It's just not right.
Grumpy old psychiatrist wonders why - and tries things to escape oppression, institutionalisaton, industrialisation of mental health and digital tyranny.
Hopefully by only bending the rules, but never breaking them.
Well, we'll see.
I have used this blog before to beef on about therapies
being branded and packaged and commodified and marketed like drugs – but a
couple of days in Verona (which I seem to be coming to more often than any
rational reason would suggest) have given me another layer of it to think
about. I suppose it is how to ‘monetise’ the therapeutic alliance.
Aldo translates for Renee
My line is always that the ‘nature of the therapeutic
relationship’ is always, absolutely always, more important than the type of
therapy. And that is backed up by the research going back to the Dodo-Bird
verdict, the statistical analyses that show that only 15% of the variance comes
from the type of therapy, the PD pilot project showing the crucial role of
engagement – and agreement about it with every therapist I have ever talked to
(though I don’t talk to pure CBT therapists very often). And it’s at the root
of the ‘quintessence’ too: the attachment
and containment need to be
securely in place before you can get on with the routine bits of therapy, and
they’re mostly unconscious anyway.
Yet the ridiculous horse race between the alphabetti
spaghetti therapies continues, and more and more horses are bred - and trained,
and put through their paces in the RCT hurdle steeplechase. They have to keep
entering more races, of course, to keep their form. When everybody knows it
doesn’t really matter who wins.
…Except that we have a competitive international research
system, run by sharp, smart and competitive research staff. This system demands
absolute certainty (well, as much as RCTs can give), a marketised system where
celebrity academics and a few others can make a fortune out of it, and a lot of
other pedantic and arcane reasons for ultimately stripping the humanity and
agency out of the decisions when the needy person actually meets the human
representative of the machine.
So I was a bit wary of going to Verona to share a platform
with my old friend Aldo (who spoke with dazzlingly animated slides of
neurobiology and sociotherapy) and an infrequent acquaintance Renee Harvey (who
presented the STEPPS model and her creative Sussex adaptations of it). My worry
was that STEPPS is one of the alphabetti spaghetti therapies I have been so
rude about in the past, and I didn’t want to fall out with Renee as I do respect
the way she works.
Indeed, it shone through how she works – in close
partnership with service users, in a very relational way, attending to
engagement, using the manual as flexibly as needed, in conflict with the
powers that be (about their anti-therapeutic demands), wanting to make partnerships
with the third sector, making full use of positive group dynamics, and seeing
it as much as a framework for therapy as a definitive intervention. In other
words, a therapeutic environment. With that lot in place, it felt quite close
to what we do, for example, in the Slough micro/macro TC.
But one tiny thing she said set me on edge: when describing
the room, she showed us a picture including ‘the cupboard where we keep all the
materials’. As if everything you needed could be bundled up and put in a
cupboard – and those materials, I assume, are like lesson plans and detailed
handouts for the highly structured sessions. So even though it’s a fairly
well-guaranteed way of establishing and maintaining the therapeutic culture
where the quality of relationships is paramount, it’s commodified and packaged
and marketed. I fear it’s the way of the world – inexorable and inevitable –
though I still don’t think it’s a price worth paying. It’s the corporate way,
and it moves authentic therapy closer to prostitution…