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| Khiron House |
This week I started a new part-time job with the grand title of Medical Director of Khiron House. It is a residential treatment unit for people who have suffered from psychological trauma, including those with what can get diagnosed as 'Complex Post-Traumatic Stress Disorder' or 'Complex Trauma' as well as 'Borderline Personality Disorder' or 'Emotionally Unstable Personality Disorder'.
I have written a small paragraph about the relationship between these diagnoses and the best way to treat them for their newsletter, so here is the expanded version.
It is a talk I gave twelve years ago, in 2003, which seems just as relevant in 2015- and reflects the view I still hold, that the treatment programme, therapeutic environment and therapeutic relationship is much more important than the niceties of diagnosis or the rivalries and turf wars between different professions.
With thanks to Sandy Bloom, whom I quote extensively, and was an inspiration to me at the time I originally wrote it
Development of Borderline
Conditions: the Trauma of Loss, Neglect and Abuse. Is there a difference
between borderline personality disorder and PTSD?
Rex Haigh, Consultant Psychiatrist in
Psychotherapy
Thanks etc.
It’s excellent to be asked along to come and share ideas in a
forum like this – where we come from various different background and trainings,
and are involved in different ways of treating many of the same people. But
more than ever at the moment, I think we are in this together – so I hope I’ll
be saying things on which we can build a shared understanding, rather than an
unhelpful rivalry.
But Suzanna’s given me a whole hour! I hope I can keep you
awake – I’ll start and finish with a bit of a rant so at least you should get
the first bit and then wake up for lunch!
Introduction
I’m going to deal with my title the other way round – Suzanna
and I came up with half of it each and that’s why it’s so long – I’ll leave you
to work out who chose which bit.
Of course there is a difference, but what is far more
important is the similarity – and how services are just not geared for the
millions of people with psychological injury – and what that says about the
wrong emphasis we have in so many of our modernised, individualistic and
paternalistic models of mental health care. It’s a system problem rather than
individuals – everybody is working extremely hard in a system where many staff
are prevented from doing clinically meaningful things – like talking to
patients – by the burden of administrative diktats. In the name of accountability, and openness or
transparency, we are so immensely preoccupied with governance, with
targets, with protocols and with bureaucracy that our mental health services
have almost completely lost sight of who we are really accountable to, and should really be open to – the people our services are there for, the human beings
we are treating as a production line of faulty machines, who actually have
feelings, thoughts and concerns that are not so different from our own. But… more
of that later.
[slide]
The track I’m going to follow, if it helps to give a bit of a
map, is to look at the diagnoses and how they relate to the rudiments of trauma
theory – on which I must say I am no expert – and then look at other theories
of just what borderline personality disorder is, and present a broad-based developmental
model. This is something we use in therapeutic communities which is really
based on a wider concept of trauma, and then the treatment implications. At the
end, I’ll put that into a framework of critical theory – which I hope will
illustrate how the scientific, technical and administrative structures we have
may be necessary for good mental health services but are certainly not
sufficient.
So, let’s start with diagnosis.
Diagnosis
I won’t say much about diagnosis itself, except to say that
sociologists have well noted the way in which it removes information in a
formulation or assessment, rather than adding anything. Of course, it is useful
shorthand, but it oversimplifies things in a way that, under pressure, can
leave us basing treatment and management on just the diagnosis, and the
protocol. That may be good practice for the paramedics diagnosing an acute heart
attack which needs an anti-clotting injection immediately, but I think it is
rarely good enough in mental illness. One of the effects is to create an
illusion of certainty, of hard scientific truth – which may have superficial
validity, but does nothing to address the areas of internal experience and
meaning, which are rather important to most people. And of course, it’s the
same process where we end up talking about “the depressive in room 6 on
buttercup ward” or “the schizoaffective who was discharged last week”. The
process defines a relationship with an “expert” making the diagnosis and a
subject receiving it, and it fails to recognize individual differences in
favour of uniform and standardised processes.
But that said, the act of diagnosis does concentrate the mind
and have useful communicative functions. So here are the current accepted
definitions for PTSD and BPD.
Here is the PTSD definition: [slide]
I won’t go through it in detail (already done?), just to
emphasise the different sections – (A) definition of the traumatic event
itself; (B) intrusive memory of it; (C) avoidance phenomena; (D) increased
arousal and then (E) about timing – and there are further criteria for acute
and chronic, 3 months I think, and (F) that it has a significant effect on
functioning. Just to particularly note the presence of an explicit CAUSE
(here in A). I’ll be coming back to some
implications of this.
And here is Borderline: [slide]
It starts with a general phrase about the parts of a person’s
life it affects (relationships, self-image, mood and impulsivity), says it
starts by early adulthood and then requires five of these nine be present:
§ Avoiding abandonment
§ Unstable and intense relationships
§ Unstable sense of self
§ Potentially self-damaging impulsivity
§ Self-harm and threats of it
§ Unstable mood
§ Chronic emptiness
§ Anger problems
and…
§ transient psychotic or severe
dissociative phenomena
There appears to be minimal overlap here – but this is
because the one for PTSD is framed in a way that includes the cause and linked
symptoms, while BPD’s definition is as objective as possible a description of enduring
personal characteristics. Chalk and cheese, if you like, by trying to
compare different types of definition. Axis I and axis ii of course. But it
also carries profound legal consequences in PTSD – for an internationally recognised
condition with an internationally recognised causal process gives legal
certainty which few other non-organic psychiatric disorders can match. And
there are numerous social consequences of having diagnoses decided as part of a
legal discourse. This may be helpful for clinicians, patients and lawyers – but
I’m not sure that defining diagnoses by litigation helps us much with
thoughtful and reflective practice!
Borderline has also only been elaborated in the last two or
three decades – and really by rather acrimonious debate about whether it exists
at all – which continues with minor academic skirmishes now, rather than full
scale conflict. When I learned my psychiatry as an SHO about 15 years ago, it
was pooh-poohed as a serious diagnosis, and was certainly something you would
get a hard time for, if you mentioned it in the examinations! You were allowed
to mention it to some friendly consultants, as long as you put it near the
bottom of your list of possible diagnoses.
Nick Manning, a social policy academic who I am
currently working with in Nottingham, takes
the line that the creation of the Borderline Diagnosis – and the work done on
it since - is an act of territory-claiming by science and medicine. Borderline UK, the
national user group, like it because it gives them a shared understanding of
why they are like they are, and a lever to argue for better services. The
upshot of the conflict is that it is in DSM-IV, but without any mention of
trauma or causes – because professionals just cannot agree on that. I’ll be
coming back to this.
But the point for us as clinicians is that there are many
people with these characteristics who are badly served by mental health
services, yet cost a fortune in repeated and prolonged hospitalisations,
frequently having identifiable episodes of depression, panic, psychosis and
other axis one conditions. So without much doubt, I would contend that they are
the business of mental health services. And the NHS guidance which was
published earlier this year – “Personality Disorder – no longer a diagnosis of
exclusion” now makes that a matter of public policy.
I’d make the parallel with ichaemic heart disease – like PD,
it is no longer a condition where people need to be treated just for their symptoms,
like angina, and their heart attacks when they have them – but it is something
they have all their adult lives – and which is amenable to amelioration and
harm-reduction in individuals, and prevention
in a population. As you should see when I talk about a developmental model of
personality disorder, prevention is something quite close to what good schools
do as part of the citizenship curriculum, churches and community groups do as
part of their neighbourhood work, emotionally literate companies do as part of
their management policy – and something that is done very badly by most of the
health service. Of course, the most corrosive and destructive consequences are
at the severe end of the spectrum and come from lifelong poverty, inequality
and other forms of social alienation. But I hope that will make sense when I
have explained how emotional developmental needs (which we all have) can be
formulated.
But let’s come back to how this relates to trauma with
another analogy. Trauma is easily understandable if a single event happens to
somebody, for which they need the right conditions to recover. If we consider a
broken arm, the type of treatment will obviously depend on the nature of the
trauma. With a greenstick fracture in a child, which is like a hairline crack
in a soft bone, it just needs a bandage and gentle handling for a little while.
Usually a simple broken arm needs a plaster cast to hold it in place for six
weeks, until it has knitted together and solidified. If it’s more complicated,
like a compound fracture which has broken the skin, it needs other thinks like
soft-tissue surgery and antibiotics. Even more treatment would be needed in an
unstable fracture, where it will never heal unless it is held together with
pins and plates and rods and external metalwork. Well, I think by now the
analogy with broken bones is creaking (and getting a bit arthritic…) – but the
point is that a single definable trauma will be treatable by different
means, depending on whereabouts it struck and how much damage was done.
But what about trauma that goes on and on – or is more a lack
of good input rather than a particularly bad experience? The first – when it
goes on and on - is like a deformity you get early in life or are born with,
and gets more complicated and disabling later in life if it goes untreated:
like scoliosis (spine curvature) or club foot. Scoliosis is a good analogy
because the pressure on the spine, as a child starts to walk is like repeated
or continual trauma that is putting the joints of the spine progressively more and
more out of line. The second – lack of a good enough environment - leads to
“failure to thrive” in children – where they fail to grow enough, without any
physical reason being detectable.
The point I want to make is that all sorts of things can be
traumatic – but if they are continuous and subtle, or hidden (perhaps because
of shame or learned helplessness), they will not be easy to detect. In the
literature we provide at Winterbourne and discussions we have with personality
disorder referrals, we give the list as trauma, abuse (which can be physical,
sexual or emotional) then neglect, deprivation and loss. As well as all being a
sort of trauma, there is a good argument to be made that they are all actually
loss – whether it is loss of something psychologically needed (like ability to
trust when somebody is secretly sexually abused), or loss of something that you
have never had (like a child growing up without the experience of ever being
loved), or loss of security and sense of the world being a safe place as a
consequence of an overwhelming event.
Now I’m going to move on to how others describe it in terms
of trauma theory, and then move towards some other – but recognisably similar –
descriptions of borderline PD.
Trauma theory
Sandy Bloom is a psychiatrist and psychotherapist working in New York setting up “sanctuary”
programmes and staff training for socially disadvantaged and delinquent
adolescents. She is interested in TC work in this country, as it uses a similar
technique of creating a suitable therapeutic environment. After describing
simple trauma, she says:
“Problems arise, however, when trauma does not stop, or when it is too
severe for anyone to deal with, or it is a secret trauma who nobody else is
allowed to know about.
[slide]
In cases like these the gap
between everyday reality and traumatic reality can continue to increase. The
individual cannot deal with the traumatic experience because it continues to
pose some kind of life threat and the culture cannot or will not help the person
come to terms with the experience. The person is unable to establish a coherent
and consistent sense of identity because the traumatised self is directly in
conflict with the normal self. He or she is unable to establish a comprehensive
meaning system or philosophy of life because they harbour too many internal
contradictions. Under these circumstances, dissociation becomes a way of life
and disintegration of the personality continues”
So, although she rarely uses the “personality disorder” label
in her writings – she is describing, from an eclectic / CBT background, exactly
what psychoanalysts have been using much more rarefied language about, for over
a century. She goes on to elaborate:
“Less understood [than the trauma of a single awful event] is what happens
to children’s growing sense of identity when they are exposed to repeated and
overwhelming stress. In these cases, their identity does not solidify around a
solid core. Instead it remains fragmented, and the fragments are separated from
and inaccessible to each other. The end result of this chronic dissociation may
be a serious inability to understand or contend with consensual reality. On the
surface, some non-violent forms of sexual abuse may not even appear to be
traumatic. It is not necessarily the pain or terror that is the most traumatic
aspect of a childhood experience but the betrayal that is so damaging. Children
are helplessly dependent on their caregivers. In order to survive, they must
trust those on whom they depend. When those caregivers turn out to be
untrustworthy, children must deny this reality. Often this betrayal is denied
or minimised by the perpetrator as well as by other family members and other
members of the child’s community. This means that the experience of individual
reality becomes increasingly divergent from cultural reality. The individual
symptoms are related to the child’s or adult’s attempt to individually make
sense of distorted reality. The child, in such a situation, must make a choice.
Deny your own individual reality and fit into the culture, or defy the cultural
beliefs and end up alone and eccentric or even “crazy”. It is an impossible
choice.”
This has strong echoes of some of the postmodern writers,
like Wilke, who says that borderline is not a condition which needs treating in
the same way as other illnesses, but is a communication of alienation which
must be heard, and a way of experiencing reality which needs to be understood.
And – if there’s any antipsychiatrists lurking I the audience – this is only
inches away from what RD Laing said when he wrote about psychosis being
understandable (Divided Self) and madness being as much a problem with
society’s view of reality as the individual’s (Sanity, Madness and the Family).
But … Going back to a
more classical view of trauma – based on learning models and fight/flight
responses, Bloom makes what I think is the essential leap into subjective
experience and the need for relationship and interdependence:
“The alternating symptoms, of avoidance and intrusive flashbacks or
nightmares, are the two interacting and escalating aspects of PTSD. As they
come to dominate traumatised people’s lives, they feel more and more alienated
from everything that gives human life meaning – themselves, other people, a
sense of direction and purpose, a sense of community. It is not surprising then
that slow self-destruction through addictions, or fast self-destruction through
suicide, is often the final outcome of these syndromes. For other people, rage
at others comes to dominate the picture. They are the ones who end up becoming
significant threats to the well-being of the rest of us”.
We have come up with a label for those particular ones in
this country – or our policy-makers have – and it’s “DSPD”, dangerous people
with severe personality disorder. Apart from where it has got money attached, I
think most people are moving back to calling it Antisocial PD, or severe
Antisocial PD. But to return to Bloom,
and how she started to recognise borderlines, she describes some of her patients:
“Many victims of sexual abuse had serious psychiatric problems, and yet
they were not psychotic. They often self-mutilated themselves, frequently on
their breasts or in their pelvic region, as well as on their arms and legs.
Many had been raped as adults as well. They tended to have extremely disturbed,
abusive relationships. Their sexual adjustment was often very distorted.
Commonly, they were either totally abstinent or promiscuous without ever truly
enjoying it. They had multiple physical complaints and surgical procedures,
often with negative findings in the face of severe and chronic pain. Eating
disorders were very common including overeating, alternating with bulimia,
interspersed with episodes of starvation, and a preoccupation with body image. They
often had weird psychotic-like symptoms and heard voices or heard things that
were not there, or acted in bizarre and spaced-out ways. They had established problematic
relationships with people in their social lives and then with us. At first they
were very good and compliant, the ideal patient, and then – at the slightest
sign of rejection – they became unreasonably hostile, angry, rejecting and
inconsolable. They were either all-good or all-bad, as were their
relationships, as was the entire world. They shared symptoms very similar to
other trauma victims. They showed physiological hyperarousal and
hypervigilance. They were unable to self-sooth or modulate emotional arousal.
They had difficulty managing anger and as a consequence often failed to self-protect
adequately while acting aggressively towards others.
So here we are seeing a mixture of the DSM features of PTSD
and Borderline, plus several others too – classically the arousal and
vigilance, but also the various emotional instabilities characteristics of the
borderline definition. She now goes on to explain the causes and consequences
of the psychotic and dissociative features:
We began to understand that much of what we had called psychotic symptoms
were actually the dissociated memories of previous experiences. The
hallucinatory voices they heard were related to the voices and sounds
surrounding the sexual abuse situation. The hallucinatory visions were
fragmentary memories of the trauma. The paranoia was fear combined with
temporary inability to separate the past and the present. The apparent lack of
awareness of their own behaviour and the subsequent failure to take
responsibility for it was related to the fact that they were relatively unaware
of much of what they did in another state of consciousness. The self-mutilation
was a form of self-control, a problematic form of self-soothing, an addictive
behaviour that had worked in the past under severe stress but had taken on
secondary meanings and uses over time.
Then she goes on to write about the effect these patients had
on her and her staff:
We had termed these patients “manipulators”, “attention-seekers”,
“hysterics” and “borderlines” – all a way of saying that our helping efforts
were thanklessly frustrated.
And then a dawning realisation that the way they had been
conceptualising these people’s difficult behaviour was the problem, and not the
solution:
When we began to understand that these patients had suffered extremely
abusive and depriving situations as children, had developed certain coping
skills to survive, and had remained arrested in an earlier stage of development
because of an extremely damaging, and often very secretive home life, our
attitudes towards them changed dramatically. We became less offended, less
threatened, by their symptoms. Now we could understand what they were doing,
what they were trying to tell us about their past lives. And we could explain
back to them what it was all about, why it all DID make sense, given the
context. Once they were able to understand, they were able to begin the long
process of gaining some compassion for themselves and their own suffering.
Using this bridge of compassion they could start the process of rebuilding, of
starting to mature again from the point where their growth and integrity was
stopped.
So here she is saying that what made the difference is
listening to the patients’ communications (at all levels – presumably including
when they are silent and uncooperative, or angry and attacking) and
understanding that it was the consequence of trauma. Which is a good point to
move to other accounts of BPD.
Borderline personality disorder
Over 200 years ago, Sydenham, of Sydenham’s Chorea fame, hit
the nail on the head when he said:
[slide]
“They love without limits those whom
they will soon hate without reason”
Gunderson describes borderline people as those who feel they
have been treated unjustly, have not received the right attention or
protection, and are angry at this. Here is a table summarising and paraphrasing
Gunderson’s ideas.
[slide]
Once these people are
young adults, they look for somebody to make up for these deficiencies, and
when they think they have found them (this may be intimate partners, therapists
or others) they form an intense relationship based on very high expectations,
and at the moment of disappointment – which almost inevitably follows such high
expectations – they feel confused and abandoned. This includes rage, despair
and self-hatred at causing their own rejection – with a strong impulse towards
self-destructive and suicidal behaviour. In others, it can cause guilt to be
felt, or protective behaviour, at their own perceived deficiencies – a process
we call projective identification. But in a different model, if any of you know
CAT – cognitive analytic therapy – this mixture of consequences and binds is
exactly what goes into a reformulation diagram.
[slide]
In a forthcoming book about treatment environments for
borderlines, an Italian psychiatrist, Aldo Lombardo,
says:
There are simply two core deficiencies – no control of frustration, and inability to trust
others. These and all the symptoms – anxiety, depression, criminality, paranoid
ideation and self-harm in its many forms (including drug and alcohol abuse, promiscuity,
overdoses, cutting, and eating disorders) – can be cured by the borderline
person him or herself if they have a programme of therapy in which to develop
sufficient ego strength to develop a core experience of identity.
Then he goes on to describe how this can allow “total
transformation of the individual”.
But this is hard work - the Seligman experiments on animals
in reversing learned helplessness have shown that it takes up to two hundred
attempts of showing them that they won’t get the electric shocks and that “the
world IS a safe place” before they learn it and believe it. There is no short
term therapy that can alter what is a physiological, maybe even neuroanatomic,
fact. Dragging people out of their metaphorical cages (like Seligman did with
the animals who had become helpless at trying to avoid the electric shocks) is
a difficult task and few helping professionals have the patience to last
through two hundred potential trials, and nor does the health care system. But
– as an aside – I would propose that people who have been through that process
of recovery themselves, and been dragged out of the cage two hundred times, may
be just the ones who DO have the patience and dedication and care to do it –
and I think that is exactly what happens a lot of the time n a good therapeutic
community.
Just to bring a couple of other writers into the frame, Peter
Fonagy describes this process as “disorganised attachment” which leaves an
individual without a theory of mind. They have no understanding of the thoughts
of others.
Briere, who is a well-renowned Californian traumatologist who
argues for the “complex PTSD” concept really sees borderline as the consequence
of unrecognised and untreated PTSD.
And Winnicott saw the absence of a secure base as the
foundation of the “antisocial tendency”.
The last point I want to make about trauma is how our systems
and practices can be experienced like the repetition of an earlier trauma. When,
for example, somebody expresses suicidal thoughts and gets detained under the
MHA, the thought may well not have been an expression of intention – but a
communication of distress. And this is an impossible-to-get-it-right bind for
clinicians: the only apparent options are to take a risk, or act defensively.
If one chooses to take the risk – it might be right, but we will have to carry
it, and be able to defend the decision, not knowing for sure until we hear
later – maybe much later - that patient is safe. And with borderlines who may
feel abandoned and not taken seriously by a clinician who has a slightly brusque
manner, or smiles in the wrong place, or forgets a small detail of their
history, that risk is a real one – self-harm may well follow, and quite
possibly an accidental suicide. On the other hand, by taking their rights away,
it will either feed an unhealthy dependence (with a possible long and disturbed
admission ahead) – or be something they feel hurt and devalued by – in which
case they may well act angrily and destructively. So an act of professional
taking-care, maybe done somewhat defensively because of the pressures in the
system to not tolerate any risk, has repeated their developmental experience of
over-reaction, inconsistency, or not being listened to. It feels like the same
thing which left them unable to form trusting and fulfilling relationships is
happening again. The trauma is being re-enacted in the transference, and it is
about the dynamics of POWER. We have to handle that power so very carefully in
these situations – and often cannot get it right whatever we do with the
resources we have.
The other solution – which is not available immediately at
the moment in Berkshire – is to have an already established “safe space” for
people in this sort of crisis to have their distress heard and their turmoil
understood non-judgementally, and probably substantially by others who have
been through it themselves. I’ll just give a quick example of my favourite
service on earth – the Open Psychotherapy Centre in Athens.
When they receive a call from somebody in distress, they
immediately call a crisis meeting and assemble a “flying squad” of four: not
people specifically on-call, just those able and willing to go when they have
heard what the crisis is about - a psychiatrist, a non-medic, and two patient
members of their therapeutic community. They go out to the home of the person
in distress, talk to everybody for a couple of hours, and decide together with
the family who needs help, and which bits of their therapeutic programme would
help. (The programme there is a kaleidoscopic collection of different groups of
different depths and type and intensity). That person (or possibly people) then
join the programme, and plan their “care pathway” through the different
therapeutic opportunities – which might be for a few weeks of focused work or
several years of deeper more intensive group therapy. There are no beds – and
some of the most psychotic and personality disordered individuals are contained
more safely than as inpatients in the state service, and get something actually
therapeutic, rather than sterile, empty, arid, and case-managed without any
therapeutic core to the work. In my view, this Athens-type service, with all
its user involvement and lack of bureaucracy, is what CPA should feel like, and
the new crisis, treatment at home and assertive outreach teams should be
modelling themselves on these sorts of ideas. With sufficient managerial
support (particularly for training) over the long period it would need to
develop, I think it should be possible for it to be a set up as a genuinely
therapeutic environment IN THE COMMUNITY – dynamically managed as a clinical
network of services. But that’s a talk for another day - back to the theory of
personality disorder now.
Developmental model
What I want to propose is a simple theory
that is a framework to the importance of the patients’ experience in determining
the treatment they need. I believe that the internal experience is what
is changes people - in the same way as our experience of life as we grow up
makes us much of what we are. It will use some sociological ideas, take some
of the psychoanalytic concepts of object relations theory and borrow from the
ideas of group analytic psychotherapy. It’s a way of putting several different
theories on a map, which is centred on the experience of the patient.
It is an overlapping sequence
of five linked ideas - five concepts describing the essential qualities of a
therapeutic environment.
[slide]
The way I have put them
together is also a progression, a developmental progression - from the primitive
vulnerability of attachment, through both supporting and
controlling aspects (maternal and paternal if you like) of containment
-- to the social interaction of communication.
Note how communication skills are always emphasised as if we can just be told
to “DO” them – I am saying that other things need to come first. Then, after
communication, onto the adolescent struggle of involvement and
the adult and empowered position of agency - finding the self
which is the seat of action, and for our patients to deploy their own power and
effectiveness.
But before that, I want to think how it
fits alongside biomedical models of personality development - as I don't
believe it is in conflict with them. Both are relevant, and completely
intertwined.
Emotional development - primary and
secondary.
In this theory, emotional development is
something that happens to all of us. It is the sequence of necessary experience
to end up with a normal personality. Of course, nobody's personality is perfect
- but for most of us, our development has been "good enough" (as
Winnicott would say) - so we survive in a reasonable way most of the time. But
some people end up with personalities that mean they have considerable
difficulty understanding themselves, each other or the world. They have trouble
in much of their dealings with what we call reality: like education, employment
and general functioning. I have already told you how Sandy Bloom sees this as a
consequence of repeated or unresolvable trauma. In object relations language,
these people lack object constancy, relate in a part-object way and live
continually through intense transferences. In psychiatric terms, they have
personality disorder and an increased risk of episodes of mental illness.
Really, borderline is only part of it, but it is the part we are dealing with
today.
Is it genetic or environmental? Nature or
nurture? I want to argue that the question is irrelevant, because it is more complex and unpredictable than you
could ever analyse, and in a way it is all of both – and maybe more as well. A child is born with a
certain genetic makeup, and history of nourishment, space, oxygenation and
chemical milieu in utero. Before birth, these have an almost total effect on
what sort of brain and body he or she has. Some children are born with much
more difficult constitutions than others: more needy, we could say. For
example, a child with certain random genes, severe anoxia at birth or exposed
to much alcohol in utero will have a different brain to a luckier child. And
some of those children will be "more difficult" - it will be harder
to meet their emotional developmental needs.
[slide]
After birth, what happens to every
child is development. For the lucky ones, as long as they have a "good
enough" parenting, they will emerge well-adjusted. The constitutionally
disadvantaged ones may come out OK if they have extra input for their emotional
development - maybe that includes professional help. But any child who has a
bad experience of emotional development will end up at risk of having an unhelpful
view of themselves, other people, and the world - in other words, a personality
disorder. By bad experience, I mean the things I have already mentioned – neglect,
deprivation, abuse, trauma, severe loss.
Some with a fortunate or strong
constitution may be protected, and able to cope fairly well as adults, because
they have some good relationships to help develop a less distorted view of
themselves, others and the world. Those who start life with a congenital
disadvantage are very much likelier to suffer a severe impact from inadequate
emotional development. Here is an oversimplified representation of this.
[slide]
And to make it more complicated still -
and even more impossible to separate out the nature and nurture effects - both
aspects (what we are born with, and environmental conditions) are continuously
variable, and not simply "good" or "bad". Environmental
conditions (including how much a child feels loved) also change over time. And
I think modern neuro-imaging and neuroscientific techniques support this idea
by showing us that environmental events can have an impact on brain structure
itself. And of course, it works the other way too. The way a child behaves -
because of its brain maybe - will have an effect on, for example, whether it is
punished or comforted. So I think it is far too complex to ever say
reductionist things like "personality disorder is 65% genetic" - it
is never possible to separate them
like that.
To go even
further, we can add the effect of human agency at every point – meaning we
all make conscious or unconscious choices that may be adaptive or maladaptive
at every decision point in our lives. These will have an impact on our
thoughts, feelings, behaviour and subsequent choices – in a systemic way with
multiple dependent and independent variables that is closer to chaos theory – than
this simple 2 by 2 table. For example, ideas such as “sensitive dependence on
initial conditions” (as the butterfly effect is properly known) and the
complexity of what is called “deterministic nonperiodic flow” (from when they
were first trying to work out the equations to define unpredictable events) –
seem much closer to this than statistical techniques like regression, however
many variables sophisticated computer programmes can now handle.
So emotional development is something that
needs to be considered for everybody - not just for those who end up with
severe and incapacitating difficulties. And what I have described is what I
call PRIMARY EMOTIONAL DEVELOPMENT.
[slide
- back]
By that, I mean what happens - or largely
happens – or should largely happen - as a normal part of growing up. So
constitutional make-up + primary emotional development = personality. And I was
taught as a medical student that personality + stress = neurosis (except we
call it symptoms nowadays). Putting those two together gives constitutional
make-up + primary emotional development + stress = symptoms. And the one I work
with, and want to concentrate on here, is the emotional development.
[slide]
Psychotherapy, and therapeutic communities
in particular, offer the opportunity to re-experience emotional
development which I call "SECONDARY
EMOTIONAL DEVELOPMENT". Hopefully, from this, people can gain
experience that leads to better adjustment, and less likelihood of breakdown
with mental illness – in other words, the impact of their genetic and
constitutional makeup, and external stress, will cause less distress and
symptoms to them, and hopefully to those around them.
So, back to the developmental sequence. I
am saying that the five necessary experiences for a satisfactory emotional
development are
• attachment (feeling connected, and belonging)
• containment (feeling safe)
• communication (feeling heard, in a culture of
openness)
• inclusion (feeling involved, as part of the
whole)
• agency (feeling empowered with a solid sense
of self)
Now I will just spend a minute on each to
explain its roots, and how we try to recreate it.
[slide]
Attachment
All
individuals start their lives attached: umbilically, within the mother and with
the blood of one flowing right next to the blood of the other. At birth, this attachment is suddenly and
irreversibly severed: it is the first separation and loss, with many others to
come later. How well the emotional and
nurturant bond replaces the physical one was classically described by Bowlby.
He describes problems resulting in anxious attachment or avoidant attachment
- and this, plus subsequent developments
of attachment theory, have been well verified by experimental and clinical research;
and of course prominent in that is the local work by Peter Cooper and Lynne
Murray. But other writers have said it in different ways too. Balint's
"Basic Fault" is about a lack of fit between mother and baby -the
bond is not secure, and nor is the infant.
When disturbance is this
fundamental, the first task of treatment is to reconstruct a secure attachment,
and then use that to bring about changes in deeply ingrained expectations of
relationships and patterns of behaviour.
What we so often find in
working with these people is that attachment is powerfully sought, but strongly
feared. This is the struggle between Fairbairn's libidinal and antilibidinal
egos: the one desperate and needy, and the other angry and rejecting – the
classic borderline split, if you like. Not enough stable ground has developed
between them, and the demands of reality almost always meet the emotional
responses of anger, shame, humiliation and pain. So clinically we need to
understand and accept the turbulent and traumatic nature of disturbed
attachment patterns. But we also need to be aware of the risks of dysfunctional
attachment – like anxious attachment (with possible pathological dependency –
and the serious consequences of staff having affairs with patients), and avoidant
attachment (with people becoming dangerously isolated, and being likely to kill
themselves).
Containment
This one is about the experience of
safety, and the capacity to trust oneself, other people and the world in
general. A balanced internal representation of containment is both maternal and
paternal – sorry to use stereotypes, but it is quicker. The maternal element is
safety and survival in the face of infantile pain, rage and despair. All those are certainly permitted, and this
in itself may be a mutative new experience for deprived or repeatedly
traumatised people, whose usual expectation will be to face hostility,
rejection and isolation. Now, in a good therapeutic environment, they have the
new experience of not having these powerful primitive feelings denied and
invalidated.
The paternal element is about limits,
discipline and rules. Again it is safety - but safety through knowing what is
and is not possible and permitted. The same as knowing the limits, or
enforcing the boundaries.
Bion described this process best: he
talked about the turbulent and primitive internal experience of the process,
and its link to thinking and the earliest mental states imaginable, when
islands of experience – such as hunger and discomfort - dominate the infant’s
mind with such overwhelming emotion and ferocity, and how this is conveyed and
contained by another, usually the mother. Winnicott described the sensuous and
nurturant qualities of the environment in which it needed to happen: he talks
about the mother who actively gives the infant a sense of its own existence. Here
is the difference between Bion’s "containing" and Winnicott’s "holding"
- one is mostly inside (in the mind), and one is mostly outside (in the
environment).
To create it, we need to have the patience
and tolerance of a mother with a screaming infant which she is trying to feed,
and the clarity of boundaries of what IS an IS NOT allowed. Good cop, bad cop I
think you could call it - hard for one
person to do both.
Communication
Tom Main wrote that the culture
of a unit is more decisive in bringing about change in human relationships,
than is the structure. He wrote of the "culture of enquiry"
. Nowadays, I think of
it more as a culture of openness to make it less inquisitorial – it’s collaborative, not
like the Spanish Inquisition. Of course, openness is what a lot of therapy is
all about: "talking treatments", "putting it into words",
and "being heard". It is very important, it is at the heart of
therapy - but I think we must not forget what comes before it, and what needs
to be done after. A demand on people for open communication is simply
not enough: they must want it, and feel safe about doing it. This requires an
intangible quality that must be present in the atmosphere. It mostly depends on
establishing the first two conditions: attachment and containment - for it is
only when a somebody belongs and feels safe that they can start to look at and
think about potentially difficult and painful experience. Patients or staff, I
would add.
I think this is what Foulkes implied when
he wrote
"Working towards an ever-more articulate form of
communication is identical to the therapeutic process itself"
- so the therapeutic process is not just one
of communication, but the struggle to get into a position to be able to
communicate. This means establishing the network of relationship in which that
can happen. The
term that group analysis uses for this is the matrix. Like for
containment, producing this sort of open atmosphere is more an attitude than a
specific skill – a way of “being with” rather than “doing to” as Heinz Wolff
decribed it. I think you can train people for it, and although it’s hard to
teach exactly what it is – it is like a capacity, and perhaps a competence.
Inclusion
This moves away
from models which fit with individual therapy, and are more specific to group
dynamics – and TCs in particular.
For 24 hours a day, all
interaction and interpersonal business conducted by members of a community
"belongs" to everybody. The
expectation will be to use it and understand it as part of the material of
therapy. Not in isolation, but in the real and "live" context of the
interpersonal relationships all around.
In this way in a therapeutic
community, individuals can find a very deep understanding of their place
amongst others: this will be examined the whole time. People are responsible
for themselves, for the others, and for the relation between the two. There is
"no place to hide" as one of our members recently put it.
When the group is considered
together, this is basic group analytic theory. Each has a different but vital
contribution to make to the health of the whole.
"The group constitutes the very norm from which each member
may individually deviate":
the aggregate of all the individual elements
produces a thing with its own qualities and a whole that amounts to more than
the sum of its parts.
Margaret Thatcher said that
there was no such thing as society, Winnicott said there is no such thing as a
baby, and Foulkes tells us there is no such thing as an individual:
"each individual is an abstraction: determined by the world
of which he forms a part".
This is the opposite of our
current individualistic views, and it gives us the possibility that the
richness and variety of the web of relationships between people, with all the
rights and responsibilities that implies, is itself a creative and
reparative force - in group analytic words, the matrix.
We create it by getting to
understand each other (staff and patients) – and for staff to understand each
other by having their own time and space to work out what’s going on.
Agency
In 1941 at Mill Hill Hospital, Maxwell Jones found that
soldiers suffering from "effort syndrome" were found to be more
helpful than the staff at helping each other. At Northfield, Bion's experiment was stopped
after six weeks when he refused to own total responsibility for the disorder of
others, and he was replaced by Main, Foulkes
and Harold Bridger. These two locations are the start of therapeutic communities,
and the point I want to make is that both made fundamental challenges to the
nature of authority. Now many of the challenges seem less strange, and they even
have become part of Government policy, like with service users becoming experts
about their own condition. But in other ways we have gone backwards – and
patients and staff have become disempowered in a command and control structure
that does not allow much professional judgement or flexibility at all.
But for therapeutic communities, this aspect
of user-power was always there. It like Jung's idea
that the patient's unconscious knows better where to guide the therapy than
does the analyst's expertise. It also
has a strong tradition in the teachings of Harry Stack Sullivan and the
interpersonal theorists, as well as Kohut, where any power imbalance is seen as
authoritarian, distancing and inimical to the establishment of a satisfactory
therapeutic space.
This is the principle of agency,
where authority is fluid and questionable. It is not fixed but it is negotiated
- and the resulting culture is one of empowerment. This
goes much further than the original "flattened
hierarchy" of democratisation, that everybody picks up on. Rather than
being a fashionable idea, or a policy which is imposed on a unit, it demands a
deep recognition of the potential intrinsic worth of each individual, and it is
about REAL social inclusion – but where everything is open to scrutiny – so
respect and authority need to be earned. Nor is it a "harmony theory"
that says we simply have to find this positiveness within people - for it
includes powerfully destructive, envious and hateful dynamics which exist in
all of us and are sometimes beyond reach. However, working this way does
presuppose the possibility of a considerable degree of professional intimacy,
which is an intimacy that is safe, open and healing rather than previous ones
which may have been frightening, dark and abusive.
Having a second try at
emotional development
So Secondary Emotional
Development is what we try to do by recreating these five conditions in a
therapeutic environment. We are trying to provide a psychic space in which the
things that went wrong or got stuck in primary emotional development can be
re-experienced and re-worked in this artificially created "secondary
emotional development". It can never be quite the same as first time
round, or quite as good and nurturant, but we try to make it as good as we can
get. People might not be fully “cured”, but we hope they’ll get a life – and go
to college or get work, rather than living off DLA.
But this secondary emotional
development can also work the other way and produce an environment which is
unhealthy, or anti-therapeutic. With a culture that discourages attachment,
that does not feel safe or containing, with perverse and distorted
communication, unspoken or top-down rules about what is and is not admissible,
and power based on arbitrary criteria.
Where human needs for secondary emotional development are being ignored
or obstructed. And this can be as much true of a school, office, company or a
hospital ward as of a family or therapeutic community: any setting where a
group of people are emotionally engaged in some sort of developmental task.
So what I am talking about is
not only about specialist hospital or prison units for treating personality
disorders - it it about everyday life, and struggling to try and meet needs
that we all have.
So that is the developmental
model of personality disorder – now I am just going to finish by pointing out
some parts of critical theory where the same sort of arguments are being made:
what two psychiatrists in Bradford have been saying, and a postmodern Guru from
Leeds and somebody who was on the radio last year.
Critical theory
The pair in Bradford are called Bracken and Thomas. Here’s their
opening argument:
In a
nutshell, this government (and the society it represents) is asking
for a very different kind of psychiatry and a new deal between
health professionals and service users. These demands, as Muir Gray
has recently observed, apply not only to psychiatry but also to
medicine as a whole, as society's faith in science and technology,
an important feature of the 20th century, has diminished.
According
to Muir Gray, "Postmodern health will not only have to retain, and
improve, the achievements of the modern era, but also respond to the
priorities of postmodern society, namely: concern about values as
well as evidence; preoccupation with risk rather than benefits; the
rise of the well informed patient." Medicine is being cajoled into
accepting this reality, but psychiatry faces the additional problem that its
own modernist achievements are themselves contested, and often with
popular support, which is not the case in other branches of medicine .
They go on to
argue, incontrovertibly in my view, that mental health cannot only be a
technical and scientific endeavour – and patients will be ill-served unless
sufficient importance is given to social and cultural factors. It seems
blindingly obvious really, but it has taken a well argued article in the BMJ
last year for most of us to rub our eyes and say “oh yes, of course”.
Their
approach has a similar perspective to Zigmunt Bauman – a sociology professor in
Leeds - about limits to how far we can
tolerate modernity, and that it needs to be leavened with something softer and
more human - less hard-edged, and more unpredictable. Here is a quote from a
Bauman paper called “postmodern ethics” [slide]
I won’t read
it all – just to emphasise these sorts of ideas – in the middle sentence:
Dignity has been returned
to emotions; legitimacy to the 'inexplicable', nay irrational, sympathies and loyalties which cannot 'explain
themselves' in terms of their usefulness and purpose.
Bauman’s
approach is also a call for accepting rather than trying to understand
and control the complexity of phenomena which we are always immersed in –
which has sympathies with the uncertainty and chaos theory that I have already
mentioned. And it has a very strong echo of Keats’ negative capability:
“When a man is capable of being in uncertainties, mysteries, doubts, without
any irritable reaching after fact and reason” – which is often cited as a
requirement for creative thought. I also believe it is what we are getting at
when we talk about psychological “containment” – how distress and disorder can
be best be dealt with by being with somebody (in a helpful way, hopefully!),
rather than doing something specific to them.
The last
connection I want to make is the Reith lectures last year – Dame Anora O’Neill.
I remember I used to catch it on my Tuesday morning journey between Fair Mile
and Winterbourne, and her main point was that we have now lost TRUST, in
each other and in our institutions. And this is to such an extent that we now
need to find ways to re-humanise so much of public life, policy and debate that
has become so untrusting – and therefore dry and technical and sterile. I think
we can see that sort of process in the early push to implement the National
Service Frameworks – very heavily from above, with no local autonomy until
trusts get foundation status – by having most of their targets met. Checkmate –
no chance of doing anything off the tick list; perfect social control.
But maybe
there are a couple of grains of encouragement to finish with. Firstly, service
users need to be seriously listened to nowadays, and they are not going to put
up with services that further dehumanise and alienate them. I think it is
exciting working with service users – because they have a fresh perspective
that makes you think “yes, why DO we do it like that?” – and sometimes you can
justify it and sometimes you can’t. But finding solutions that satisfy both of
you can be very creative.
Secondly, I
think the opportunity is there for us as clinicians to put the flesh on the
skeleton of “modernised mental health services”.
What we need
to end up with is user-friendly services within the given frameworks, so they
are compassionate, and humane, and hopefully therapeutic in the widest sense -
and avoid being bureaucratic, inflexible and insensitive to people’s subtle and
different needs.
We need to
collaborate with our patients to do this, and I hope managers will be able to
help us with the task once they let us get on with the job, which I seem to
remember them promising a couple of years ago – when they were talking about
management fading into the background.
But if we can’t
get back to having meaningful clinical input and working together on these
fundamental patient-centred considerations – about things like the real trauma
people have experienced, and the difficult way they relate to others - I don’t
hold out much hope for our managers doing it by themselves with a bunch of flip
charts and option appraisals.
