Catania Visiting Project Forum, Terra Nostra LLE and REMS

The energetic, creative and slightly chaotic growth of the Sicilian Visiting Project marches on - this year in Catania. Which, oddly, has a tube map in the car park underneath the conference venue...

Then another of the lovely LLEs on the social farm at Terra Nostra: including donkey care and waste recycling as part of the greencare activities, along with egg collection, vegetable watering and harvesting. Here's everybody getting their certificates at the end

And here's the group photo - donkey and all!

One of our activities, it must be said not one that was approved by all the staff team, was a 15 minute drive to the local REMS. 

REMS are the new non-state run forensic units - and this one is a full-blown TC. We had coffee and ice creams with the inpatient group - who were clearly working relationally, and pretty democratic in the way the impromptu group worked. Some of its residents were Sicily's most difficult offenders - and one, who was extremely attentive to us, previously had to have numerous attendants and no furniture or plumbing, as he would have destroyed it all - and had a history of ripping sinks from the wall and toilets from the floor. His settling in over the last year or so is seen as an absolute triumph of TC methodology. And so it is...

When is a therapy?

I have used this blog before to beef on about therapies being branded and packaged and commodified and marketed like drugs – but a couple of days in Verona (which I seem to be coming to more often than any rational reason would suggest) have given me another layer of it to think about. I suppose it is how to ‘monetise’ the therapeutic alliance.

Aldo translates for Renee

My line is always that the ‘nature of the therapeutic relationship’ is always, absolutely always, more important than the type of therapy. And that is backed up by the research going back to the Dodo-Bird verdict, the statistical analyses that show that only 15% of the variance comes from the type of therapy, the PD pilot project showing the crucial role of engagement – and agreement about it with every therapist I have ever talked to (though I don’t talk to pure CBT therapists very often). And it’s at the root of the ‘quintessence’ too: the attachment and containment need to be securely in place before you can get on with the routine bits of therapy, and they’re mostly unconscious anyway.

Yet the ridiculous horse race between the alphabetti spaghetti therapies continues, and more and more horses are bred - and trained, and put through their paces in the RCT hurdle steeplechase. They have to keep entering more races, of course, to keep their form. When everybody knows it doesn’t really matter who wins.

…Except that we have a competitive international research system, run by sharp, smart and competitive research staff. This system demands absolute certainty (well, as much as RCTs can give), a marketised system where celebrity academics and a few others can make a fortune out of it, and a lot of other pedantic and arcane reasons for ultimately stripping the humanity and agency out of the decisions when the needy person actually meets the human representative of the machine.

So I was a bit wary of going to Verona to share a platform with my old friend Aldo (who spoke with dazzlingly animated slides of neurobiology and sociotherapy) and an infrequent acquaintance Renee Harvey (who presented the STEPPS model and her creative Sussex adaptations of it). My worry was that STEPPS is one of the alphabetti spaghetti therapies I have been so rude about in the past, and I didn’t want to fall out with Renee as I do respect the way she works.

Indeed, it shone through how she works – in close partnership with service users, in a very relational way, attending to engagement, using the manual as flexibly as needed, in conflict with the powers that be (about their anti-therapeutic demands), wanting to make partnerships with the third sector, making full use of positive group dynamics, and seeing it as much as a framework for therapy as a definitive intervention. In other words, a therapeutic environment. With that lot in place, it felt quite close to what we do, for example, in the Slough micro/macro TC.

But one tiny thing she said set me on edge: when describing the room, she showed us a picture including ‘the cupboard where we keep all the materials’. As if everything you needed could be bundled up and put in a cupboard – and those materials, I assume, are like lesson plans and detailed handouts for the highly structured sessions. So even though it’s a fairly well-guaranteed way of establishing and maintaining the therapeutic culture where the quality of relationships is paramount, it’s commodified and packaged and marketed. I fear it’s the way of the world – inexorable and inevitable – though I still don’t think it’s a price worth paying. It’s the corporate way, and it moves authentic therapy closer to prostitution…

The vibrant Verona gang!

The book of PIPEs

This is the foreword from 'Transforming environments and offender rehabilitation: understanding and harnessing contextual factors in the rehabilitation of offenders', which contains what I hear is the first definitive published account of what PIPEs are. It is chapter 9, pages 179-197, by Nick Benefield, Kirk Turner, Lucinder Bolger and Claire Bainbridge. But the rest of the book is well worthwhile too, and this is what I wrote about it:  

Therapeutic environments have almost certainly existed since time immemorial, but it is a struggle to recognise their importance in a modern world where individualistic enumeration of all our activities has become paramount. In his grand sweep of anthropology and history, Harari persuasively argues that our forebears, as hunter-gatherers, and even Neanderthals, were more socially cooperative and community-minded than we are[1]. Perhaps we have lost something that we need to rediscover – or reinvent - in order to improve our lives today.

 The earliest documented accounts of a deliberately constructed therapeutic community, or enabling environment, is usually given as the village of Geel in thirteenth century Flanders – where those with ‘mental afflictions’ came as pilgrims to worship at the holy shrine of St Dymphna. Most of the pilgrims would probably be diagnosed with learning disability or epilepsy nowadays. When they arrived in Geel, they were taken into the care of the villagers, who were all engaged in working on the land. The success of their care was measured by an annual weighing ceremony, where those who had gained the most weight were the ones thought to be doing the best. An environment was constructed in which people with severe disabilities could be treated as human, and have their basic physical and social needs met.

 Other notable events in history show the same interest in the ‘psychosocial environment’ – such as the implementation of ‘moral treatment’ by the Quakers in York at the end of the eighteenth century, progressive education and democratic schooling for troubled children since the end of the nineteenth century, the rehabilitation of battle-shocked soldiers at Northfield and Mill Hill in the Second World War, and R D Laing’s rather chaotic experiments with ‘unlabelled living’ in the sixties. Perhaps one day historians will add the current reform of penal institutions, with the realisation that attention to the same factors can make twenty-first century prisons more effective and humane.

 The British criminal justice sector has been important at several points in devising the structure for ‘Enabling Environments’, on which most of this work is based. In 1998, the ‘Kennard and Lees Audit Checklist’ (‘KLAC’) was produced in order to be able to audit the prison therapeutic communities (TCs) as part of the Offending Behaviour Programmes Unit. The prison TCs were at that time seen as the only area for therapeutic communities which seemed to have a positive future, as all other sectors seemed to be closing them down or reducing their size. The KLAC formed one of the most important documents in setting the standards for all therapeutic communities when the ‘Community of Communities’ quality network was started at the Royal College of Psychiatrists in 2002. After the network had gathered much data over five or six years, the ‘core values’ were extracted and used to define the requirements for the ‘Enabling Environments’ (‘EE’) award. With this, the essential relational qualities of therapeutic communities could be used in any setting, without needing the whole apparatus of particular groups, specific staffing and suitable buildings – or the need to formally consider oneself as a ‘therapeutic community’. Therapeutic Communities remained the specialist and ‘pure’ implementation of a highly structured psychosocial therapeutic programme, but the ‘quality of relationships’ upon which they were built could now be replicated elsewhere.

 This facilitated the development of ‘Psychologically Informed Planned Environments’  (‘PIPEs’) – which had a particular structure, defined by the National Offender Management Service – as part of the response to the Bradley Report on the management of Mentally Disordered Offenders. By this time the concept of ‘relational security’ was also becoming well known in high secure NHS settings. At the core of the PIPEs was a process which trained and supported staff to establish their prison wings or other units as Enabling Environments, and to work towards achieving the Royal College of Psychiatrists award to recognise that.

 A parallel process, started in the government’s Department for Communities and Local Government, but without the continuing support or funding, established ‘Psychologically Informed Environments’ (‘PIEs’) for the homelessness sector. PIEs are more loosely defined than PIPEs, and do not require participating services to meet EE standards, but they have a clearly articulated structure which is based on the same relational values.

 Once non-participating prison units saw the value of PIPEs, many of them decided to apply to become Enabling Environments, independently of the PIPEs programme. This has raised wider awareness of healthy psychosocial environments throughout the criminal justice sector, and at the time of writing two whole prison establishments are working towards becoming ‘whole prison EEs’, rather than just specific wings and units. At a conference in early 2016, the head of the National Offender Management Service affirmed the priority which is now being given to this work.

 However, it is not easy. As well as the institutional inertia and the staff’s personal feelings of resistance to change and loss, there are major structural obstacles. The task for us in penal settings is to accommodate the very exacting and precise demands of policies and procedures, which allow no flexibility and very little individual discretion, alongside the recognition that basic humanity in relationships is required, in order to stop prisons having persistent negative effects on prisoners.

 This book offers hope that it is possible to do both: to recognise the profound importance of the social matrix and milieu, while measuring, regulating and risk-managing all the necessary aspects of participants’ behaviour. Prisons and forensic settings are amongst the most socially controlled settings, where operational details of security must always trump therapeutic principles - and all the work must demonstrate metrics of outcome such as reduced probability of future offending. Yet this collection of chapters shows that it is possible to find space for humanity, in the way people relate to each other, in these difficult settings. If there is hope here, maybe there is hope for us all!

---

[1] Yuval Noah Harari (2014) Sapiens: A Brief History of Humankind. Harper Collins, New York

IT'S OFFICIAL: Democratic Therapeutic Communities are now an evidence-based treatment!

And here's the text if you don't have access to the BJPsych:

Therapeutic communities enter the world of evidence-based practice

In this edition, Steve Pearce and colleagues have demonstrated that it is possible to do an experimental study on a complex treatment modality that has been in use for over 50 years. This is an important study, and is a landmark in being the first ever randomised controlled trial on democratic therapeutic communities for personality disorder. In the seven decades since their role in psychiatric services was established, clinicians in therapeutic communities have generally preferred qualitative approaches to research (1). These were seen to have a more congruent epistemological basis, but were a richer vein for anthropological and sociological enquiry than they were for clinical studies. An extensive systematic review in 1999 (2) found few studies were suitable for inclusion in the meta-analysis, and those that were included were too heterogeneous and imprecise to give robust results.

For psychiatrists who remember democratic therapeutic communities in their heyday, they were based on Rapoport’s the four themes (democratisation, permissiveness, reality confrontation and communalism) which he identified at Henderson Hospital in the late 1950s (3). Although the service in this study is based on some of these fundamental principles, they are overlaid with several decades of development and modification. Newer TCs now bear few superficial resemblances to these residential services which were formed in the heat of the social psychiatry revolution of the 1950s and 1960s. No wholly group-based residential therapeutic communities now remain in the NHS, and all of those that still function are day units, as in this study (4,5). The laissez-faire attitude of ‘leave it to the group’ rarely prevails, there is a high level of structure and order, and there is very little opaque psychoanalytic interpretation delivered by remote therapists. Modern therapeutic communities have a strong emphasis on empowerment, openness and ‘ordinariness’, which soon dispel any notions of therapeutic mysteriousness and charismatic leadership. They are tightly managed services with clear admission, review, progression and discharge protocols (6). 

The ‘Community of Communities’ quality network at the Royal College of Psychiatrists Centre for Quality Improvement (CCQI) was one of the first projects there in 2002, and it helped democratic therapeutic communities to agree the nature of best practice and to consistently deliver it (7). Part of this process involved the distillation of ten core values that underlie the measurable standards. These would be entirely familiar to early therapeutic community pioneers: a culture of belongingness, enquiry and empowerment; democratic processes whereby no decisions can be made without due discussion and understanding; and the fundamental importance of establishing and maintaining healthy relationships (which are not always comfortable and are seldom without conflict). This work has also led to the ‘Enabling Environments’ award at the Royal College, and the development of Psychologically Informed Planned Environments (PIPEs) in criminal justice settings, and ‘Psychologically Informed Environments’ (PIEs) in the homelessness sector (8).

The publication of outcome studies for personality disorder treatment have had something of the quality of a ‘horse race’ or ‘beauty contest’ in the last decade. New treatments have been constituted from various old psychological theories, which have been branded and packaged, then manualised and researched with much energy and competitiveness. In this way, they have been suitable for ‘selling’ to mental health commissioners as simple value-free ‘commodities’ or ‘products’ (9). In a way, this study indicates that therapeutic communities have now entered this race. However, it is worth proposing that Pearce et al’s study is not of a simple ‘brand’ of treatment, but of a therapeutic philosophy with a long and distinguished heritage, which has been now adapted to fit into the wider ‘whole system’ of a twenty-first century mental service. Therapeutic communities offer a democratic way of conducting therapeutic business, demand specific attention to the coherent and coordinated use of the different therapeutic approaches, and deliberately provide an overall therapeutic environment (10). These do not often happen in other therapies.

Therapeutic communities also specialise in being able to treat those who have a particular severe presentation of personality disorder, such as in prisons. This severity can be measured by diagnostic criteria, comorbidity, risk, complexity or unmanageability (11). The therapeutic environment, including techniques such as peer mentoring and deliberate informality, facilitates engagement of people who would otherwise be ‘untreatable’. Also, by managing risk primarily through continuing, empathic and intense therapeutic relationships, therapeutic communities can manage levels of risk that would be unacceptable in other services.

This study demonstrates that democratic therapeutic communities have now started to accumulate the evidence to earn a place in the therapeutic pantheon for moderate and severe personality disorder.

750 words

References

(1) Lees J, Manning N, Menzies D, Morant N. A Culture of Enquiry: Research Evidence and the Therapeutic Community. London: JKP; 2004.

(2) Lees J, Manning N, Rawlings B. Therapeutic community effectiveness: a systematic international review of therapeutic community treatment for people with personality disorders and mentally disordered offenders. University of York: Centre for Reviews and Dissemination; 1999.

(3) Rapoport R. Community as Doctor. London: Tavistock; 1960.

(4) Haigh R. The New Day TCs: Five Radical Features. Therapeutic Communities 2007;28(2):111-126.

(5) Pearce S, Haigh R. Mini therapeutic communities: A new development in the United Kingdom. Therapeutic Communities 2008;29(2):111-124.

(6) Pearce S, Haigh R. A Handbook of Democratic Therapeutic Community Theory and Practice. London: JKP; 2017 (in press).

(7) Haigh R, Tucker S. Democratic development of standards: the community of communities - a quality network of therapeutic communities. Psychiatric Quarterly 2004;75(3):263-277.

(8) Haigh R, Harrison T, Johnson R, Paget S, Williams S. Psychologically informed environments and the “Enabling Environments” initiative. Housing, Care and Support 2012;15(1):34-42.

(9) Haigh R. Industrialisation of therapy and the threat to our ethical integrity. Personality and mental health 2014;8(4):251-253.

(10) Haigh R. The quintessence of a therapeutic environment. Therapeutic Communities 2013;34(1):6-15.

(11) Department of Health. Recognising Complexity: Commissioning Guidance for Personality Disorder Services. 2009.

Rex Haigh
Consultant Medical Psychotherapist, Berkshire Healthcare NHS FT
Honorary Professor of Therapeutic Environments and Relational Health, School of Sociology and Social Policy, Nottingham University.

Conflicts of Interest:
RH leads the Enabling Environments project at the Royal College of Psychiatrists Centre for Quality Improvement. No financial conflicts.