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| Drinks reception and book series launch with 6 titles |
There’s good number of Lacanians amongst them, and Winnicott is staging
an emergence from retirement – and although Bion still plays strong, they
haven’t yet got the rhythm of Foulkes’s numbers…
A weirdly compelling day!
Here's the short talk I gave:
Thank you
very much for inviting me to this – I really believe in what this association
is trying to do, although I’ve been rather nervous in thinking about what I
could write and have to say to real academics and intellectuals in a field that
seems so far away from what I know anything about (which gets less as the years
go by, I do feel). But then I saw Sasha do a talk at the Institute of Group
Analysis a few weeks ago, based on her own research, and had one of those ‘aha’
moments: we’re actually thinking about the same things – that are very
difficult to put words on – but are fundamentally about relationships. I felt
that she was talking about ‘how we find our place amongst others’ – which is
one of the emotional development principles behind a lot of TC work.
The relationships
which we’re both talking about are with the world, with our own culture and
tribe, with our acquaintances, with our family and intimates, and ultimately
with ourselves. As I’m growing into a green and grumpy old psychiatrist, I’d
also say relationship with the planet and nature. As I said at a Royal College
of Psychiatrists event a couple of weeks ago, the aim of our current work to
run therapeutic community programmes in an environment centre is to “connect people to each other and to nature,
to help people to see that there is a life worth living, and on a planet that
is worth living on.” But more of
that later – that is where we are going; we have to get there first.
So, once I
had clicked that we are talking about the same fundamental things, just in
different languages as it were - I felt that I could probably say something to
this audience and in this discussion with my rather awe-inspiring colleagues on
the platform. So I’m aiming to tell you a bit about the forgotten (and I feel
neglected) story of therapeutic communities over the last thirty years or so.
Somebody said, in a large group at an NHS campaign meeting a few weeks ago that
‘TCs are the last remaining vestige of
truly democratic practice in the NHS’. I didn’t know him, but I wanted to
rush across the room and kiss him – but that wouldn’t have been within the
acceptable boundaries of large group practice, of course! However, I do feel
that there is some extraordinary work being done in therapeutic communities,
which is very much in the face of increasing regulation, which is very
individualistically and rights-driven, and experienced as persecutory. The whole
thrust of it denies any importance to interdependence, mutual responsibility,
social cohesion, and group process – let alone what we call the dynamic
unconscious and the whole irrational realm of how humans operate at their best.
Which includes things like spontaneity, holding uncertainty, imagination, and
what I call ‘therapeutic ordinariness’ and ‘creative chaos’.
I won’t
labour this point, but it does feel like we all now live under a public
management tyranny that is based on the ideas of cognitive-behavioural therapy,
with an underlying principle of instrumental rationality. I was looking
for the right words for this thing, and ‘instrumental rationality’ seemed to capture it best – the definition
(Wikipedia, I’m afraid) is "A
specific form of rationality focusing on the most efficient or cost-effective
means to achieve a specific end, but not in itself reflecting on the value of
that end, nor the means of arriving there". So the way we work in TCs is to some extent
an antidote to that way of thinking – although it is becoming increasingly
difficult to protect the space within which the TC can happen. And maybe this
means that we in the TC field – and perhaps wider therapy world - need to
change our tack, rather than keep trying to ‘keep calm and carry on’. And I
think that’s what I’m here to talk to you about – TCs, and the philosophy and
values behind them, being a radical force for challenging the prevailing view
that instrumental rationality is good for your mental health.
My own educational
background is relevant, because – in the days when being a medical student was
paid for by the state and we received a maintenance grant from the county
council – I did an elective third year of two subjects which were at war with
each other: experimental psychology and social psychology. In some ways, the
experimental psychology was a doddle – we had already done half of it in
anatomy and physiology the year before. But in other ways, the critical theory
in the social psychology made me doubt that you could believe anything in the
experimental psychology, for example IQ testing, because of the political
framework it was in. At the very least, what actually mattered more to me (as a
rather confused undergraduate) seemed to the reading we did of Laing and Winnicott,
than of Skinner and Eysenck. And in a way, I have lived in that polarised
professional world ever since – physical sciences versus social sciences, ‘real
medicine’ versus psychiatry, CBT versus psychodynamics, diagnosis versus
formulation, biomedical versus psychosocial, mental illness versus personality
disorder, and perhaps TCs versus the rest!
So, back to
TCs. In the 1950s the British social psychiatry movement was storming the
world. In 1952 the World Health Organisation published the following advice:
'The
most important single factor in the efficacy of the treatment given in a mental
hospital appears to the Committee to be an intangible element which can only be
described as its atmosphere, and in attempting to describe some of the influences
which go to the creation of this atmosphere, it must be said at the outset that
the more the psychiatric hospital imitates the general hospital as it at
present exists, the less successful it will be in creating the atmosphere it
needs. Too many psychiatric hospitals give the impression of being an uneasy
compromise between a general hospital and a prison. Whereas, in fact, the role
they have to play is different from either; it is that of a therapeutic
community.'
And at the
forefront of this movement was the Henderson Hospital, where Maxwell Jones was
the medical superintendent. Maxwell Jones was a respiratory physiologist who
ran a programme for battle-shocked veterans at Mill Hill Hospital in the Second
World War, and started to realise that they were better at helping each other
to get over what we would now call PTSD, than he was. He was giving them
lectures about how their breathing makes them panicky, but – in the time
between lectures as it were – they were sharing the emotional meaning of their
symptoms with each other. So when he set up the Henderson after the war, that
was the principle it was based on. An anthropologist called Robert Rapoport did
a detailed ethnography on it, resulting in the book ‘Community as Doctor’ –
which boiled it down to four themes: democratisation, permissiveness, reality
confrontation and communalism.
·
Democratisation:
every member of the community (all patients & staff) should share equally
in the exercise of power in decision making about community affairs
·
Permissiveness:
all members should tolerate from one another a wide degree of behaviour that
might be distressing or seem deviant by ordinary standards
·
Reality
confrontation: patients should be continuously presented with
interpretations of their behaviour as it is seen by others, in order to
counteract their tendency to distort, deny or withdraw from their difficulties
in getting on with others.
·
Communalism: there should be tight-knit, intimate sets of
relationships, with sharing of amenities (dining room, etc), use of first names
and free communication
Although
these made Henderson famous throughout the world, Maxwell Jones didn’t like
them – and nor do I. Not because they are wrong, or it wasn’t good research,
but because they don’t capture that ‘essence’ that the WHO was talking about.
Apart from perhaps communalism, they are very behavioural – and don’t at all
capture the quality of experience and particularly the quality of relationships
that members of a TC – both staff and service users – actually experience. A
more modern version of ‘TC theory’ that is now quite widely used is much more
inclusive of different types of TC (apart from just the Henderson model), and
is based on five necessary experiences for emotional developmental, and how we
recreate them in a TC: attachment and feeling a sense of belonging; containment
and experiencing emotional safety; openness of communication in a
culture of enquiry; inclusion and interdependence by finding our place
amongst others, and empowerment or personal agency through finding an
authentic sense of self. But that’s a different talk for another day.
We all know
that everything changed in 1979, and I’m sure that most people here can
articulate that much more eloquently than I can. But one of the consequences in
our corner of the mental health world was that selfish individualism (for want
of a better word) made TCs less and less acceptable. I think the same is
probably true of group therapy in general. In their heyday, the 50s, 60s and
70s, every psychiatric hospital in the country had a residential TC, some whole
hospitals were run on TC principles, and community day centres were run as TCs.
Then everything changed as the wind came from a very different direction – and
without giving a grizzly account of all the closures – there are now precisely
no residential TCs in the NHS, the non-residential day units have been reduced
from 5 to 3 to sometimes one day per week and most of them shut altogether; the
latest one I have just set up in Slough is just two hours – the rest the
‘patients’ do themselves and elsewhere, and I’ll say more about that later. There
was a brief respite during the Department of Health’s National PD Programme
between 2002 and 2011, when several new non-residential TCs were set up in the
NHS, but most of those are now being closed because they don’t fit into the
IAPT programme – which is where PD now sits in the Department of Health policy
terms.
Yet we pay
seven million pounds for new fences at Broadmoor, and send ‘difficult’ patients
to locked wards in the private sector which cost £250,000 per year, where they
receive a trivial amount of trivial therapy, and have quite expensive and
extremely individualistic mental health services which Sue Bailey, described as
a ‘car crash’ as she recently retired from being president of the Royal College
of Psychiatrists. Our policy priorities have certainly changed! But I must stop
ranting like a grumpy old psychiatrist, and get back to TCs.
It is true
that a few of the TC principles from the social psychiatry revolution live on,
though in a very attenuated and pale form. Examples include service user
involvement, community meetings on some of our ghastly inpatient wards, and
maybe some hope and creativity in parts of the contemporary recovery movement.
But these are grounded in the soil of marketised and commodified mental health
care, and lack the radical roots of people really
taking responsibility for themselves and each other and challenging the power
base of the system. They are still fundamentally paternalistic.
But I want
to turn to where we are right now in 2014. I think a tide is turning and there
might be opportunities for a new form of TC value base to have a wider
influence – hence the link to the ‘enabling society’ of our title here. We have
been doing a lot of work at the Royal College of Psychiatrists since 2002, when
UK TCs were probably at about their lowest ebb. With lottery money, formed a
quality improvement project called ‘Community of Communities’ – and we’ve had
just under a hundred members for the last twelve years. At a formal level, it
works just like any other audit or even action research cycle – decide and set the
practice standards together – review them – action planning – make changes –
start all over again. But where it differs is the fact we insist on communities
visiting each other, and being visited, each year – not for an inspection
process, but for support and nurturance from like-minded people. And of course,
it includes both services users on these visits, as well as staff of all
seniorities.
From this, about
five years ago we distilled a set of ‘core TC values’ as well as the more
prosaic ‘service standards’. The service standards define what TCs need to do,
and most other places don’t do, but the core values are not TC-specific at all:
they are as close as we have yet got to the ‘essence’ that the WHO directive
identified. And with that set of ten values we have established a different
sort of quality process – what we call the ‘Enabling Environments Award’ –
which is as applicable to a prison or office or school or church or business as
it is to a therapy unit. It’s going down very well in the criminal justice
sector – and we’ve just had a launch of it for the health sector, with
endorsement by RCPsych for it as a potential solution for lack of compassion in
the NHS, in the wake of the Mid-Staffordshire crisis.
Finally, a
few wilder ideas on the fringes of enabling environments – which are to a wider
RCPsych initiative called the ‘Positive Environments Framework’, to our tiny
social enterprise called ‘Growing Better Lives’ and the Institute of Mental
Health in Nottingham’s ‘Social Futures’ centre. These are just vague threads at
the moment – and I have no idea if they will come together or not, but quite a
lot of us are trying…
Greencare is
the inclusion of nature in therapy programmes – and combined with TC-type
groups which our social enterprise runs in a yurt at an environment centre between
Slough and Uxbridge, they seem to be very acceptable and effective. We’re also thinking
of using permaculture and transition town ideas to give it a more than just
‘group therapy plus horticulture’ by itself.
A
psychiatrist colleague in Columbia, Alberto Ferguson, is in his seventies and
has run TCs all his life. He has experienced a similar TC trajectory to what
has happened in this country: first residential, then day units, then without
dedicated premises. To me this shows that ‘the TC in the head’ matters more
than the TC in the building – and in his small town near Bogota there is a
widespread understanding of TC-type social cohesion. Ex-patients now run groups
there to bring together families and individuals involved in the drug
conflicts, to make reparation and have the different factions come to some
understanding of each other.
So, to
finish off, and take these ideas back to our 2-hour per week TC in Slough. The
phrase a few of us are putting about – perhaps a bit mischievously, but only
half tongue in cheek – is ‘Slough as a Therapeutic Transition Town’. Instead of
the ‘TC’ being seen as the two hour group we run every Tuesday, that is just
one hub for all the other therapeutic things people can plug into: from
mindfulness and psychoeducation groups run by the NHS psychologists, to a very
successful mental health choir, to greencare in our yurt, local sports for
health groups, a therapeutic digital photography group with Arts Council
funding. People’s experience is then of the whole range of activities -
delivered by all sorts of different organisation – as being THE therapeutic
community. Yes, I am talking about poor old Slough – if you believe that is
possible, you’ll believe anything. But we’re going to try!
