Therapeutic Communities in Sicily

While the fortune of British 'Democratic' therapeutic communities always seems to be teetering on the brink of oblivion, it seems like the Sicilian version is going from strength to strength, and with government backing. They are expanding in all directions: adults, personality disorder, psychotic illness, homelessness, adolescents, refugees, forensic and group apartments; properties are also being repossessed by the government from convicted mafiosi and given over to social enterprises to set up as therapeutic communities.

A thriving network of community-based units already runs a sophisticated quality network (adapted from 'Community of Communities' at the Royal College of Psychiatrists) which held its first Annual Forum last year with twelve members, and is planning its second one (with many more members) at the end of this year.

The psychiatric authorities in Sicily also want to forge links with the British ‘Living-Learning Experience’ (LLE) therapeutic community training (www.livinglearningexperience.com) which has been essential TC training in the UK for nearly twenty years now. This has involved close liaison with the British ‘Living and Learning’ team, which already includes two Italians and another Italian-speaking therapist (from Uruguay).

The "regional psychiatric authorities"

Numerous LLEs have been held in Sicily since 1999, twice at Erice, in Caltanisetta, Partenico, and with two based on a converted fishing boat in Trapani  (for training new British personality disorder teams, one from Oxford and one from Nottingham). A formal one-day event, organised by the regional psychiatric authorities, was held in Piazza Armerina, for about a hundred delegates, in 2008. After much work developing their clinical model of therapeutic ‘community in the community’ practice, this was followed by the first LLE for Sicily’s new therapeutic communities at Caltagirone in 2013, and a second one last weekend at Altavilla Milicia, near Palermo.

The setting was a 50-bedroom monastery with one monk, looking out at the sea on one side and the mountains on the other, sat in the middle of a large garden filled with lemon and orange trees, and olive groves. We had the venue to ourselves: the guest rooms were converted monastic cells, and the group rooms were normally for lectures and seminars, from which we carefully removed various Catholic artifacts and set the chairs in circles.

The monastery with one monk

We started the workshop as always, with the staff (six of us this time) meeting for a team meal, the night before the participants arrived. This ensures good ‘team bonding’ and was particularly important for this workshop, as some of the staff had not worked together before. It also allows us to relax and unwind after our various journeys.

The 19 delegates started arriving a little before midday on Thursday, while the staff team was preparing lunch, Sicilian-style. This was the first of several culinary extravaganzas, subsequently effortlessly prepared and elegantly presented by various groups of delegates. The show was on the road! Apart from the usual community meetings and small groups, we were all involved in numerous games, activities and fun – although my own linguistic deficiency (non parlo l’italiano!) left me almost entirely in the dark about what we were doing until we actually did it. But everybody seemed to get a great deal out of the experience – and one of the Italian staff took a video of everybody’s evaluation and feedback – see [www.insert.link.here.it].

After we had all said our goodbyes, the team went to meet a Professor of Psychology at Palermo University – who is helping the research and development project for TCs. We learned of how all Sicilian forensic mental health facilities are to be closed, and the service users transferred to the day-to-day care of social cooperatives (while remaining under the supervision of government-employed psychiatrists). These cooperatives are to be run as TCs – about four of them residential, with fifty places, and the rest – for people less likely to be a danger to others – will be non-residential community places.

We also heard of how the TC standards for Children and Young People have been translated into Italian, and are being used for quality assurance and improvement. We left feeling excited about all the action going on in Sicily – and perhaps a little regretful that therapeutic communities back home do not enjoy the same level of formal and organisational support.

But it should give a good opportunity for plenty of future cooperation and collaboration for training, research and service development in the Sicilian sunshine! 

Is 'Open Dialogue' the new mental health revolution ...or just the latest 'big thing'?

The Round Chapel, Hackney

When they cancelled the lunches by email, the day before, I wondered if there would even be a dozen people there – but I was wrong to doubt the strength of this movement, as there were 120. It looked pretty slick – in that MBA/project management/young entrepreneur sort of way – too: QR code check-in at registration (although hardly anybody had printed out their tickets or had them available on a smart phone – these are mostly NHS therapist types, after all! – so they were just nodded in), and a folksey singer playing the grand piano. Wires, a big mixer desk and sound systems with video cameras on high tripods at both sides of the hall. Strange red lights (which turned out to be heaters) dotted about the auditorium. The auditorium itself is well-worth mentioning – it is a deconsecrated round church, elegantly restored, in Clapton, Hackney. Despite lots of stations in Hackney, it seemed to be just about the most difficult place within the M25 to get to by public transport. But was this a gig or a therapy workshop?

A musical welcome

The ‘main man’ of Open Dialogue UK was the warm-up: Nick Putman. A cross between the looks of a singer-songwriter like James Taylor and the demeanour of Ricky Gervais in The Office, he told us tales of early inspiration by Ronnie Laing’s work, and how he dropped out of clinical psychology training, travelled, qualified in psychotherapy – and more recently chanced upon Open Dialogue from Western Lapland in Finland. He is now a trainee in the Open Dialogue movement in USA. The approach is now catching on in other northern European countries, it seems, and he has set up Open Dialogue UK to bring it to these shores – and hopefully in a way that’s deeply embedded in the NHS. Of which, more later. This, he explained to us in a somewhat sleep-deprived state, is the first full six-day event in the UK to ‘spread the word’. It comprises three whole weekends held over a couple of months. A full training programme is anticipated for late 2014.

So we were introduced to the headline act:  two longstanding therapists from the original project in Western Lapland, Markku Sutela and Maria Kurtti, who worked as a ‘double act / reflecting team’ through the rest of the weekend. They explained how the approach had developed in Finland over about thirty years, much of it by serendipity. I was rather taken with how they saw it as an approach, maybe a therapeutic philosophy, rather than a brand-in-a-box (see my previous post from BIGSPD about ‘alphabetti spaghetti’ therapies for a rant about that particular point!). And also, the fundamental embracing of uncertainty that it demands, and the absolute requirements of flexibility, spontaneity and openness. But it’s also harder than that – as the method demands that you can never be certain that what you are doing is right. "The way that can be named is not the true way…". This is the sort of therapy that I have respect for...

We also did some small group work – for half an hour at a time in groups of about ten, with built in reflecting teams. One interesting stream of thought in ours was ‘what do you have to give up, as a therapist in your own favoured tradition, in order to work in this way?’. We felt that it was the ‘security blanket’ of theory, from our own long-cherished therapeutic trainings. Working in this ‘unlabelled’ way, perhaps like Laing described as ‘unlabelled living’ at Kingsley Hall, leaves us with only our selves and our relationships to work with. But it is all strictly done with shared responsibility – so one is never alone. The one question left hanging in the air for me was what we in the UK see as 'service user involvement' - not only doing the clinical work in authentic partnership with service users, but also the choice of services that people want - and the administrative clockwork (of real jobs etc) to go with it. Open Dialogue is clearly a very professionally run outfit, without the inevitable confusion and messiness we have to negotiate and hopefully enjoy when working absolutely alongside service users in planning and developing new services.

The therapeutic influences were explained – with the strongest influence being Milan-style systemic family therapy with extensive, integral and continuous use of reflecting teams. The one powerpoint slide that blew my mind was what they call their ‘Principle Number One’, dating back to 1984: “You are not allowed to talk about patients or their families when they are not present”.

I think that is sufficiently radical to stop there, and reflect on it…

Is this a gig?