I love it because you are fabulously looked-after in a three day conference of like-minded people talking about and doing interesting things.
I hate it because you are fabulously looked-after in a three day conference of like-minded people and many many people who should be there can't be, because it's too expensive.
This year's was even more conflicted for me, as the organisers (of which I am one) made a decision (without me) to base it on the 'Quintessence' paper I wrote ages ago and am still not happy with - with me doing the opening talk about it. And, although I don't mind ranting to people I hardly know, I feel quite self-conscious and embarrassed doing it in from of professional friends..
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| The Windsor Conference - 10 years ago |
First, thanks you for inviting me – this
is like the anchor point of the TC year, like the annual residential community
meeting for us all in this beautiful park. And I think this is the biggest
number we’ve ever had, which is great to hear.
And it’s a great privilege to be
asked to speak here, so thank you very much, organisers.
What I’m going to do in this talk is
go back to an old soap-box of mine – about the experiences people need to have
in TCs. It’s a theme that I started in about 1994 and will never get completely
finished. But a fairly up-to-date version of it was published in the TC journal
last year – as the ‘quintessence of a therapeutic environment’ – with five
sort-of developmental themes that make up the emotional experience of being in
a TC – and actually the experiences we all go through in our own development,
for better or for worse.
So as part of this introduction to
the conference, I’m going to
explain what drove me to it – and
what is still driving my enthusiasm for TCs –
then
explain how it’s relevant to the
speakers who are here for the next three days,
and finish off by
thinking about where we are now with
the TC ideas in it, and where we might go.
So, to start where I started in it
all – with a bit of my own story.
I got a bit of a shock – a good shock
– as a medical student when I did Social and Political Sciences for my third
year. It was very different from the logical and orderly world of anatomy and
biochemistry and pharmacology that I had been in until then. Cambridge was a
hotbed of radical and critical thinking in the late 1970s so the first things I learned about psychiatry
were about Laing and Szasz – alongside things like psychoanalysis and feminist
theory.
Of course Ronnie Laing himself was
still alive then, and he was guest of honour at the annual MedSoc dinner that
year (although sadly incoherent with the abundance of fine wine on High Table).
But it was with these ideas fizzing around in the back of my mind, that two
years later, I was about to have my first ever encounter with clinical
psychiatry, and start as a clinical student at Littlemore Hospital, on the
Phoenix Unit. Being sent to the Phoenix Unit - a phrase that struck terror into
the hearts of medical students when they learned that was their allocated
psychiatry placement!
I had been warned by previous
students that this was not somewhere to wear the normal tweed jacket and sober
tie (which was the standard medical students uniform for psychiatry at the
time), and to be prepared for anything. I was not to be disappointed!
So I kitted myself out in a big red
sweater and jeans, and I arrived there on a bicycle a couple of minutes after
the suggested 8.30, and had to get past a couple of blokes wearing hardly any
clothes sitting on the doorstep smoking roll-ups – like bouncers at the disco,
maybe. Without any words being spoken, they looked me up and down and casually
pointed me in the direction of a large dilapidated room - where I soon had to
forget any ideas I had of hospital hygiene, with most people smoking and a
thick fog I could barely see across. I expect they would go bananas nowadays if
the infection control matron or the health and safety people saw it.
I squeezed into the room between two
people’s backs, to be confronted with a large circle of chairs - perhaps 40
people - where it wasn't possible to tell the consultant from the cleaner. I had to find my own chair on the other side
of the room and pull it up next to a large restless man who just looked at me
and laughed. "What's your diagnosis then, eh? You must be manic like me
with a jumper like that." He trumpeted this at about 120 decibels, and I
just wanted the ground to swallow me up and go back to proper medicine. There was an excruciating silence (probably
all of twenty seconds) before everybody introduced themselves.
After my initial culture shock of joining
a therapeutic community, I went on to thoroughly enjoy it. I found something
completely different about the way people were with each other - I learnt my psychiatry
the same as other students who were on traditional wards, but I also got an
inkling of something that is very hard to define or put in words. It was
something about being allowed to be yourself, about playfulness, and creativity
– just being human together yet also be able to be fully professional. And I
have been looking for ‘it’ and thinking about ‘it’ ever since – that quality of
relationship. I have visited dozens of
TCs all over the place, and worked in quite a few, and nearly always been inspired
by them – because it’s there. Which is sometimes a problem because I can get
inspiration fatigue – ‘oh no, not another marvellous, warm, welcoming and
impressive TC’ – and quite forget that the rest of the world isn’t at all like
that, and come to realise with a bump that it isnt!
I think there’s several reasons that
it is hard to put a definition of this essence
into words. My first thought it that it is about preverbal areas of experience
that simply exist before words we had words, to describe it with; in the
quintessence these are the first two experiences – attachment and containment –
that are mostly experienced non-verbally.
And this probably fits into some of
neuroanatomical ways of looking at it: it is about the emotional and motivation
systems of the brain, which are technically primitive, and were there way
before the evolution of our big cerebral cortex which does all the things like
thinking and talking. I think this idea – that maybe a lot of important things
about us that aren’t just in the cortex - was elegantly and vividly covered by
Colwyn Trevarthan when he gave his talk here at the Windsor Conference two
years ago.
Another neuroanatomical angle on it
does involve the cortex – or at least half of it – in that ‘it’ is something much
closer to connectedness and relationship (to each other and to the natural
world perhaps) and about that sense of holism, imagination, creativity and ‘the
big qpicture’ …than it is about… sequential and logical problem-solving. I have recently read Iain McGilchrist’s
‘Master and his Emissary’ book which is a very impressive and erudite account
of the difference between left and right brain functions – and by mentioning it
so briefly, I know I run the risk of oversimplifying a very subtle concept – but
the sort of qualities I am trying to pin down are much more akin to right-brain
functioning than left. For most people the language centres are in the left –
so communicating this essence through words is not going to be so easy (like it
is about communicating things like numbers, and outcomes, and logical
processes). But this shouldn’t be a cause of worry for us – because it means
that what we’re exploring is more interesting and mysterious – and harder to
grasp through words than it is through ‘just being somehow or other’ – what I
have called ‘therapeutic ordinariness’ before. It does however, make it
difficult to get it over in words – in other words to explain what we do - to
the accountants, and commissioners, and outcome-measurers, and budget-holders,
and policy-makers who live mostly in a left-brain world.
Another relevant neuroscience angle
on it comes from what Chris Holman was talking about in his Maxwell Jones
lecture a little while ago: how mirror neurones can give us a model for how
empathy works – with adjacent brain cells being activated by seeing or
experiencing something rather than necessarily doing it. I know that’s an
oversimplification, but it makes the point that something like empathy – that
can only be described in clumsy verbal expressions like ‘putting yourself in
somebody else’s shoes’ or ‘I feel your pain’ – has a mechanism there in the
brain for being communicated from one person to another without the need for
words. And I would say that most of the business (or ‘emotional work’) that
happens in a TC is like that – it’s not the words that matter, but the whole
experience.
Putting it in good words is probably
more of a job for poets and songwriters and artists than people who are
primarily clinicians, or academics and researchers. But that doesn’t and
mustn’t deny the reality – or seriousness - of this ‘thing’ we’re grappling
with. If we ignore it because we can’t describe it very well, we will be left
with something very unsatisfying – and thin and arid – that misses the point
about being complex and emotional – and human. Perhaps like over-manualised CBT
treatment – effective as far as it goes, but actually rather superficial.
So the quintessence paper was my way
to have a first go at pinning down this thing that people experience in a TC –
or an ‘enabling environment’ or a ‘psychologically informed planned environment
(PIPE)’ or a psychologically informed environment (PIE)’, or what I’m now
trying to describe more broadly simply as a ‘positive environment’. Whether these
five things are present or not in our social worlds makes an awfully big
difference to our lives, qand the people we are there with.
The quintessence paper itself, in the
1994 version, was the theory paper or dissertation for my IGA training – and it
was a collection of the different theories that I had come across in that and
my psychiatric training – assembled into a sort-of developmental sequence. It
was my attempt to make sense of what was going on in the therapeutic
communities I had come across and worked in. It was also a reaction against the
dominant theory at the time, that seemed to be an over-identification of just
one particular way of doing TCs – which was Robert Rapoport’s description of
what he saw, as an anthropologist, at the Henderson Hospital in the late 1950s:
democratisation, permissiveness, reality confrontation, and communalism. That
troubled me for two reasons – first that it seemed to be a ‘recipe-type’
approach to standardise TCs. It became a definitive statement of ‘this is how
it works so this is what you must do’, and it didn’t fit with my experience of
many other TCs which couldn’t really justify using those words – or could only
do so at a stretch which rather distorted their meaning, in order to fit. I
think it could be called reification of the concept: – it made ‘the TC’ into an
solid entity rather than a complex and never-quite-pin-downable attitude,
process and ‘quality of relationship’.
The second thing that worried me
about it was that, when I read Rapoport, I couldn’t find any trace of a whole
range of qualities that I knew I had always found in the TCs I visited. Again,
there is that ‘how do you put it into words’ problem but it’s about nurturance,
genuineness, authenticity, belonging, playfulness, joy and perhaps love – just
to pick a few words out of the air. It’s close to attachment too, though I
think is more than just ‘attachment theory—type attachment.
So to turn to a quick resume of the
quintessence, attachment is
where I start, and indeed how we all start: umbilically,
within our mother and with her blood flowing right next to ours, separated by
only a thin membrane. At birth, this
physical and physiological attachment is suddenly and irreversibly severed: the
smooth and fairly tranquil life of swooshing around in a warm ocean that is
your whole world, without ever needing to eat and breathe, is over. It is the first separation and loss, and many
more will certainly follow. The
effortless existence is lost, and experience suddenly becomes discontinuous or
bumpy: with good parts and bad parts, and if you are lucky, with people close
enough to help you through it.
For the baby who is fortunate, the physical and physiological bond
will be smoothly and seamlessly replaced with an emotional and nurturant one,
which will grow and develop until various features of that too are invariably
broken, lost and changed in the relentless inevitability of development. This secure
early attachment gives the infant a coherent experience of existence, and
protects against being later overwhelmed by life's vicissitudes. This places
loss - of contact, of relationship, of security, of hope - centre stage in the
process of individuation: attachment must take place so that loss can happen.
It is through the successful endurance of loss that we all have to survive and
change to live on. So I want to emphasise that attachment- as I see it – is not
a soft and cuddly sort of process – it is all about a sort of fall from that
perfectly nurturant and peaceful world before birth through a series of tragic
losses throughout life, to the ultimate loss of our own death – and most
importantly, the things we pick up on our journey through life to make it all
bearable.
For a less fortunate baby, born with greater needs, or for whom
the process does not go so well, the emotional bond is not secure. Attachment
research shows that if the bond is not secure for the infant, nor is the adult
who grows from it. When the failure or deficiency of emotional development is
severe and incapacitating, people can well end up with lives of unrelenting
pain and chaos – not just for themselves but also for people all around them.
And we are very fortunate to have Gwen Adshead with us here at the
Windsor Conference to guide us through some of this attachment territory – Gwen
has been, for many years, a forensic psychotherapist at Broadmoor Hospital,
dealing with people who have had âqparticularly severely disturbed attachment,
with some of the most disturbing and ghastly coinsequences imaginable. She also
– referring back to my utopian vision of how the baby smoothly graduates from a
physical bond to an emotional one – has a particular interest in what goes
wrong when parents, particularly mothers, abuse and sometimes kill their own
children. So, we will be hearing about the not-so-cuddly side of attachment,
from a world authority in it.
One of the other earliest things that "grown-ups" do for
babies on that bumpy ride through infancy is to be
there and accept their extreme feelings of primitive and boundless distress.
This process is the template for containment,
the second theme of the quintessence - and for infants who get a satisfactory
experience of it, it forms the basis of a safe world in which experience – a
lot of which which feels intolerable - can be survived.
I look at this as having both maternal and paternal elements,
although I know that isn’t very 1politically correct in ‘Modern Families’ terms!
But I don’t have any issue with who supplies what – but just that they do
actually get supplied. The first is
safety and survival in the face of infantile pain, rage and despair. In a
therapeutic community, these primitive feelings are often re-experienced, and
survival without hurtful criticism or rejection may in itself be a mutative new
experience for members, whose usual expectation will be to face hostility,
rejection and isolation. Now they have the novel opportunity to have these
powerful primitive feelings accepted and validated.
An aspect of safety which comes a little later for children could be
called the paternal element: about limits, discipline
and rules. This is the safety of knowing what is and is not possible and
permitted - done through the task of enforcing boundaries. This is somewhat at odds with the view of permissiveness
as a required quality of therapeutic communities: if the experience of
containment is to be achieved through holding the boundaries as well as holding
the distress, although the emotions may be boundless, the actions they
precipitate are within agreed limits. It is therefore more fundamental for a
place to feel safe than for anything to be allowed. And
emotional safety is exactly what is experienced in the culture of a community
when it is well-contained: it needs to tolerate severe disturbance so it can
witness and then digest violent emotions, and still feel safe. However, the size of the stage on which the
dramas are played is not limitless - and members need to know where its edges
are so that they can feel that safety.
The holding process also depends on the sensuous and
satisfying qualities of the environment. These qualities will bridge the gap
between the reality of holding and the experience of being held. It is the difference between
"containing" and "holding" - one is mostly inside, and one
is mostly outside. Each is weaker
without the other: sympathetic and compassionate holding is unlikely to be
usefully internalised without a deep and significant internal experience of
containment of powerful emotion, and that containment at this Áintensity would
be difficult and somewhat sterile without some grounding in the qualities of
real relationships - which people experience within a community, and within a
therapeutic community.
One of the odd things I’m involved with at the moment is a
campaign to recognise that staff do not feel ‘contained’ or safe in their
working life in the National Health Service at the moment. The working
environment, if you like, is toxic – and fails to recognise the emotional needs
of staff. One of the people who has written most lucidly about this – and what
may lie behind it – is Penny Campling, who tomorrow is going to talk to us
about how institutions contain – or fail to contain – the anxiety and emotional
distress that they need to. Penny, together with John Barratt, have recently
written what musty be the most psychologically sophisticated management book
for a long time: called ‘Intelligent Kindness’. I know it’s important, because
my wife – who is a senior nurse in the operating theatres in Oxford – was
recently told to read it by her own managers, and she went out and bought a
copy before she even knew that I already had one on my bookshelf! So we are a
two-Penny household. If anybody wants to borrow a copy, we have two! Penny and
I have been TC colleagues for many years – and I have always enjoyed her talks
at Windsor – and am certainly looking forward to tomorrow’s.
Now, once the primitive and turbulent preverbal work is in
hand, a major developmental task is to make language-based contact with others,
enjoy mutual understanding of common problems and find meaning through this
connection. This is what I chose as the third of the five – communication. For children,
this of course starts in earnest once they begin to talk - although there is
very deep and rich communication in the primary intersubjectivity which starts
growing in the primary bond immediately after birth – which Colwyn Trevarthen
told us about so clearly here, a couple of years ago. However, it is by
striving to put it into words that symmetrical contact is made through symbolic
representation, that existence and identity is confirmed through mirroring -
and that despair and distress can be articulated and made bearable in a more
symbolic and less primitive way than through the largely unconscious processes
of attachment and containment that I have been talking about so far.
This openness is unremarkable for ‘ordinary psychotherapy’,
where the therapist is protected by the ground rules of whatever therapy they
are using (like being an opaque analyst, or a problem-solving CBT therapist, or
a circular questioning systemic therapist) - but working in a therapeutic community does
not give that protection. For a therapist, it is reasonable and relatively easy
to have a "therapeutic demeanour" in a group, but much harder to know
just "how to be" when sitting together at lunch, or playing a game
together. When this rough and tumble of this everyday milieu is avoided by
staff, the openness gets undermined by "us and them" feelings, which can
be very unhelpful in a therapeutic community.
A whole approach to therapy that I have come across in the
past year is based on this sort of utterly transparent communication – where no
conversations about service users even take place in their absence. It is
called Open Dialogue Approach, and it has been developed in Southern Lapland,
in Finland, over the past thirty years. It has the benefit – which we in the
world of TCs lack – of having collected, analysed and published enough outcome
research to be taken seriously. Several NHS mental health trusts are starting
to train staff in it, and I think it is really helpful for our conference here
– and perhaps helping us to think ‘out of the box’ as they say – that Val
Jackson is coming to talk about it to us tomorrow afternoon. Val is in the
vanguard of pioneers in the approach in the UK, having done quite a lot of her
own training in Finland. The approach comes from the same roots in 1960s and
70s critical psychiatry as TCs do – so I hope it will help us to think about, its
similarities and differences to us, and what it has done to get itself
recognised. SO I’m looking forward to hearing about that tomorrow afternoon.
The three principles described so far - attachment,
containment and communication - could apply to different forms of
psychotherapy, in different measure. But the next two are more specific to
therapeutic communities: perhaps they take the developmental sequence through
adolescence into adulthood - and real life - in a way that other therapies do
not. They also provide a radical challenge to the nature of managerial authority,
which I fear is currently being squashed by ever less democratic management
practice.
The term living-learning experience was Maxwell
Jones’s early description of therapeutic communities, and that is part of what
this principle represents. Everything that happens in the community - from who
makes the coffee, to the board games, to the requests for holiday - can be used
to therapeutic effect. A disagreement in the kitchen can be more important than
a therapeutic exchange in a group; it is as much part of the work of a junior
doctor to play rounders or go swimming with the community as it is for him to
formally assess patients' mental states.
This goes beyond openness, in that it requires the sum of
the experience of all the members all the time to come to bear in understanding
ourselves in relation to the human environment. So the meaning of an
individual's existence is as much in the minds of others as in the
physiological or biochemical reality of an isolated person: we are mindful of
others and they are mindful of us. One member of a community is held in mind by
all the others, and they are all held in his mind. In a community where people
are together for considerable time at considerable depth, and often uncertain
definition of where their edges are, this is an almost tangible realisation of
how we are only meaningfully defined through these social processes.
In the old residential therapeutic communities, this
holding in mind was made utterly tangible: no longer a fantasy, but reality.
For 24 hours a day, all interaction and interpersonal business conducted by
members of the community belonged to everybody. In day TC units, other ways are
used to bridge the gaps and ensure that ‘out of sight’ does not mean ‘out of
mind’. The expectation will be to use all aspects of interaction and understand
it as part of the material of therapy. Not in isolation, but in the real and
"live" context of interpersonal relationships all around.
This discourse leads to a position where any separation of
an individual from society or constitution from environment leaves the
definitions empty and meaningless: the very opposite of an individualistic
world-view. Social cohesion becomes the dominant aim; interdependence emerges
through intersubjectivity and its perceived responsibilities - more than by
demanding rights; fragmentation and alienation are reduced through finding
meaning in relationship to others.
In some ways, we take this interdependence to the limit in
therapeutic communities. Each has a different but vital contribution to make to
the health of the whole.
I think we are moving into a world where we can’t do these
things in a way we want to and maybe we always have - a point I will be
returning to in the last section of this talk – and any communities that rely
on whole time programmes with their own buildings and rooms will find it much
harder to survive than those which exist in a much more open and flexible way.
That probably isn’t true for ones where people are necessarily resident anyway
– such as prisons and children’s homes and housing organisations, but others
that only come together to be a TC, I think, will need to find different ways
to do it. The importance of the TC is IN THE HEAD - of which, more later.
And to give us an insight into the world of ‘real world adaptation
of TCs’ we have Clare Richie to come and talk to us on Wednesday morning. Clare
is a commissioner for services for homeless people in London – and she is one
of the people who has been promoting ‘PIEs’ – or psychologically informed
environments. These are units which deliberately use that
difficult-to-put-into-words attribute – which I call the ‘quality of
relationships’ in a context where it would be impossible and unrealsistic to
try running a ‘proper TC’. If I were to put it a little more provocatively, I
could say that this is about making TCs fit for the real world out there - that
we now live in, whether we like it or not.
So, onto the final quin of the quintessence – agency and
empowerment.
In 1941 at Mill Hill Hospital, Maxwell Jones was running a
unit for soldiers suffering from "effort syndrome" (probably called
PTSD nowadays) and he soon noticed that fellow-patients were more helpful than
the staff at helping each other. At Northfield, Wilfred Bion was taken off his
therapeutic rehabilitation wing after six weeks, probably because his
experiment was unacceptable to the military hierarchy. These two locations were
the start of therapeutic communities as we know them in mental health, and they
both made fundamental challenges to the nature of authority. At that time, they
probably seemed countercultural and somewhat subversive, but in many ways they
were ahead of their time - and many subsequent social changes since have
undermined our notion of traditional authority, and made us re-evaluate how it
is now carried and administered. Although most psychiatric providers have moved
from a traditional authoritarian model to a modernist managerial one, to
provide an environment for the development of authentic personal agency demands
a further move – to a world where a dazzling array of relationships and
networks makes any sense of ‘firm ground’ open to challenge. Perhaps it could
be called a ‘postmodern perplexity’.
But for therapeutic communities, this challenge to
authority, and the primacy of the ‘network of relationships’ over any social
hierarchy, was there at the beginning. It’s also close to Jung’s idea that the
unconscious (of patient and analyst) know better where to guide the therapy
than does the analyst's expertise - and
the general belief that most therapeutic impact comes from work the service
user does, rather than the therapist. In
group therapy terms, it is at odds with the models where therapists do
individual work in the group (where group therapy started from), or only offer
group-level interpretations (the Tavistock model). In both of these there is an
underlying assumption that the therapist "knows best" or at least
knows what is going on: information which the group members 1cannot know, or
which is delivered to them under close control of the therapist.
In communities where members are afforded this sense of
personal agency, things are different. An asymmetry and difference between
therapist and patient is accepted, but an automatic assumption of authority is
rejected: members acknowledge that anybody in the group might have
something valuable to contribute to any other member. This is the essence of
therapy by the group, and it deconstructs the powerful ‘us and them’
dynamic. Authority is fluid and questionable - not fixed, but negotiated. The
culture is one in which responsibility for all that happens within specified
limits is shared: members are empowered to take whatever action is decided.
However, a major part of the non-clinical work is to specify those limits and
ensure that the space within them is kept free from authoritarian or managerial
contamination.
Extrinsic authority and rank will come to mean much less
than intrinsic authenticity and demeanour – back to those non-verbal
hard-to-define qualities. Only through this process of experiencing parts of real
relationships, beyond the transference, can a true sense of personal agency
develop. Then action and feeling will have a clear connection to a true core
self, and they are not held by a role or prescribed behaviour.
When members of a community take responsibility for each
other as part of a live and intense process or relationship that really makes a
difference, it is worth infinitely more than a risk assessment, or a procedure,
policy or protocol. It demands that
authority must always remain negotiable - authority is something that exists between
people rather than in individuals or policies. Of course this is not anarchy or wholesale
delegation of responsibility - or an unreal world with no outside references. In reality, we all work within a framework in
which we are accountable for what we do. But what we are currently up against
(at least in a lot of the public service) is a sort of tyranny of American
management techniques – driven only by data and economics, where things only
matter if they can be measured, predicted and controlled. Uncertainty is not
tolerated and human factors – like the quality of relationships – are not
relevant. But we are replacing a linear form of authority with an open, continuously
negotiated – and dare I say more democratic – form of getting things done. Not
all organised in advance by a strict project management process – but allowed
to happen in an organic and emergent way.
But I had better stop my rant there, as I am going off
track for our final speaker’s contribution to the conference. Hanna Pickard is
an Oxford philosophy don from All Soul’s college – and she has been working for
several years with Steve Pearce and the team at the Oxford TC, which is one of
a small handful of surviving non-residential TCs in the British National Health
Service. She has used her philosophical expertise, together with experience of
the TC therapy, to analyse what happens in TCs and construct some rigorous
philosophical theories about why TCs are different, and what is special about
them. She and Steve have published papers and articles about it in, for
example, the British Journal of Psychiatry and other influential places. It
should round our conference off, on Wednesday afternoon, with a very clear and
erudite message that we in the world of TCs have got something important and
unique to offer.
So that is a quick rundown of the main talks that are
happening here over the next three days – but before I finish I want to think a
little about where it is all going. What seems to be in keeping with the times (so
likely to flourish and grow)? and what seems likely to be lost in the Darwinian
struggle to survival that we all face?
There is one more part of the quintessence paper that
we’re not particularly talking about here at the conference – but I think runs
through the whole theme. It is that this isn’t just a description of theory for
some rare and specialised treatment units – which we call therapeutic
communities – but it is about the experiences every one if needs to thrive, and
grow, and survive the vicissitudes of life. This is quite like the difference
between what David Clarke once called ‘TC proper’ and ‘TC approach’ – and what
is now at the heart of the ‘Community of Communities’ (which brings ‘TCs
proper’ together with a common understanding of what they’re doing) and
‘Enabling Environments’ (which is a process to recognise a ‘TC approach’,
wherever it might be happening).
And moving into that area has opened up some exciting
possibilities, and set some impressive initiatives going. First, just to recap
on the process that led from therapeutic communities to enabling environments.
In the early years of Community of Communities – and even before it – we
regularly received comments like ‘this is all very well, but we’d never be able
to be a real TC and meet these standards’ or ‘why can’t you change it to
include our sort of place, and units that aren’t just TCs’ or more dismissively
‘you’re doing this community of communities things for such a small speciality
that it is irrelevant’ or – perhaps most famously - ‘TCs are an evidence free
zone’.
At this time, about six or seven years ago, we were
evolving a set of what we still call the ‘core standards’ for TCs – the things
that other places didn’t generally do, and TCs nearly always do. There are ten
of them, including things like:
· ‘Community members work together to review, set and maintain the
rules' and
· ‘Community members share responsibility for the emotional and
physical safety of each other’.#
So we then decided to hold a series of workshops –
wherever we could really – with TC members to find out what the values were
behind these ten statements. The question we started with was without thinking
about the particular techniques or structures, what are the values behind what
we do in TCs?’ I remember doing it in
some completely different settings – like the TC we know in Bangalore and at
the TC conference in Melbourne I was invited to go to tell them all about
Community of Communities. For me the most interesting thing was how the same
words and ideas kept coming up, wherever we did it – so it was not a difficult
task to derive the value base for TCs, which was again a list of ten
statements. So these are about what we in TCs believe in, but think could be
applied much more generally. Again, I’ll give a couple of examples:
· A safe and supportive environment is required for an individual to
develop, to grow, or to change.
· Each individual has responsibility to the group, and the group has
collective responsibility for everybody in it.
From these values, the team at CCQI wrote standards so
that it was possible to work out whether they were happening or not in a place.
And now remember that this is ANY PLACE AT ALL where people work, or hang out,
or play, or even pray, together. And if they can show us that they do so – in a
way that is rigorous for the Royal College of Psychiatrists to recognise that
it’s true – they are what we now call an ENABLING ENVIRONMENT. The process of
showing it is actually through putting together a portfolio and having it
reviewed by the team – and people often find that the process itself, of
thinking about how they do what they do, for example about how they support
each other, is a very positive thing itself. As if teams come together to
recognise why they are good at being a team, and get even better at it.
Okay – so back to the Darwinian struggle to survive. One
of the facts of it all, in this country at least, is that a lot of TCs have not
survived the last ten years or so – and most of the rest have had a real tough
struggle to survive and not be shut down. I’m not going to go into all the
possible reasons for that, and I’m sure there are very many and it would make a
fascinating research study, but just make the general point that they have not
been able to fit well enough into their own environment. External changes – in
funding, or regulation, or accepted practice, or whatever else, have meant that
many TCs have not been able to change enough to fit with the changes around
them. Others I know have changed too much, and wouldn’t be recognisable to us
as TCs any more – like the Norwegian network of TCs that went along with the
research evidence to reduce their programme where it was’t essential – so
stopped all the social activities and eating together - and completely lost
that intangible quality that makes a TC, and left them as group therapy clinics
almost without a soul – and, from what I hear informally, became much less
appealing to work in - and not able to hold onto some of the more troubled
group members who they had previously helped.
But if this is true of how ‘therapeutic Communities
PROPER’ are struggling to survive, I don’t think it’s so true of the
‘therapeutic community approach’. There are two projects which have really
taken off – and I expect there are many more we don’t know about. These are the
PIPEs and PIEs. PIPEs are ‘Psychologically Informed Planned Environments’,
which is the phrase used for a specific programme being used in the British
Criminal Justice Sector for prison and probation facilities that have
particular training for the staff, and are working towards becoming (or already
are) Enabling Environments with the process which Sarah and Susan and the team
have set up at CCQI. And very successful they are too.
PIEs are ‘Psychologically Informed Environments’ – which
are catching a lot of interest in the housing and homelessness sector. However,
they have been promoted by a different Government department – the Department
for Communities and Local Government – in a much looser and more flexible way
than the prison programme. They don’t necessarily join the Enabling
Environments process, and Clare Richie – who is talking to us on Wednesday
morning – is the commissioner in Lambeth who feels very passionate about their
value. So they have different ways to be part of the ‘extended family’ of what
we’re calling ‘Positive Environments’. That’s a phrase I’m going to be pushing
hard over the next year or so – because it covers all these things that have
the sort of value base that means they have a ‘therapeutic community approach’.
So I’m going to finish off with three thoughts about where we need to go next,
to thrive as a movement - as well as a modality of treatment.
Firstly, we need to think therapeutic environments – or
positive environments – or PIPEs, or PIEs, or EEs, or whatever they get called
– and not just ‘pure TCs’. As a field, we need to start working on how top
apply TC principles more widely. TCs are
a tiny thing in this country at the moment, and after about 25 years of being
involved with them and hoping for it, I’ve finally given up the idea that they
will ever be as influential again as they were in the heyday of social
psychiatry. But, as the world and all the systems around us get more
industrialised and mechanical in the way they treat humans, people are crying
out for positive or therapeutic environments. So TC expertise is just what’s
needed to make ghastly wards and ghastly prisons and many other ghastly places
a bit more humane and user-friendly. So my message for this one is – think positive environments, and make them
happen.
Secondly, we need to think about the ideas behind what we do as a way of containing and sustaining us,
as a movement, rather than the specific structures and exact procedures which
have evolved over the years. Containment
is only ever an illusion. Once we’re out
of that old womb, it’s based on an act of faith. Of course it is much more
secure for us to have bricks and mortar and a written programme, and a manual, so
you know what you are actually doing: but we must be wary of using these things
to build a bunker and hide from the real globalised world that we all now live
in. The therapeutic community – or positive
environment - is going to be safest and most effective of all if it is in our
heads and our hearts, not in buildings or policies or particular structures. Which
means my phrase for this one is the TC
in the head, because that’s where it matters. That might mean all sorts of
new structures and forms – but with these experiences we’re talking about at
the conference as the core.
Thirdly and finally, we need to think of all the other
people and things and movements and organisations that are growing up with
similar ideas. Whether it’s use of social therapy, or alternatives to
medication, or service user involvement, or new types of group homes, or the ‘recovery
approach’ – there are many people sharing and using the same sort of ideas that
were once TC ideas. I don’t think it’s any good for us trying to claim them
back – as if they were our intellectual property. We need to share them out and
invent new things in collaboration with non-TC people. If we take a line like
‘this is the way we’ve always done it, and we know it works best’, we will
become increasingly isolated and irrelevant. As I have already said, I think
the answer is going to be through using the TC in the head wherever and however we can - to make positive environments in what is
currently a pretty negative world…
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