The Group Analytic Society Individual takes research seriously - and the meeting in Aaarhus, my first ever time in Denmark, was a good mix of type I evidence, politics, progressive thinking, and the usual argy-bargy about the alphabetti spaghetti therapies.
Here's an edited version of my two-pennyworth:
Therapeutic communities for the future:
surviving modernisation and staying at
the radical edge
Therapeutic Communities (TCs)
developed from models of treatment that broke from traditional practice, and
posed profound challenges to dominant thinking at various times: at the end of
the eighteenth century (Tuke, 1813), during the Second World War (Bion, 1961; Harrison, 1999), and in the 1960s (Foucault, 1965; Goffman, 1968; Laing,
1967; Rapoport, 1960). More recent descriptions encourage medication
reduction and use of other radical ideas (Haigh, 2007).
Their clinical work also takes account of the interface between the
individual and their social and cultural setting (Jones, 1956). Therapeutic communities involve user
empowerment, and the development of a sense of agency; democratisation, through
user involvement in the day to day running of the community, shared
decision-making, and peer therapy (Haigh, 2013).
Therapeutic communities, both democratic and substance abuse, operate
all over the world, in diverse countries and cultures, and have had to adapt to
local demands (Haigh and Lees, 2008).
Many clinicians, academics
and service users who understand therapeutic communities believe that they are guided
by an underlying radical challenge to authority and oppression (Baron, 1987; Jones, 1979; Spandler,
2006, 2009) that was articulated in the 1960s (Cooper, 1968), and if that underlying therapeutic
philosophy is lost, they will have moved from being an emancipatory movement
for the dispossessed to becoming a mere therapeutic technology in a crowded
field.
This intention of this paper
is to illustrate the adaptations that democratic therapeutic communities have
made in the last two or three decades in the United Kingdom. To turn from ideas
of revolution and emancipation to the subject of survival, these changes have
been undertaken in to cope with threats in the real world. Although those
threats can be seen as ontological, ideological or existential, they usually
impinge in a less abstract way: with economically-driven closure of services,
loss of clinicians’ jobs and the sale of property and land. The response to the
threats has been underway for more than twenty years, and is presented in four
different areas. To start with a ‘what TCs need to do’ list:
1.
TCs
need to… Know what they are doing and doing
it well: quality improvement, such as the Royal College of Psychiatrists’ Community of Communities project, started
in 2002 in the UK. Also developed in Australian TCs since 2007 and in Sicily since
2012.
2.
TCs
need to… Understand what they are doing,
and showing that it works: this is producing the research evidence in the
right way for people who run and pay for mental health services. Nick Manning,
the eminent sociologist calls it the ‘politics of data’: to what extent can we
work with ‘the system’, and to what extent do we need to resist it?
3.
TCs
need to… Offer training which can convey
the unique experience of having the sort of relationships people have in therapeutic
communities, which is difficult to describe without experiencing it.
4.
TCs
need to… Be willing to operate therapeutic
communities differently, to spread the ideas beyond therapeutic communities
– and join forces with others who have a similar therapeutic philosophy.
These four themes are quality,
research, training and innovation.
1
QUALITY: Knowing what TCs are doing and doing it
well.
The ‘Community of
Communities’ started in London in 2002: members of the steering group of the
Association of Therapeutic Communities (ATC) approached the Royal College of
Psychiatrists to set up a project, initially funded by the National Lottery, to
bring therapeutic communities together. The methodology reflected the beginning
of the ATC in 1972 – with communities visiting each other, and sharing their
ideas and practice - but also incorporating the rigour of contemporary quality assurance.
The aims were to reduce isolation, increase professional confidence in the TC
ways of working, and provide support – as well as measuring and improving
quality in a way that was accepted by the formal organisations and institutions
which the field needed to relate to. It also had to be done in a way which was
based on TCs’ democratic and relational principles.
The idea of written standards
was incorporated – to ensure sufficient objectivity, and have the authority of
the Royal College behind us. But the standards were democratically developed,
using therapeutic community principles. All participating TCs were involved in
the discussion, and in agreeing and voting on the first version of the
standards. This ensured that the member TCs felt that they were meaningful, and
owned by ‘the Community of Communities’ (Haigh and Tucker, 2004). By contrast, national standards
overseen by regulatory organisations are often seen as persecutory inspection
undertaken in a mechanical way by people who did not understand the processes
being inspected.
This project rapidly became
a recognised quality improvement process, as well as a way for therapeutic
communities not to feel isolated, or not knowing if ‘they were doing it right’.
Member communities became quite comfortable using language like ‘sharing best
practice’, ‘benchmarking’ and ‘action planning’. We had been ‘modernised’, done
the right thing, called ‘quality improvement’ - but in a therapeutic community
way, that we could live with. And several other British quality networks in
mental health have used some of these ideas – such as how to co-create a
process with service users being completely involved, and develop a friendly
informality within which the formal work is done.
By believing in the central
importance of relationships, in process as well as content, we had also
produced something that was more meaningful than a treatment manual. Perhaps this
has introduced something of a Trojan horse, to spread a message of gentle
subversion and quiet revolution, into the dry and technical world of the Royal
College of Psychiatrists, and all their quality processes. There is only one
quality network there that is older than us, and about twenty newer ones –
covering everything from ECT suites to mother and baby units, and acute wards
to psychological services. We introduced them all to working in a way that we
call ‘an antidote to inspections’.
The standards and the
process are all available on the RCPsych website (Royal College of Psychiatrists, 2015) – and versions have now been adapted
and used in Australia, Sicily and Northern Italy.
2 RESEARCH:
Understanding what TCs are doing,
and showing that it works
As a product of
globalisation, medical research has become very standardised across the world –
and the only ‘language’ that everybody understands is numbers. Statistics and graphs can be understood without much
translation. However, those who work in complex interpersonal and relational
systems do much that cannot be measured in numbers. Also, many ‘scientific’ or
‘biomedical’ psychiatrists say that the only evidence that is ‘good enough’ in
the ‘hierarchy of evidence’ is ‘Type 1 evidence’. That means a meta-analysis of
high quality randomised controlled trials (RCTs). This is why somebody who is
now a very senior government psychiatrist once called therapeutic communities
an ‘evidence-free zone’.
RCTs are difficult in TCs,
because there are so many ethical problems and methodological difficulties in
doing a meaningful experimental study on therapeutic communities – as well as
the bluntness and coarseness of the polar ‘yes or no’ results that they give. But
without these experimental studies, influential individuals and organisations
can promote the idea that we are an ‘evidence-free zone’. This specific
requirement for experimental studies is at the heart of the government’s National
Institute for Clinical Excellence’s (NICE) work, and it is a very powerful
process in the British health system. Although its stated are intentions are to
provide ‘guidance’, this is often interpreted to mean ‘instructions’. Its
methods are also being adopted internationally.
In my work on the committee
for drawing up guidelines for Borderline Personality Disorder, I soon saw that
no equivocal evidence, or doubt, or shades of grey are tolerated in what the
committee see as satisfactory evidence. The process adheres very strictly to
the hierarchy of evidence. To me, this represents a ‘zero tolerance’ of
uncertainty. In this specific guideline I was involved with, there was little
‘high quality evidence’ for treatment of Borderline Personality Disorder, so a
useful and ‘common sense’ guideline emerged which was not too prescriptive.
That was because it was based on a good consensus between the experts by
experience, the clinicians and the researchers on the panel. But this is called
‘clinical consensus’, which is very low-rating in the ‘hierarchy of evidence’. Perhaps this shows that ‘no high quality
evidence’ can be quite a good thing for common sense and thoughtful clinical
practice! (NICE, 2009)
However, the volume of ‘acceptable’
research is growing – particularly for psychotherapy treatments for borderline
PD, and therapeutic communities would have soon become invisible unless we had
started to produce our own acceptable evidence. We used to say that ‘no evidence of effectiveness does not
mean evidence of no effectiveness’, the
only fact being that the research has not been done. Unfortunately, nobody who manages
or commissions services takes much heed of this.
My own response to this has
been to think that the whole ‘evidence-based practice’ principle is based on
absolutely sound principles, but the spirit of the whole evidence initiative
has been lost to an unrealistic quest for absolute certainty. As a result, the
whole process is reduced to an arcane and annoying game, with rules too complex
for everybody except those whose careers depend on it. Such meticulousness and
precision might be understood for cancer chemotherapy, but it seems out of
place in disciplines like psychiatry – where diagnosis and psychopathology are
based on no equivalent basic science. However, we must play the game, with all
the complex rules, in order to communicate the ‘scientific fact’ that therapeutic
communities are an effective treatment, to the important officers and
organisations they depend upon for their continued existence.
Many colleagues with long
clinical careers in TCs are convinced that people benefit from time in them. This
makes equipoise difficult when randomising subjects to treatment as usual. Also,
most clinicians believe that the small proportion of people who might be harmed
by them can be helped to get out, with due clinical sensitivity, before they are
done any damage. However, many clinicians and service users remain unconvinced
that RCTs and standardised questionnaires and protocols will pick ‘outcome’ up
in a way that is meaningful or sufficient. Perhaps, in a digital world where
the only possible answers are ‘yes’ or ‘no’, this is asking for more than
experimental methods can achieve. At the very least we need to undertake good
qualitative research alongside the data from RCTs. In this way, we might start
to understand what the numbers do not tell us.
In the last year, the first
ever RCT of non-residential democratic therapeutic communities has been
completed and published - to the standards required of the medical research
establishment (Pearce et al., 2017; Haigh, 2017a). The results are generally positive,
and longer-term follow up results are expected in the next few years. However,
others in TCs now need to become involved in serious research and to follow
this up by undertaking whatever data collection or research they can (Lees et al., 2004). There are at least two reasons for
this.
The first is that there will
need to be more trials in the next few years to back up the first one. Research
is never finished – there is always more to know, as well as needing to test
out the first results, and gather enough data to do a meta-analysis of several
studies. Therapeutic communities need to get together to plan this, so that the data can make a real impact by doing
large and multi-centre clinical trials.
And the second reason
applies to all therapeutic community: unless you can justify the existence of
your therapeutic community, with data in hard-line objective and numerical
terms, you may not be able to survive. It means collecting, analysing and
communicating outcome data. It could start as service evaluation (such as an
annual report to demonstrate what you are doing and how it helps) but it does
need to develop into, and join with, substantive and formal research
programmes. Therapeutic communities as we know them will not survive in the
long-term unless they show that they are doing something that works, in the
format and language that the international health field demands.
In a very different frame of
reference, Nick Manning, a prominent medical sociologist, asks difficult
questions about what he calls ‘the Politics of Data’: where the real power is,
how funding decisions are made, and what are the unstated assumptions and
biases in the process (Manning, 2014). If TCs are to keep to their principles
of challenging authority and holding it to account, they will need to become
involved in these matters.
3 TRAINING:
the only way is experiential:
the “Living-Learning experience”
There is something about the
‘atmosphere’ or ‘culture’ of a therapeutic community that is very difficult to
put into words, in any language. It is about the quality of relationships – the
way people are with each other – that is experienced in a preverbal or
non-verbal way. Some describe these qualities as ‘ineffable’ or ‘numinous’. Any
number of books, academic papers or lectures of can try to explain what it is –
but can never recreate the experience itself. Personal therapy might give some
idea, perhaps more so if it is in a group format, but this will still not give
a realistic experience of what it is like in a therapeutic community. People
who are trained in group analysis, psychoanalysis or existential psychotherapy
will probably have some idea of it – but not the continuous ‘edginess’ of it,
or the ‘hurly burly’ that it often feels like. Manualised and directive
therapies have reasonably high levels of predictability: this is not so in
therapeutic communities, where tolerance of not knowing what might happen in
the next hour, day or week is an important therapeutic factor. The spontaneous
and creative solutions that the group needs to find very often mark a turning
point in how people relate to each other, and to themselves.
For staff, it is very useful
training to experience this, but away from the heat of day-to-day clinical
work. Hence the development of the ‘Living-Learning Experience’ workshops over
the past thirty-odd years (Lees et al., 2016). These are three-day residential
transient therapeutic communities for staff to attend as residents, which are
conducted by senior TC staff and ‘experts by experience’ (people who have been
through therapeutic communities themselves, as client members, and had relevant
subsequent experience and training). The format is for 15-25 strangers (most of
whom are staff from different therapeutic communities) and 3-5 workshop staff
to conduct it. In England, it is run it several times per year in a large manor
house in Kent, which is part of an organic farm study centre. Exactly the same
workshops also take place regularly in Italy (Sicily, Rome and occasionally
elsewhere), India (near Bengaluru), and irregularly in other countries (which
include Australia, Northern Ireland and Portugal).
It is managed by a
not-for-profit organisation called ‘Living and Learning’. The organisation
draws on fifteen suitably qualified and experienced staff members of different nationalities.
The international group is called ‘International Network of Living-Learning
Experiences’ (Living and Learning, 2017). Basic information about the events,
and brief staff biographies are kept on the website.
By attending these events,
and maybe only by doing so, TC staff can really come to understand what their
patients and clients and service users feel like when they start in a
therapeutic community, and have to deal with the process of forming numerous
new relationships in a short period of time. Participants need to make
decisions about what to do together, to have small stranger groups (90 minutes
each, five times – regular group analytic format) with other members with whom
they live with in the same house, and make meals for each other. Usually it is
also quite playful, and people generally have fun together as well as
experiencing intense and sometimes difficult emotions. Music is often enjoyed:
one of the staff team regularly takes a guitar, and another musician on the
staff team took a ‘cello once – and he sat in the kitchen playing Vivaldi while
the rest of us made lunch. Various other domestic and rural activities take
place, in the building, grounds and surrounding landscape. All decisions about
the activities are made in the morning and evening community meetings. On the
third day, everybody tidies up after lunch, says goodbye and leaves - and might
never see each other again.
Experience of the group over
many years indicates an extraordinary intensity, scope and level of emotional
and interpersonal work that many participants do: how far the individuals and the
group come in such a small period of time.
Courses are always evaluated
with questionnaires at the beginning and the end, and then for follow-up a few
weeks later. With this, we hope to be able to understand how people feel that
they benefit or not, and we can adjust the programme accordingly. As well as
receiving predominantly positive comments, we have done some basic quantitative
analysis. This has shown high and increasing level of satisfaction. More
recently, formal qualitative research has been undertaken using ethnographic
methods. This has already shown that the courses meet the ‘Community of
Communities’ standards (Rawlings, 2005), and the results are now starting to
show interesting differences from other types of group relations events. Data
is also being collected to demonstrate how LLE courses need to adapt to local
cultures – such as the difference between (superficially) identical courses run
in urban Sicily and rural India, for example. We hope this work will develop
and grow into something that can be published in the scientific literature to
help understand the theoretical basis of therapeutic communities, and the
acceptability of the method across different cultures.
4 INNOVATION:
Using therapeutic community ideas in new ways
As a result of external
pressure, as much ideological as economic, much has changed in the type of democratic
therapeutic communities in mental health services. We have lost all the seven
day ‘total immersion’ residential therapeutic communities – no more now exist
in the UK. The Cassel Hospital continues to offer medium to long term inpatient
intensive psychoanalytic psychotherapy, but it no longer defines itself as a
therapeutic community per se. The Henderson
closed in 2010, and Francis Dixon Lodge has become a 3-day per week unit since
then.
There are a few, including
new types, growing up as charities and cooperatives. The state sector – the NHS
in the UK – is very highly regulated and risk-managed, and is becoming an
increasingly difficult context for therapeutic communities to flourish, or even
survive. But these charitable or social enterprises, or sometimes commercial, therapeutic
communities now sell their places to the state system when the local services
have no suitable facilities to help. A more flexible range of facilities, with
varying degrees of ‘TC-ness’ is a possible future development: different places
for those who need a therapeutic environment with specified levels of physical
containment, with types of therapy programmes suited to their particular
circumstances. Not all like traditional therapeutic communities, but with some
or many of the features and qualities – and the underlying values.
As well as closing the beds,
non-residential therapeutic communities have also ‘reduced the dose’ over the
last ten years – and TCs have evolved from 5 days per week to three, to one, or
even less. A ‘micro-TC’ started in 2013 gives even less time together – it only
meets together for two and a half hours per week, but is connected to numerous
other therapeutic and social activities that are available in the town (Haigh, 2017b). Some are run by health services,
others by social services and some are in the charitable and voluntary sector. Members
of the ‘micro-TC’ make their own ‘pick-and-mix’ therapeutic programme. In this
way, various therapeutic elements (psychotherapy, sociotherapy as well as the
traditional psychiatric treatment) are distributed across the whole town, but
with the continuity established between them - through people feeling that the whole
system is joined together. This gives ‘continuity of care’ rather than
‘fragments of services’ which is otherwise so often the case. There is an interesting
debate about what to call it – is it a ‘micro therapeutic community’ because it
only meets for 2½ hours a week, or ‘macro therapeutic community’ as it is like
it is a therapeutic community without walls, that involves elements from across
the whole town?
Perhaps this is a ‘post-post-modern’
therapeutic community, and it shares some features with a faith community on
the south coast. This is a church-based therapeutic community without buildings
or even staff: members meet in various places in the town, and sometimes live
in each other’s houses. What seems to matter most, and is the common factor with
long-established TCs, is ‘the therapeutic community in the head’. That means
experiencing the nature and quality of
relationships around you that make you feel safe enough to be able to do the
work you need, even if they are only physically present for part of the time
and are with different people.
An important consideration
for the future of TCs is perhaps to better recognise this ‘therapeutic
community in the head’ (Haigh, 2013). In this way, the experience of being
with each other is the essential element, and not the timetable or buildings. The
physical space and regular timing become less prominent. This could also lead
to the development of virtual, or partially virtual, therapeutic communities.
Most crucially, members feel they have a sense
of belonging in the community for 24 hours a day and seven days a week.
A different innovation has arisen
from the work of the Community of Communities (see ‘quality’, above). In 2007, a
set of ‘core standards’ was defined – the specific factors that exist in all therapeutic
communities, but are not generally present in other types of service. From
these, a set of ‘core values’ was established. These were the values that
underlay the core standards – you did not need to be a formal ‘therapeutic community’
to hold those values, but all therapeutic communities did– as did many other
places that looked and felt like therapeutic environments (Haigh et al., 2012).
Here are ten the values which
are thus defined for ‘Enabling Environments’: recognizing the importance of RELATIONSHIPS
is always a central requirement; BOUNDARIES
are what keeps a space safe; all behaviour can be seen as COMMUNICATION; DEVELOPMENT
needs spontaneity for creativity and growth; INVOLVEMENT means everybody is
responsible for the place, and each other as well as themselves; SAFETY is created
through support; STRUCTURE gives a purpose to people; EMPOWERMENT comes through
authority being open to question and discussion; the LEADERSHIP is responsible
for making sure the environment is enabling; and external relationships are
sought and valued in a culture of OPENNESS.
Standards were then written
to embody these values, with several flexible criteria for each. The criteria
show how to demonstrate that a unit or service is meeting the value-based
standards. To work towards the award itself, there is a process of compiling a
portfolio, which is often done with great pride and energy, and submitting it.
As we might expect in a therapeutic type of activity, the process of doing this
preparation work is more important, and enjoyable, and meaningful, than simply
getting the award at the end (Royal College of Psychiatrists, 2016).
The Enabling Environments
project now has nearly two hundred units as part of it network. It has been
particularly successful in the criminal justice world – where prison staff are
finding a new sense of purpose in their jobs, there is much less violence on
prison wings, reoffending is reduced, and morale of prisoners as well as staff
is demonstrably higher. Because of its success, the head of the UK Prison
Service has publicly supported the project, setting it as an aim for all
probation hostels, and as an aspiration of values across the prison estate. This is at a time when British prisons are
under great pressure and strain, where this project and its outcomes are seen
as an area of hope in a grim landscape. Wider scope for enabling environments,
particularly in the health and social care systems, is now being planned.
These examples illustrate
some examples of how TCs can be adapted to fit well within modern
highly-specified services - by modifications to the traditional TC programme,
and using the longstanding therapeutic community ideas as the fundamental
principles behind all services where relationships are important. It is likely
that there are many other people, projects and organisations doing similar
things, and we all need to draw support from each other.
Discussion
Global managerial processes
- particularly through ‘New Public Management’ (Gruening, 2001) have
led to health and social care systems being more standardised, risk-averse and
regulated. While this is undoubtedly of benefit in terms of efficiency and
effectiveness in areas such as cancer care or ischaemic heart disease, it
produces a mechanical and technological framework for mental health services
which allows little recognition of the importance of creativity, spontaneity or
playfulness. It can also support care that is devoid of meaningful human
interaction, compassion or kindness (Ballatt and Campling, 2011). Well-functioning therapeutic
communities thrive on such elements, and cannot function well without them.
Most significantly, they prize relational practice – where every individual is
treated as an individual with their own personality, talents and problems
recognised and respected - above procedural practice, with performance-managed
adherence to closely-defined policies, targets and goals (Hoggett, 2004).
It is often a natural
reaction of any team, in times of staff reduction, service cuts and efficiency
savings, to ‘batten down the hatches’ and protect what they have, rather than
try to change it. However, in therapeutic communities this has led to a climate
of fear which has brought about rigidity, inflexibility and an inability to
grasp the size and scale of changes needed – simply to survive. Therefore, many
TCs have not survived: there are now less than twenty residential therapeutic
community beds in the National Health Service, and nearly all the
non-residential day-TCs have reduce from five-day programmes to three, two or
one days per week.
But this could be seen as
not so much a decline, as an accommodation – with its own distinctive clinical
advantages (Haigh, 2007). Although, while we in a state of
apprehension and uncertainty about survival, it is natural to fight to continue
what we are doing, that is unlikely to increase the probability of that
survival. The TC ‘movement’ needs to be more willing to adapt and change –
while keeping to the therapeutic philosophy described above – in order to keep
the underlying emancipatory ideal alive. It is not helpful to fight for the
detailed structures, programmes, buildings and guidelines that worked fifty –
or even five – years ago. The individual elements that are worth preserving
include experiences that are difficult to isolate or enumerate: such as
emotional safety, interpersonal conduct, continuity, feeling empowered, allowed
to act authentically – and, dare I say – about having fun. Therapeutic
communities value the playful aspects of the work, although there seems to be
little corporate recognition of its value in any public services.
Modernisation may also be a
reaction to some fundamental fear of ‘other’ in a very diverse and globalised
world: with lack of trust in relationships is growing with the global tensions
and responses we see around us, we retreat into technical solutions, certainty
and individualism. In contrast, Foulkes, the founder of group analytic
psychotherapy, noted that “each
individual is an abstraction, determined by the world, the community and the
group we live in” (Foulkes, 1946). This idea of fundamental human
experience being more about our relationships than about us as individuals can
be used to draw an analogy with the well-known phenomenon of wave-particle
duality in physics. Although the two seem incompatible, both are valid, and electrons
can only be understood if we understand their nature as both a probability wave
function and a particle with uncertain position or momentum. Particles could
represent the individual view of human existence, and wave the relational
aspect. We need to accept both. Reflecting on the recent discovery of the
Higg’s Boson: if Higg’s Bosons are the things that gives matter its mass, then
relationships could be seen as the things that give humans their meaning.
Perhaps TCs can leapfrog
over ‘modernisation’ – and get to a more holistic, wholesome and complex way of
organising our services (Haigh, 2005a). This is beyond modernism as we know
it: not minimalist, sterile and automated, but human, complex, uncertain and
authentic. We can incorporate some of the ‘efficiency benefits’ of
modernisation (such as flexible use of new technology), but the new focus will
be relational, not performative, transactional or procedural. In that way, it
could be seen as post-modern. This has a close parallel with Bracken and
Thomas’s coinage of ‘post-psychiatry’ (Bracken and Thomas, 2001).
Because the therapeutic community field has been working progressively
for many years, in ways such as transparency, democracy and service user
partnership, it is familiar territory. Using these principles, along with the
underlying emancipatory philosophy, could be even more exciting and worthwhile
than being part of traditional therapeutic communities, and trying to maintain
what they have always done. The placing of relationships at the centre perhaps
moves even further – beyond the post-modern dogma of relativism, ‘anything
goes’ and ‘no grand narratives’. The relational framework itself could be described
as a new ‘grand narrative’.
However, leadership to
promote such ideas is not common in state-commissioned services, and an
accommodation must be found to ‘keep the flame alive’ while getting on with the
business of doing effective clinical work - in an increasingly regulated and
managed system. Manning (2013) clearly articulated this in ‘Charisma
and Routinisation’: having a powerful charismatic leader is not a stable or
sustainable position, while becoming routinized and bureaucratic is no better.
It is a fine line to tread, and I have previously argued that the ideas behind
therapeutic communities carry plenty of their own charisma – and that the key
is to place relationships (at every level) at the centre of the work and the
development of the field, rather than have celebrity-type individuals as its
powerful leaders (Haigh, 2005a), or to turn to bureaucratic and
administrative solutions (Haigh, 2005b).
We who work in mental health
know that we can only ever work in uncertainty and probability, but the world
in which we now exist increasingly demands certainty. A current example in the
UK is the ‘zero tolerance of suicide’. In the digital tyranny that computers
demand of us all, only zeroes and ones are allowed, and no fuzzy indeterminacy
is permitted. This ‘untrusting performativity’ characterises the ‘New Public
Management’ and now permeates everything we do in health services and
universities – and other public sector organisations. It is also becoming dominant
in the voluntary sector, for charities and social enterprises. Unless one shows
corporate understanding of the layers of governance, risk management and
compliance checks, funding is unlikely to be granted.
This process fundamentally
does not trust relationships: this is not acceptable as the core foundation for
human services, particularly mental health. Mental Health needs to be seen
again as a social movement as it was in the 1790s (with moral treatment) and
again in the 1950s (with antipsychiatry) – with the challenge to authority and
oppression which that needs. The work and thinking of therapeutic communities
needs to be a part of it. With much of the current culture based on mistrust
and fear, therapeutic communities, and other relational approaches, need to
work hard to demonstrate that there is a different way to live our lives, and a
better way to be with each other.
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