Currently,
narrow industrialised models of public service interventions ignore many
factors in the wider system, including the need to take a broader approach to
the complexity of relational working. The powerful effect of managerialism and
market competitiveness combine to produce a milieu in which human values and
relationships are not explicitly prioritised: the experience of public services
is increasingly impoverished and alienating for those providing or receiving
them. In the current situation, professionals face the risk of losing their
capacity to maintain a relational basis to the work.
This chapter
outlines the process that led to the recognition of this ‘relational practice’
deficit, its definition and recognition, the change needed, the intention of
the campaign and the underlying theoretical framework. We call for change in
the training and practice of all professional and ancillary staff working in
public services. Service commissioning will need to drive these changes if
future public services are to be fit for 21st century requirements. To
implement this, an active campaign is needed.
Introduction
The English
Department of Health’s National Personality Disorder Programme (2003 – 2011) was launched
with the publication of ‘No Longer a Diagnosis of Exclusion’ (NIMHE, 2003) and closed with the
publication of a practice handbook (Winifred Bolton et al., 2014), and a qualitative service evaluation (Wilson and Haigh, 2011). The whole process became a vehicle for the
identification, research, and development of ‘relational practice' (Haigh and Benefield, 2020).
This was
achieved through establishing a range of different pilot projects across the
country (Haigh, 2007), studying them with a mixed methods research
programme (Crawford et al., 2007), and implementing a ‘training escalator’ to develop a
workforce with suitable knowledge, understanding and attitudes (NIMHE, 2003). The programme also supported the development of a
rigorous but relational and values-based process for identifying, measuring and
ultimately accrediting best practice, through the Royal College of
Psychiatrists Centre for Quality Improvements ‘Enabling Environments’ programme
(Haigh et al., 2012).
This was all
to provide innovative solutions to what was seen as the ‘burden’ of ‘personality
disorders’ in community and inpatient mental health services (Soeteman et al., 2008). This was
traditionally seen as a traditionally ‘hard-to-reach’ population who were
often excluded from mainstream services; these people were often disliked as ‘patients’
and working with them was seen as difficult and inappropriate by many staff –
as they did hot have ‘proper mental illnesses’ (Lewis and Appleby, 1988).
Rationale
When human
development is disrupted, the psychological, social and economic consequences
can reach into every area of an individual’s personal and social world, resulting
in alienated and chaotic lives and repercussions throughout their communities.
The causes and consequences are largely relational. They may include child
abuse, inadequate parenting, failed attachment, trauma or emotional
deprivation. The causes can also be social: material poverty, or the poverty of
expectation that leaves individuals feeling powerless to have any impact on the
world in which they live.
Over-riding
differences in class and educational advantage confer some with strong
constitutions - or a range of poorly understood ‘protective factors’ – which
may be sufficient to enable them to withstand the impact of these environmental
failures and emerge from their early experience to live what appear thriving
and healthy lives (Bellis et al., 2016). However, very many end up in a situation where
they are excluded from mainstream society, rejected by those who might be able
to help them, and destined to live lives of unremitting frustration, without
the happiness and fulfilment that most of us would consider just - and expect
for ourselves and our families.
These
individuals, and often their families, have little psychological sense of their
place amongst others or where they fit into society. School, working lives and
almost any pro-social relationships are difficult or impossible to establish
and sustain. They experience the world as a hostile, unhelpful, threatening or
undermining environment, living in a marginalised underclass with high levels
of substance misuse, self-harm, criminality, and suffering severe, enduring and
disabling mental distress (Horn et al., 2007). People in this situation will often use a
considerable range of statutory services to little benefit (Coid et al., 2009).
If our
systems could respond in a relational way, our experience in working with
‘personality disorder’ services and systems shows that many obstacles,
obstructions and conflicts could be prevented. This applies at the individual
level (when those seeking service input feel respected and not overpowered by
the professional they consult); the service level (where those working in the
service have meaningful engagement with their task, believe in what they are
doing and can operate from a position of authenticity and wanting to help –
rather than by just following a rulebook); at organizational level (these
principles need to be prioritised and not over-ruled by role hierarchies or
inflexible procedures); at political level ( so that policy makers in different
areas can develop a shared understanding of how changes in this direction will
lead to greater efficiency and satisfaction, for both service users and
providers).
Contextual History
The
phenomenon of ‘personality disorder’ first caught public and government
attention following the 1996 murders of Lin and Megan Russell, and the
attempted murder of Josie Russell, by Michael Stone in Kent (Kent County Council, 2006). This led to what became known as the DSPD
(Dangerous People with Severe Personality Disorder) programme (Maden, 2006). The political objective was the research into
improved management of high risk offenders whose risk to others was linked to
their diagnosis of personality disorder.
The outcome was the piloting of new assessment and treatment services
base in prisons and forensic NHS secure services and community forensic teams.
This programme provided a joint financial investment by the Department of
Health and Home Office. As part of the policy plan it made a commitment to
improve mainstream community mental health and social care services for those
failed by existing services because of their identified ’personality disorder’
presentation. This then became
established as the National Personality Disorder Programme in 2003.
At about the
same time a self-help organisation called Borderline UK was set up with a
Millennium Lottery grant; it was headed and run by people with lived experience
of personality disorder, with some support from sympathetic professionals. There
was, and still is, considerable controversy about use of the ‘personality
disorder’ label itself. In terms of provision, many anguished voices claimed
unhelpful and harmful treatment from statutory services (Castillo, 2003; Robinson and
Cox, 2006; Sibbald, 2020).
These comments
were gathered by Borderline UK’s members and organisers, for example:
·
How can the
experts really treat it seriously and with any degree of compassion, when they
define it as attention seeking or manipulative?
·
Had I been
helped when I was younger, I would not have got this bad.
·
We cannot
call ourselves a civilized society when so many people are outcasts and are
simply not understood.
·
Specific
services for this are helpful – but general mental health services are not
helpful and can be abusive.
Recognising
these unmet needs, the Department of Health set up two working groups to
prepare a policy implementation document on strategic changes that might help.
In 2003 Personality Disorder, No Longer a Diagnosis of Exclusion (NIMHE, 2003), with clear
evidence on what service users were asking for, was published alongside the Breaking
the Cycle of Rejection: Personality Disorder Capabilities Framework (NIMHE, 2003), which was a guide
on workforce development and establishing a training escalator relevant to all
disciplines and levels of seniority. A National Personality Disorder
Development Programme, for services in the community, was established. The
three stated aims of the national programme were (1) to produce innovative
service developments, (2) to have a national evaluation of the new services,
and (3) to implement national regional training developments.
The new
services were established in 2004. There were five medium secure services and
11 (non-residential) community one (Haigh, 2007); the programme was also allied to 12 multi-systemic
therapy projects for children and the four existing DSPD units mentioned above
(which received the lion’s share of the funding, but were only set up for 300 patients). A
deliberate feature of the 11 commissioned community programmes is that they
were all different. Bids were invited, emphasising the value of novel thinking
and bringing together different elements, services and sectors - to bring fresh
thinking to a largely unsolved problem.
In 2006, the
national learning network was established as a forum, which was attended by
service users, staff and managers from all 11 community pilot projects. The
discussions were fertile ground for sharing best practice, and new knowledge,
as well as the inevitable obstructions and difficulties.
The formal
research project with the national program was called ‘Learning the Lessons’
which was conducted by Michael Crawford at Imperial College in London. It
included (1) an organisational evaluation; (2) a user-led qualitative
evaluation; (3) a cohort study; and (4) a Delphi study of the views of
academics, service users and providers about the integrity of the diagnosis (Crawford et al., 2007).
An important
part of the program was the extensive involvement and partnership with service
users, also now also known as ‘experts by experience’ (‘XBXs’ or ‘EBEs’) or
‘people with lived experience’. This partnership started by developing a
relationship with those who ran the ‘Borderline UK‘ organisation, which
later merged with an arts organisation called ‘Personality Plus’ to become ‘Emergence’. As part of the
merger, Emergence and Personality Plus held a major arts inclusion event at
Tate Modern, sponsored by the Tate Gallery and the National Programme, on 29
October 2007. Emergence became a community interest company run by those with
lived experience of ‘personality disorder’, with some board-level support
from established professionals. It ran various consultation, training and
research projects, the largest of which was with the National Personality
Disorder Programme.
The most
influential product of the partnership, and of the cooperative and trusting
relationship between professionals and those with lived experience, was the
Knowledge and Understanding Framework (‘KUF’) training. It was set up in 2008, with
Emergence plus three partners: the Open University, Tavistock and Portman NHS
Trust, and Nottingham’s Mental Health Institute. There were three levels of training on
the ‘career
escalator’: the awareness level training - which had been delivered to
nearly 200,000 people by the end of the mid 2010s; a stand-alone BSc course
which later became CPD modules; and an MSc delivered across four centres. The principle of the KUF training is that it
is co-produced at all levels - from writing the material, to recording videos,
the online content, and the delivery. For example, the three face-to-face days
on the awareness training are always delivered by a lived experience
practitioner partnered with a sympathetic clinician, who had been through a
train-the-trainers programme together.
Three
important government documents were published in 2009: The ‘Recognising
Complexity’ commissioning guidance for
personality disorder services (Department of Health, 2009), and the NICE guidelines on Borderline Personality
Disorder (NICE, CG78, 2009) and Antisocial Personality Disorder (NICE, 2009b). These strengthened the understanding of how
different presentations would need specifically designed services, and provided
commissioners with a model for developing services for people with complex
emotional needs. At its peak, the new community PD services were only covering
12% of the English population: questions were being asked about what existed
for the other 88%. Even within the 12%, the work undertaken was done in very different
ways, by services that had different outcome targets, different populations,
and very different methods. Despite the clear need for expansion, the
anticipated growth of the programme - to implement the government policy guides
- never came to fruition. This is probably because the complexity of training
needs and wide-open scope of the programme unearthed large areas of unmet need,
and many more problems than it was feasible to address at that time. At a
similar time, the ‘Improving Access to Psychological Therapies’ (IAPT) programme, was
able to reassure ministers that relatively simple solutions to common mental
health problems were possible, and measurable, in terms of ‘return to work' and other politically
attractive outcomes. Consequently, the lion's share of any new government
funding available for national programmes was allocated to Talking Therapies
(IAPT), and by 2011, the effects of the economic crisis led to the community
programme being closed.
However,
following the recommendations of the 2009 Bradley Report (Bradley, 2009), much of the learning from the community programme
was incorporated into the joint Ministry of Justice/NHS Offender Personality
Disorder Programme in 2011. This programme has seen the biggest development of
sustainable services within the criminal justice pathways for high-risk
offenders. These assessment and
treatment services include prison based Therapeutic Communities (Shuker and Newton, 2008), specialist Psychologically Informed Planned
Environments (PIPEs) (Benefield et al., 2017) and numerous prison units joining the programme to
become ‘Enabling Environments’ (Haigh et al., 2012). For these
men and women, who have complex needs and have histories of relational
difficulties, we have provided innovative interventions and improved relational
environments. In doing so we have developed our understanding of relational
practice and the need to focus on the provision of reliable, consistent longer-term
relational experience.
The
programme itself finished with two publications, and a number of other indirect
developments. The first is a qualitative evaluation of all eleven community
pilot projects, ‘Innovation in Action’ (Wilson and Haigh, 2011) which recognised
the importance of the quality of relationships, and described many
common factors and whole-system features (‘general therapeutic factors’) of what was to become ‘relational
practice’. The second publication was ‘Meeting the Challenge, Making a
Difference’, a handbook for working in various
settings where mental health is a factor (from homelessness hostels and social
care settings to psychiatric hospitals, for example). It is a user-friendly,
accessible and practical guide, based on all that had been learnt from the
pilot projects (Winifred Bolton et al., 2014). Linked work at the Royal College of Psychiatrists
Centre for Quality Improvement, from 2007 onwards, these publications led to an
accreditation process for ‘Enabling Environments’, which was based on ten
relationship-based values. The ten standards represented the core features of
any relational practice environment together with a process through which they
could be established, recognised and sustained (Royal College of
Psychiatrists, 2016).
Intention for a ‘Relational Practice
Movement’
Widespread understanding and implementation of
relational practice is required in order that future delivery of public
services involves due attention to the quality of relationships necessary to
satisfy basic human requirements for effective and meaningful exchange. It is likely that the health of all involved,
support for their resilience, and effectiveness of the work, is contingent upon
the quality of the relational environment in which they work. In any pathway of
engagement between an individual and the services they use, the foundation of
that engagement is a relational one. This requires that the exchange is
respectful and personalised, and takes account of the previous experience and
present position of all participants. The intention is to build a productive
relationship between those who use services and those who provide them, in the
context of shared ownership and effective personal agency, with understanding
of any intrinsic power differences.
This is important because the provision of education, good mental
and physical health, social and criminal justice care and support is not
provided for purely by the system of delivery, but also by the quality and
collective understanding of those professionals engaged with this delivery. A
healthy workforce must not be stressed to the point of burn-out, lost to sick
leave, or to leaving their various professions. Rather, a healthy workforce is
one in which people enjoy their relational contacts with clients and
colleagues, and feel valued and directly involved in a shared endeavour that is
inherently meaningful, worthwhile, and interesting. However, relationships
cannot be prescribed, or pre-determined, to be positive. Relational practice is
not a definitive solution, and working in this way must acknowledge how future
relationships are often determined by the quality and problems of participants’
previous relationships. Managing, or just enduring, difficult relationships is
an unavoidable part of the work.
For too long
public services have pursued an increasingly narrow, managerial performance
framework with the unintentional consequence of distancing service users and
having an unhelpful impact on accessibility to help, support and intervention.
Public services need a new vision to ensure that the best psychosocial
environment is reliably and consistently available in all interactions between
providers and recipients. This should aim to make services more accessible and
effective; more helpful than harmful.
We now have
18 years’ clinical practice, lived experience and evidence from the developing
field of personality disorder, meaning it is now possible to identify and
deliver the service design and workforce development needed for relational
practice. As yet there is only an
established policy in specialist areas of criminal justice and mental health
services. What is required is a movement whose campaigning objective is to make
the case for designing, staffing and developing relational practice, at all
levels, in a range of public service settings.
Expectation
of reasonable human rights in a public service system are all based on a
relational understanding that there should be:
•
Access to meet
need
•
Respect and
dignity
•
Understanding
and empathy
•
Empowerment
and participation
•
Consistency
and informed choice
This
requires all staff to be trained, skilled and supported to understand and
provide a meaningful relational response.
Definition of Relational Practice
Relational
Practice gives priority to interpersonal relationships, in both external and
internal aspects. It is the foundation upon which effective interventions are
made, and it forms the conditions for a healthy relational environment. It
requires relationships based on reliability, consistency, curiosity,
flexibility, and authenticity; an enabling and facilitating attitude; and an
understanding of the conscious and unconscious lives of individuals and groups
in their social field. Depending upon the setting, there will be variations in
the balance between these various elements.
Research and Evidence Supporting
Relational Practice
Although the
research does not use the term ‘relational practice’, there is a growing
evidence base that these approaches have positive benefits and outcomes in
prison populations (see for example (Auty and Liebling, 2020). A relevant NIHR-funded study of service user
perspectives on current provision clearly identified the central importance of
relational practice, and labelled it thus (Trevillion et al., 2021). Further studies are underway including a
literature search and systematic review; a Delphi-exercise is planned.
Training for Relational
Practice
For the government sponsored ‘personality disorder’ pilot projects
and the wider dissemination of suitable working practices it was essential, from
the very beginning, to consider workforce development and increasing capacity.
The plans were published alongside ‘No Longer a Diagnosis of Exclusion’ as the
‘Capabilities Framework’ (NIMHE, 2003) which proposed a ‘training escalator’ which
started at ground level (people with interest and aptitude but no specific
training) and went up through various tiers to an MSc suitable for leaders and
pioneers in the area. It was open for anybody to get onto the escalator
wherever they were and get off wherever they wanted. Importantly, the whole
process was to be co-produced with people who had themselves been through the
system as clients, patients or service users. When commissioned, this was the Knowledge
and Understanding Framework (KUF) and in its first decade it delivered
awareness-level training to over 80,000 people, and produced numerous graduates
of its MSc programme. It is has been recommissioned and redesigned following
the pandemic, and now has a clear strand of ‘relational practice’ running
through it (KUF Hub, 2022).
Other training activities, specifically focused on using
relationships in clinical practice, have been developed, mostly in the
voluntary sector. Specific examples are
·
A three
day immersive residential therapeutic environment from the Mulberry Bush Organisation
(The Mulberry Bush, 2023)
·
Hope in
the Heart is a National Lottery-funded social enterprise which “inspires change
through compassionate connection” (Hope in the Heart CIC, 2023)
·
Community
Housing and Therapy is a charitable provider organisation which runs specific relational
practice training (CHT, 2023)
Recognition of Relational
Practice
Figure
1 shows some of the current activities in four areas of relational practice: policy,
training, research and campaigning. The initiatives with most anticipated
impact are those outlined in bold.
Figure
1: Organisations and activities identified as involved in Relational Practice
(mid-2022)
The ’Enabling
Environments’ programme is based on ten values which reflect the quality of
relationships in a working or social environment, operationalizing them with
relational quality standards, and recognising them through an accreditation
process. It is operated in a process of engagement and collaboration.
Figure 2: The ten values by which the Enabling Environments project
recognises relational practice
The ten values and standards are as follows.
BELONGING: The nature and quality of relationships are of primary
importance
BOUNDARIES: There are expectations of behaviour and processes to
maintain and review them
COMMUNICATION: It is recognised that people communicate in different
ways
DEVELOPMENT: There are opportunities to be spontaneous and try new
things
INVOLVEMENT: Everyone shares responsibility for the environment
SAFETY: Support is available for everyone
STRUCTURE: Engagement and purposeful activity is actively encouraged
EMPOWERMENT: Power and authority are open to discussion
LEADERSHIP: Leadership takes responsibility for the environment
being enabling
OPENNESS: External relationships are sought and valued
Details of how services using relation practice principles can be recognised
and accredited, and more details, are available from the Royal College of
Psychiatrists (Royal College of
Psychiatrists, 2016).
This framework has been most extensively used in criminal justice
settings, with services from various other sectors also achieving accreditation
– as a quality mark to demonstrate, amongst other valuable characteristics,
that they have relational work at the heart of their operations.
Theoretical Framework
underpinning Relational Practice
This specification is based on a model of human
development (Haigh and Benefield, 2019) which draws on a wide range of basic concepts with
relevance to ‘relationship’ and explicit theories of need and causation of
behaviours and emotions. This embraces the fields of education, life-course
development, social sciences, psychoanalysis, neurosciences, management and
organisational dynamics.
The underlying premise is a very simple one, that a vast range of
internal and external factors determine the lives we will all lead. The whole
range of factors is almost impossible to precisely define, and the fixed and continuous
interactions between them all creates an almost infinite number of paths for
personality development, as well as life outcome and what we all leave behind. The
‘outcome’ perhaps defined as ‘what our life is like’ is an emergent property of
a complex and possibly chaotic system.
The model was developed over several years by an iterative
consultation process with experts-by-experience, clinicians and academics at a
UK-based annual conference. It starts before birth and finishes after death;
major areas between the two are emotional development, life experience and life
outcome. All these areas can be influenced by adversity – by omission or
commission – and modified by a range of ‘bio-psycho-social’ factors. All these
elements and interactions are seen to exist in a relational field, part of
which is experienced consciously (and therefore subject to a degree of rational
understanding); but much is unconscious (or autonomic) and therefore not
explicable by the straightforward logic of cause and effect.
Figure 3: The complex interplay of numerous variables in human
development
Levels of Relational Practice
As clearly identified ideas, principles and values emerged, the
concept of relational practice gained greater definition, and a framework for
how it could be implemented across a wider field of public and human services
emerged. It can be argued that the root of many prominent breakdowns in
delivery of public services can be seen as a failure of relational practice –
at individual, practice or organisation levels
Relational Practice is predicated on the recognition of the fundamental
importance of the relational field, and that all professional work requires
good quality relationships. For this to happen, we must:
·
Use a model
which is based on a biopsychosocial approach.
·
Facilitate the
development of healthy psychosocial life.
·
Understand the
relationship between the personal, the professional and the social in all
domains.
·
Promote a
psychoanalytic understanding of unconscious and irrational processes as they affect
feelings, attitudes and behaviours.
·
Ensure
professional work is based on developing knowledge and understanding of
essential relational capabilities.
·
Engage with
wider social change that supports relational values and meaning.
·
Facilitate
informed leadership that recognises relational principles and practice which includes
being compassionate, tolerant, adaptive and available.
More specifically, relational practice needs to happen at several
levels: the individual one-to-one encounter; the group or team within which
practitioners are working; the wider organisation which is responsible for
delivering that work – and the relationship between it and other organisations,
as well as the political or commissioning structures within which the
organisation exists.
Personal Qualities/Capacity
Each individual’s capacity to participate in good quality relationships requires
consideration of their personal and emotional capabilities in delivering
professional tasks. Failure to do so can undermine the effectiveness of their
professional role and risk burnout or harmful mental health consequences, and
can have a negative impact on others, including service users. Although all
interpersonal work requires relational understanding, recruitment to roles
requiring specific relational skills need to consider criteria to identify relevant
vulnerabilities and capacities in more depth.
One to One Relationships
The Quality of Relationship is a measure of the way in which
relationships are established, maintained, developed, and concluded. Establishing
a one-to-one relationship requires an attitude of genuineness and authenticity,
based on a consideration of how it must feel to be in the other’s place. It is
often helped by behaviour demonstrating openness and informality; understanding
any power differential and the intended purpose is essential. Speaking from a
script, or working purely from a decision tree, are not sufficient in
themselves. Developing the relationship is important in relationships
which will endure across time. This requires different actions depending on the
intervals between contacts, and the duration of engagement. The intention is to
produce a feeling of safety within which confidence can be established. A sense
of playfulness may help. Maintaining the relationship needs both reliability
and flexibility. The experience of being fully heard requires a particular
quality of listening, and willingness to hear. It must include an understanding
of the conscious and unconscious impact of the emotional content, and our way
of processing it. The purpose of the relationship is kept in mind, and
boundaries are understood. Cancelled appointments or change of personnel,
particularly at short notice, are harmful to relational continuity and
organisational trustworthiness. Disagreements, breakdowns and ruptures in the
relationship need to be mended wherever possible. Ending all relationships has
significance which needs consideration, particularly those of longer duration
or importance. Endings are best when agreed and accepted, and should be based
on principles of reliability and consistency.
Endings are transitions which may have problematic associations for
those who have had earlier difficulties with attachment and separations.
Missing or avoiding an ending must be avoided.
Group Culture
One-to-one relationships always exist in the context of a wider
group. The group environment needs to facilitate the conditions for healthy
one-to-one relating while recognising the constraints of different settings.
Belonging and connection form the basis of engagement and identity; involvement
and inclusion are needed to feel part of something and to take a participating
role; boundaries and limits are required to provide an experience of
psychological containment, within which thinking together is more possible;
safety and confidence arise from a psychosocially designed environment;
authenticity and communication provide a way to give behaviour meaning;
openness and transparency reduce suspiciousness, support honesty, and allow the
development of trust. Spontaneity and flexibility can provide an opportunity
for exploration of imaginative and innovative ideas and thinking; ownership,
responsibility and power create conditions for mutual control, shared
accountability and self-determination; personal agency and freedom allow
individuals to maintain their own mind and have freedom to make choices. All
relational environments require clarity of purpose and leadership to ensure
that a relational environment is maintained.
Organisational Culture
Service pathways involve a range of organisational settings. Each
organisation will have its own culture relating to its primary purpose, but it
will need to establish an environment in which relational practice can be
sustained. For services and teams, the setting requires physical facilities and
organisational conditions to optimise interpersonal relational life; the
leadership needs to understand and be committed to establishing and maintaining
a relational environment as central to healthy working conditions and staff
wellbeing, as well as improved effectiveness and satisfaction, with fewer
complaints. Arrangements for support and supervision must be integral to the
organisation’s design. An atmosphere of curiosity ensures a reflective approach
to all aspects of the service environment and enrichment of the organisational
culture reaches beyond the primary task by providing experience and allowing
access to imaginative and creative experience.
For workforce development, all organisations and teams in public
sector pathways need to have a relational practice training strategy. This will
cover awareness, understanding, skills, and the recruitment and selection of
staff, which needs to continue as part of professional growth. Service-specific
elements of relational practice training will be required in different
contexts. Depending on the organisational context, this may include the risk to
self and others, attitude to rules, and issues of discretion.
Conclusion
Relational Practice is a way of working that was identified and highlighted
through the implementation of the Department of Health’s ‘National
Personality Disorder Programme (2003-11). It’s relevance is much wider than
’personality disorder’, or mental health, or indeed all health services. Human development
is something we all experience (Haigh and Benefield, 2019), and healthy development forms the basis of
requirements needed to produce suitable therapeutic cultures and working
practices (Haigh, 2015; Royal College of
Psychiatrists, 2016). An understanding of the relational field provides
a working understanding of human exchange that should guide the daily practice
of public sector tasks.
This work must continue, develop and extend as research and evidence
emerges to demonstrate improved professionals’ working culture, and increased
effectiveness - with improved user outcomes. This is relevant across all
sectors of public service, and the manifesto’s strategic plan is shown in figure
4.
Figure 4: Process for embedding relational practice across the
public sector
There is now
a need for an active campaign to bring about change. The movement that has
happened to date has raised professional awareness and found a high level of
support amongst those with lived experience of services. The next step needs to
be widespread consultations - across all organisations, professions and sectors
– and coordination of an effective campaign to bring about these changes. A
draft of a ‘rallying call’ manifesto, taken from the text of this chapter, is
presented in figure 5.
Figure
5: Statements from this chapter
incorporated into a draft ‘manifesto’.
References
Auty, K.M., Liebling, A., 2020.
Exploring the relationship between prison social climate and reoffending.
Justice Quarterly 37, 358–381.
Bellis,
M.A., Ashton, K., Hughes, K., Ford, K.J., Bishop, J., Paranjothy, S., 2016.
Adverse childhood experiences and their impact on health-harming behaviours in
the Welsh adult population. Public Health Wales NHS Trust.
Benefield,
N., Turner, K., Bolger, L., Bainbridge, C., 2017. Psychologically Informed
Planned Environments: a new optimism for criminal justice provision?, in:
Transforming Environments and Rehabilitation. Routledge, pp. 179–197.
Bradley,
K.J.C.B., 2009. The Bradley Report: Lord Bradley’s review of people with mental
health problems or learning disabilities in the criminal justice system.
Department of Health London, London.
Castillo,
H., 2003. Personality Disorder: Temperament Or Trauma?: an Account of an
Emancipatory Research Study Carried Out by Service Users Diagnosed with
Personality Disorder. Jessica Kingsley Publishers.
CHT,
2023. Training | Community Housing and Therapy. URL https://cht.org.uk/training/
(accessed 3.12.23).
Coid,
J., Yang, M., Bebbington, P., Moran, P., Brugha, T., Jenkins, R., Farrell, M.,
Singleton, N., Ullrich, S., 2009. Borderline personality disorder: health
service use and social functioning among a national household population.
Psychological medicine 39, 1721–1731.
Council,
K.C., 2006. Report of the independent inquiry into the care and treatment of
Michael Stone.
Crawford,
M., Rutter, D., Price, K., Weaver, T., Josson, M., Tyrer, P., Gibson, S.,
Gillespie, S., Faulkner, A., Ryrie, I., 2007. Learning the lessons: A
multi-method evaluation of dedicated community-based services for people with
personality disorder. London: National Co-ordinating Centre for NHS Service
Delivery & Organisation.
Department
of Health, 2009. Recognising Complexity: Commissioning Guidance for Personality
Disorder Services.
Haigh,
R., 2015. The quintessence of a therapeutic environment: the foundations for
the Windsor conference 2014. Therapeutic Communities: The International Journal
of Therapeutic Communities 36, 2–11.
Haigh,
R., 2007. The 16 personality disorder pilot projects. Mental Health Review
Journal 12, 29–39.
Haigh,
R., Benefield, N., 2020. Personality Disorder: breakdown in the relational
field, in: Working Effectively with Personality Disorder: A Paradigm Shift.
John Wiley & Sons, Chichester, pp. 35–52.
Haigh,
R., Benefield, N., 2019. Towards a unified model of human development. MH
Review Journal 24, 124–132.
Haigh,
R., Harrison, T., Johnson, R., Paget, S., Williams, S., 2012. Psychologically
informed environments and the “Enabling Environments” initiative. Housing, Care
and Support 15, 34–42.
Hope
in the Heart CIC, 2023. Training for Service Providers [WWW Document]. URL
http://www.hopeintheheart.org/training-for-service-providers.html (accessed
3.12.23).
Horn,
N., Johnstone, L., Brooke, S., 2007. Some service user perspectives on the
diagnosis of borderline personality disorder. Journal of mental Health 16,
255–269.
KUF
Hub, 2022. KUF Training - Home [WWW Document]. URL https://www.kuftraining.org.uk/
(accessed 3.12.23).
Lewis,
G., Appleby, L., 1988. Personality disorder: the patients psychiatrists
dislike. Br.J.Psychiatry 153, 44–49.
Maden,
T., 2006. DSPD: Origins and progress to date. The British Journal of Forensic
Practice 8, 24–28.
National
Institute for Mental Health in England, 2003. Personality Disorder: No Longer a
Diagnosis of Exclusion. Policy Implementation Guidance for the Development of
Services for People with Personality Disorder. Department of Health.
NICE,
2009a. Borderline Personality Disorder (CG78).
NICE,
2009b. Antisocial Personality Disorder (CG77).
NIMHE,
2003. Breaking the Cycle of Rejection: The Personality Disorders Capabilities
Framework. DH.
Robinson,
L., Cox, V. (Eds.), 2006. Voices beyond the border: living with borderline
personality disorder. Chipmunkapublishing, London.
Royal
College of Psychiatrists, 2016. What is the Enabling Environments award?
Shuker,
R., Newton, M., 2008. Treatment outcome following intervention in a
prison-based therapeutic community: A study of the relationship between
reduction in criminogenic risk and improved psychological well-being. The
British Journal of Forensic Practice 10, 33–44.
Sibbald,
S., 2020. Life and Labels: Some Personal Thoughts about Personality Dsorder,
in: Working Effectively with Personality Disorder (Eds JoRamsden, Sharon Prince
and Julia Blazdell). Pavilion, Shorham-by-Sea, pp. 23–33.
Soeteman,
D.I., Roijen, L.H., Verheul, R., Busschbach, J.J., 2008. The economic burden of
personality disorders in mental health care. Journal of Clinical Psychiatry 69,
259.
The
Mulberry Bush, 2023. The Living Learning Experience (LLE) [WWW Document]. URL
https://mulberrybush.org.uk/eventstraining/the-living-learning-experience-lle/
(accessed 3.12.23).
Trevillion,
K., Stuart, R., Ocloo, J., Broeckelmann, E., Jeffreys, S., Jeynes, T., Allen,
D., Russell, J., Billings, J., Crawford, M.J., 2021. Service user perspectives
of community mental health services for people with complex emotional needs: a
co-produced qualitative interview study. medRxiv.
Wilson,
L., Haigh, R., 2011. Innovation in action [WWW Document].
Winifred
Bolton, Kath Lovell, Lou Morgan, Heather Wood, 2014. Meeting the Challenge,
Making a Difference. Department of Health.
