Monday 17 December 2018

Seven reasons why psychiatric medication is wrong in therapeutic communities



I'm off to a formal meeting on Wednesday to discuss the prison policy on psychiatric medication in the democratic TCs. So here's some notes I have made to help me think it through...

1    'Medical' or 'psychiatric' treatment should not necessarily have to have to include, or even consider including, any pharmacological component. TCs are such a treatment: they arose from a different therapeutic philosophy in contexts where medication was not relevant or not invented. There is no evidence that their effectiveness has been enhanced by allowing psychotropic medication to be used for their members, except perhaps to increase staff sense of 'knowing better' and social control. TCs are a safe place in which the effects of no medication can be carefully monitored and responded to by psychotherapeutic means

2  Psychiatric drugs directly hamper TC treatment. All groups of psychiatric medication have effects on mental functions that hinder the therapeutic process, or block it: minor and major tranquillisers cause drowsiness and lack of full attention; drugs used for depression and other stimulants can give a false sense of elevated mood; lithium is often reported to leave people 'feeling like a zombie', and most people on it recognise the emotional blunting it causes.

3  Psychiatric drugs indirectly hamper TC treatment. The other way medication hampers TC treatment is that it takes away responsibility for how one is feeling, thinking and behaving - and allows swallowers to think that a pill can cure one's woes. Taking a pill is much easier than making a decision to pursue a more the more difficult option - which involves allowing oneself to trust the holding, containing and transforming effects of therapeutic belongingness. The symbolic meaning of medication also prevents the relational equality needed in a TC: the relationship between the prescriber and the swallower is necessarily unequal.

4  No psychiatric drugs are licensed for the specific treatment of 'Personality Disorder', for which therapeutic communities are a definitive treatment. The diagnosis of 'co-morbidity' usually covers this - but the co-morbid conditions are only symptoms (such as depression, anxiety, agitation, insomnia, voices) of the underlying condition. Medication can doubtless help symptoms, but that is all it does. Diagnosing co-morbid conditions can be seen as an exercise of professional power, which is not subject to the enquiry and scrutiny of other decisions made about members of a therapeutic community. 

5  Medication is less effective than advertised. The general trajectory of many psychiatric medications is enthusiastic optimism, followed by extensive routine use, followed by problems and questions - examples include barbiturates, amphetamines, benzodiazepines and most recently SSRIs. Advocates of new medications often include influential clinicians, guideline-issuing bodies, professional organisations as well as the pharmaceutical industry. The recent challenge of the 2017 NICE depression guideline by numerous experts and fourteen professional organisations opens the question of possible pharmaceutical bias - at the highest levels.

6  Long-term use of medication is harmful. Detailed work by Joanna Moncreiff in the UK and Peter Gotzsche in Denmark have made a strong cases against the way in which psychiatric drugs are currently used. Moncreiff argues that drugs do not specifically target any 'diseases', but have specific effects that may ameliorate symptoms; thee neuroleptics cause brain atrophy, tardive dyskinesia and poorer long-tern outcomes than no medication. Gotzsche goes further and presents evidence to show how psychiatric drugs kill half a million people every year in the USA and Europe.

7  There is a wider movement going on for a more relational and democratic type of psychiatric care. Therapeutic communities and their progeny have always had these core principles, but many other organisations and movements are now espousing similar values: Open Dialogue, Soteria Houses, Multifamily Therapy, Greencare, Hearing Voices Network - as well as numerous small service-user led groups and networks.

In the wider sweep of the history of psychiatry, I believe that many of our current medications will look as archaic as chaining people up and beating them, or putting them into a coma with insulin. But the same may be true of current psychotherapies. Not so sure about psychedelics, though - they seem to have been used fairly well for many centuries...

Thursday 29 November 2018

Measuring what matters: ReQoL


This is ReQoL day, in a grey and rainy Sheffield.

I'm not usually somebody who gets at all excited about psychometric 'instruments' (as their manufacturers rather grandly call them sometimes) - but ReQoL feels a bit special. In the same way that CORE did three decades ago - something that can really let us and our service users know how we're doing. And this one is based on a value set that comes from research showing what matters to service users themselves - not by clever academics in a university, or powerful doctors in the clinic, saying what should matter. And even more fun was meeting a mystery man on the way into the conference room, who knew me,  but wouldn't tell me who he was (though I recognised him, despite 20+ years since last meeting). When he stood up to speak - about the scientific process behind the new measure - I knew: it was Mike Barkham, one of the main developers of the CORE - and regular in the snooker room at the Raven Hall Hotel at the annual Society for Psychotherapy Research (UK) bashes in the 1990s.

The morning was quite energising, and felt like this was a good new measure that was designed around measuring something that really mattered – and could help us all coordinate across services, research, commissioning and policy.

But then the afternoon came along.
I found Tim Kendall very dispiriting – his vision extending no further than which bits to spend a little bit of extra money on, and a rather nihilistic mood agreeing it’s all bad and won’t get much better (in my working lifetime, at least!)
And as for the best thing Andrew Lansley did was to make the NHS even more hierarchical and driven top-down– I was close to passing out with despair.
It was probably worse because I found the afternoon ‘cafĂ©’ workshop perhaps the dullest event I have ever been to – and annoying in confirming my fear that legions of clever people are running round feeding the machine – and getting quite excited about it.
But where are the service users in it all?
And where were they today? A: not there, because it was all about the experts doing clever and complicated things without them.
And as Tim said, their scores aren’t what really matters, because it’s the measures that show how well that machine is working that he is interested in.

Then he goes and says that an ‘official’ PD measure is being written – probably by people none of us have ever heard of, with a big grant that’s not connected to any of the other work that’s been done in the field over many years, or is currently going on.
And he was extremely lukewarm about ReQoL, which I thought was going to get his backing - as a sensible and robust outcome measure for us all to coordinate ourselves around (and, dare I say, more democratic and meaningful to service users than bureaucratic old warhorses like HoNOS). But no. Aargh.

So NHSE is even more of a disorganised and fragmented mess than I thought – as a personality disorder consultant colkleague, from the Cassel, exactly put her finger on in questioning him. It’s not harder hierarchical management it needs – it relationality at all levels (not performativity) and real service user co-production!
And as for the withering scepticism he expressed in his aside about ‘being human’ (or something like that) …my blood ran cold.

In the old days, like when he was chairing the Borderline NICE group, he used to wear a black polo-neck and tight black jeans – like a baddie out of a Bond film. But I find the new look, with suit and tie, and Robin Day glasses, much more sinister!

Thursday 19 July 2018

Medication, trauma and psychiatry


As the UN Special Rapporteur announced last year:

 “Mental health policies and services are in crisis - not a crisis of chemical imbalances, but of power imbalances. We need bold political commitments, urgent policy responses and immediate remedial action.” 

“We need little short of a revolution in mental health care to end decades of neglect, abuse and violence.”

However, there is no sign of a revolution around the corner: indeed, with the economic power vested in the pharmaceutical industry and the social power in the medical profession, any UK policy change is likely to be fiercely fought - and very slow.

But there are some signs of an evolution – from the World Health Organisation, from some British professional institutions, the voice of service users, and from a small independent clinic in Oxfordshire – by using the lens of trauma treatment.

WHO
·         Historically, the psychiatric profession has defined disorders by their symptom presentation rather than by cause. This is changing with the 2018 publication of ICD-11: see previous blog ‘Thinking about Diagnosis’.

British professional institutions
·         The British Psychological Association has published a detailed critique of biomedical practice in the ‘Power Threat Meaning Framework’. Its central ideas include trauma-informed thinking, formulation rather than diagnosis, and relational practice.
·         Public Health Wales is running a large public education and information campaign about ‘Adverse Childhood Experiences’ and their consequences for individuals and society.
·         ‘Enabling Environments’ and ‘Psychologically Informed Planned Environments’ are becoming well established in the criminal justice sector, with government support.
·         ‘Psychologically Informed Environments’ are becoming similarly established in the voluntary sector, particularly for homelessness, with support from local commissioners, and lottery funding.
·         Several organisations have come together for a parliamentary launch of a consensus statement about ‘personality disorder’, led by Norman Lamb MP.
·         The Royal College of Psychiatrists is working on a parallel position statement.

Service users and other critics of mainstream services
·         Trauma is often not recorded or registered, and rarely taken seriously.
·         Mainstream psychiatric provision often re-traumatises people.
·         Medication only ever offers temporary and partial relief.
·         The most acceptable services are co-designed with experts by experience.

A small Oxfordshire clinic
·         Khiron House is residential trauma treatment service which takes private and NHS referrals
·         It combines a rigorously designed therapeutic environment with intensive individual and interpersonal neurobiological therapies (based on the work of Daniel Siegel, Pat Ogden and Bessel van der Kolk).
·         No other residential units in the UK offer this level of specific trauma expertise.
·         It prioritises psychosocial treatment over biomedical, and aims to work in collaboration with prescribing doctors.
·         It follows a wholly non-paternalistic model, and expects its residents to be able to take day-to-day responsibility for themselves.
·         Its current working practices are not suitable for CQC registration.
·         A higher dependency unit is being planned, with full nursing cover – for those who experience severe dissociative symptoms which require a higher level of psychosocial containment. This is likely to seek CQC registration.
·         Declaration of interest: I work for them as medical director (ie communication channel to the mainstream system), chair of ethics and governance board, and clinical advisor (specifically on therapeutic environments). It is a very part-time role, and does not involve any contact with the residents or involvement in the specific therapies.

Wednesday 18 July 2018

A real alternative to traditional treatment

There is a wind of change in the air, as evidenced by several formal processes related to mental health policy. This includes the publication of ICD-11, the parliamentary launch of the consensus statement on personality disorder, the Welsh government's public health strategy on adverse childhood experiences (ACEs) and trauma, the serious professional challenge to the NICE revision of depression guideline, emerging evidence of severe long-term adverse consequences of neuroleptics, and a recent report by the UN Special Rapporteur - who called for a revolution in mental health. LINK (also see previous blogs)

The therapy yurt under the apple blossom at Khiron House


Why Khiron is different
A small part of that revolution is what we are doing at Khiron House: delivering an intensive programme in which the primary modes of treatment are psychotherapeutic and psychosocial, and biomedical psychiatry has a secondary role. Many patients and clinicians appreciate that mainstream and traditional approaches can only offer superficial ways of coping with the consequences of severe and complex trauma - without ever truly overcoming it. We believe that our expectations and ambitions should be higher, as the growing body of research evidence indicates. Khiron’s work is based on providing a rigorously planned therapeutic environment in which highly specialised trauma-focussed psychotherapies can be delivered. This field is sometimes called ‘interpersonal neurobiology’, and the definitive interventions are based on the work of Pat Ogden, Daniel Siegel and Bessel van der Kolk. The planned environment work is based on several years' research and development on which the Enabling Environments award at the Royal College of Psychiatrists Centre for Quality Improvement is based.

What we are up against
One of our difficulties is how the whole health system, and its regulation and governance structures, is based on traditional views of disorder, ultimate responsibility and individualism. Our therapeutic philosophy is quite different: we see formulation and understanding as more important than diagnosis, we always try to help people to take responsibility for themselves in the face of paternalistic requirements of the system, and we believe that our residents’ forces of healing come as much from each other as from expert therapists. This means we do not fit very well with regulators’ expectations of zero tolerance of risk, or of staff being wholly responsible for the thoughts, feelings or behaviour of others; nor can our therapeutic and relational methods of promoting and maintaining safety ever meet strictly objective criteria.
However, through our Ethics and Governance Board, we intend to square this circle, and run an extremely safe service which exceeds regulators expectations, without perverse rules or policies, and is in line with our theoretical model, our therapeutic philosophy and our ethical stance.

Medication
One specific area of conflict is often that of prescription of psychotropic medication. Unfortunately, for many patients this has become the defining modus operandi of modern psychiatry. We do not deny the power or usefulness of medication, but only when it is used in specific circumstances and as a secondary means of support: the primary treatment with us is always psychosocial. 
All classes of psychotropic medication influence people’s mental state and experience of their own emotions: this is their purpose. However, this often impedes access to the feelings, thoughts and emotions which need to be dealt with by the psychotherapy process. This is why we encourage our residents to understand the medication they are on, be aware of what effects it might be having on them, and be taking as little as they need.
When severe emotional instability or dysregulation inhibits somebody’s capacity to participate in psychotherapy, judicious use of medication does have a role.  This is time-limited and the medication needs to be safely tailed off when the capacity for self-regulation capacity has been established through psychotherapeutic interventions.

Collaboration
We hope that our referrers and fellow-professionals understand and respect the way in which our stance is different to mainstream approaches – and that we all chair the common task of trying to provide the best ways for individuals to get the help they need. To do this, we want to work collaboratively with colleagues working in other settings, by sharing expertise and responsibility.

We do not prescribe medication at Khiron House, and we encourage our residents to keep a diary of their medication - and discuss it with their prescribers. These can be referring private or NHS psychiatrists, or home or local GPs. Our residents are strongly encouraged to understand why they are taking the medication which they are prescribed, and to have an active part in any decisions about it. We recommend that those with trauma-based conditions are on as little psychotropic medication as possible, and on none indefinitely.



Rex Haigh
Medical Director, Khiron House
Professor of Therapeutic Environments and Relational Practice, School of Sociology and Social Policy, University of Nottingham
Clinical Advisor, Enabling Environments, Centre for Quality Improvement, Royal College of Psychiatrists, London

20 July 2018

Wednesday 11 July 2018

Training for an age of chaos


In therapeutic communities, many of us have always resisted the push to be objectified or reified into ‘things’. I am a wholehearted believer that we are more interested in ‘a way of being with each other’ (aka ‘relational practice’), and a political and emancipatory movement – than in defining a fixed ‘treatment brand’. To me, this also means that the expression of these ideas has to keep up with the world in which they need to exist: TCs need to continually change and modify themselves. IF not, they risk being seen as throwbacks to a past age of radicalism with no contemporary relevance. And I wonder to what extent this is already true. I sometimes get a sense that some “TC hardliners” would rather have TCs die - than that they actively evolved. I fear that some some wallow in wistful sadness, righteous indignation and elemental fury that the ‘pure’ model of TCs has been challenged and found wanting. And that the process has, maybe sadly, killed off some of the best known of them.

But one adaptation I think we are nearly all agreed on is the need to spread the ideas and disseminate the practice beyond the world of ‘pure TCs’ – and to do this in a way that works in the current context. This is the idea behind both EEs (the ‘Enabling Environments’ initiative) and TCEPT (‘Therapeutic Communities and Environments Practitioner Training’). The course is pitched at a level between a short course (such as for EMDR or basic skills) and a full professional qualification (such as a UKCP registered psychotherapy), and it will be suitable for people at all levels of the hierarchy (in true TC fashion), and in all relevant professions (as well as adjacent ones). One of the main pedagogical principles is that we all have much to learn from each other.

That said, it will be rigorous. There will be three residential 3-day blocks to the training: a ‘basic theory module’, followed by an ‘intensive experiential’ one and finishing with the ‘advanced theory module’. They can be completed in just over a year, or participants can take longer if they want. Alongside this, members of the course need to be working in a suitable setting – on which they can reflect in monthly online supervision sessions. This can be anything from a traditional TC to a wide range of places that want to establish more therapeutic ways of working. This includes psychiatric wards, prison wings, voluntary sector projects, or indeed anywhere that wants to become a better therapeutic environment. In addition to this, other course elements include visits to established therapeutic communities, psychologically informed planned environments (PIPEs), psychologically informed environments (PIEs) and enabling environments, and various other ways of learning about them. There is no written work, but participants are encouraged to work in project teams that are linked to their day jobs, and everybody will do a group exercise to rate their ‘before and after’ competencies.

The three residential modules will be held in a beautiful organic farm study centre in Kent, with between twelve and twenty participants, and a staff team of experts in the field. It is starting in October 2018. If you are interested, please contact Sue Pauley through the TCEPT website: www.tcept.org. 


Friday 22 June 2018

Thinking about diagnosis



In psychiatry, a diagnosis can only ever be an ‘expert opinion’, because there are no x-rays or blood tests to show what is going wrong in the brain or nervous system. Over the last twenty years, much effort and expertise has been spent on trying to refine psychiatric diagnoses and make the process more ‘scientific’, so detailed questionnaires and structured interview schedules have been produced with sophisticated statistical analyses to show ‘validity’ and ‘reliability’. Although this ‘scientific’ process has helped researchers to define who should be in their research studies and who should not, it has misled public opinion and given the process of diagnosis an importance and authority it does not deserve. It is not coincidental that a great deal of psychiatric research is funded by the pharmaceutical industry, and funding for psychotherapy research is very much lower.

Problems include:
·         The internationally agreed diagnoses are agreed by committees of experts with no objective or incontestable basis (such as radiology or biochemistry).
·         The need for diagnosis, at least in America, is driven by the medical insurance industry.
·         Until recently, diagnostic systems have deliberately excluded anything concerned with the cause of the disorders.
·         The diagnoses all have ‘fuzzy edges’, and often overlap with diagnoses that sound quite different (as Stephen Fry has said, “it is a moot point where bipolar disorder ends and personality disorder ends” )
·         Most people with severe problems have overlapping problems which can be given more than one diagnosis.
·         In mainstream practice, which is usually based on a biomedical model, there is neither time nor expertise to untangle somebody’s symptoms into very tightly defined diagnoses. It is more important to see what somebody’s immediate needs are, and to address them.
·         In psychotherapeutic or trauma-informed practice, a narrative to make sense of the symptoms – a formulation – is produced, ideally in full collaboration with the subject. Although this is normally experienced as helpful in understanding the symptoms and problems, it is opposition to the diagnostic approach. This is because it a formulation is  different for everybody, and not generalisable. Therefore, without a diagnosis, however flawed it may be, it is not possible to be precise or systematically about deciding treatment.

However, things are changing. The new edition of the World Health Organisation’s diagnostic manual (International Classification of Diseases version 11, “ICD-11”) has just been published on their website, and is due to come into full operation in a couple of years. It contains some interesting changes from the previous version.
Here are some of them:
·         There is a new section called ‘Disorders specifically associated with stress’ (6B41) which includes PTSD, Complex PTSD, Prolonged grief and adjustment disorder. The important one here is ‘Complex PTSD’ which requires repeated or prolonged stress – and have many symptoms overlapping with what we previously called ‘Borderline Personality Disorder’. Because of this, it may well now be better-justified – as well as more acceptable to patients/clients/service users - to use the CPTSD diagnosis instead of BPD.
·         Personality Disorder itself has been given a complete make-over in the new classification. All the old categories like paranoid, avoidant, borderline, antisocial, narcissistic and histrionic have gone, to be replaced by a simple measure of severity – severe, moderate and mild. There is also a ‘personality difficulty’ level, which includes a large proportion of the human population – but is not classified as a disorder. For greater descriptive power, each level of severity can be assigned one or more of six ‘flavours’, which are somewhat similar to the old categories: ‘negative affectivity’; ‘detachment’; ‘dissociality’; ‘disinhibition’; ‘anankastia’ or ‘borderline pattern’. This means that each person will only have one diagnosis, not many – although the more severe diagnoses are likely to have more ‘flavours’. The lines between the levels of severity have not been firmly specified yet, but are intended to reflect how many areas of a person’s life are affected, and how persistently.
·         Another new section - much elaborated from the old single condition – is ‘dissociative disorders’. This itself reflects the greater prominence given to internal mental mechanisms – and indicates a less biomedical approach to mental life. The particularly interesting new addition is Dissociative Identity Disorder (DID – previously also known as ‘multiple personality disorder’). This is a diagnosis that has generated much heat and little light amongst psychiatrists in the past, and its addition to ICD-11 might leave some old-school psychiatrists – and their modern followers – rather unhappy. There is also a milder category of the same condition called ‘Partial DID’, which is less continuous and pervasive:
The non-dominant personality states do not recurrently take executive control of the individual’s consciousness and functioning, but there may be occasional, limited and transient episodes in which a distinct personality state assumes executive control to engage in circumscribed behaviours, such as in response to extreme emotional states or during episodes of self-harm or the re-enactment of traumatic memories.

As with Complex PTSD (above), this may well become a popular replacement for the old ‘Borderline PD’ or ‘Emotionally Unstable PD’, or alternative to the new ‘Personality Disorder with Borderline Pattern’.

All in all, this looks to represent a movement away from the biomedical hegemony towards a more open and flexible diagnostic system. It does not answer the critics of westernised psychiatry’s colonisation of the territory, across the world, but it goes some way to acknowledging that ‘what happened to you?’ is more important than ‘what’s wrong with you?’.

Thursday 31 May 2018

The End of an Era: Greencare moves on

Today was a big day. an ending and loss; and hope for a future of which we know few details.  We knew it was coming, and we were as well organised for it as a royal wedding - with a great deal of work, a good bit of ritual and a fantastic cake.

Here's a video snip of my last walk to the yurt:



There were about twenty of us to do the day's business - group members past and present, staff, ex-staff, peer mentors from Hope Recovery College, and - in the afternoon - out special visitors. Of which, more below.

The event marked the end of our time at Iver Environment Centre, and the dismantling of the yurt -and putting it into storage until Hope Recovery College (which is part of Slough Borough Council's social programme for mental heath) finds a site to continue the Greencare work. And when it continues, it will be run by the recovery college, and its marvellous team of peer mentors - many of whom have been involved with the Greencare project over the last few years.

We have been unable to stay at Iver for several reasons - some of which are sad, and some of which point to a new hope for the future.

The sad ones include the way we have found it increasingly difficult, particularly over the last year or so, to fit with the corporate vision of National Grid, who are the owners of the land. They are moving towards an increasingly commercial use of the site - with little scope or space for small and somewhat unusual social enterprises like us, run and staffed by committed and passionate volunteers.

In some ways, it has never been an ideal site - several miles out of town, across the county boundary, and accessible by public transport only by a slow and circuitous bus journey. But the new hope comes from what we have built together over the last seven years there - the passion and dedication of everybody involved in the group, both members and staff - and the group dynamic methods we have developed by co-creation. The plans mean that the responsibility for, and ownership of, the yurt and greencare project now pass from the directors of Growing Better Lives (who will no longer be involved in the groups) to the peer mentors and staff of Hope Recovery College.

Once a new site is found for the yurt, it will allow a blossoming of the work to include many others who can benefit from its unique therapeutic qualities - in easy reach of town, but with all benefits and joys or working as we have all learned to do. That is our sincere hope, and we know it is shared by those who have leadership roles in Hope Recovery College.

After an extraordinary effort to dismantle the yurt before the anticipated downpour, which was completed by early afternoon (including coffee and pizza breaks), we had the ceremonial 'handing over' at 3pm. And still no rain.
The ceremonial handing over of the yurt

Introduced by music in 'The Garden of Time', members of the group and the staff enjoyed poems and moving testimonies before the formal business. One of four poles from the door section of the yurt was handed over to Geoff Dennis, the head of the Borough's mental health services, and Hope Recovery College. A magnificent yurt-shaped cake - lemon and elderflower flavoured - was cut and enjoyed by all. Just like Harry and Meaghan's, I was told.

Before the yurt is re-erected, the poles will be engraved with the mission statement of Growing Better Lives (in the right hand column of this blog).

So our dear yurt was packed away in a tiny cubicle of the yellow storage company - an extraordinarily alien environment - awaiting its release, and new home.

Watch this space to find out where it will be...

Sunday 27 May 2018

Stiamo ancora imparando da Basaglia


Titolo: Il Post modernismo

Autori: Rex Haigh
Traduttore: Laura Liverotti

Luogo: Forum di Catania - 25.05.2018



Il Postmodernismo

In una comunita’ terapeutica, affinche’ si possa lavorare in modo efficace, c’e’ bisogno di usare modalita’ che differiscono da quelle adottate per esempio nell’istituzione della Psichiatria Biomedica.

Recentemente, ho letto un libro che parla in modo molto approfondito di Franco Basaglia, scritto da uno storico Britannico di nome John Foot. Devo dire che la sua storia offre molto di piu’ di quello che pensavo e, l’esperienza italiana di cio’ che viene definito l’antipsychiatry’ (l’anti-psichiatria), continua ad avere ancora una certa rilevanza nel contesto attuale, a differenza dei lavori di Laing, per i quali non e’ piu’ cosi’ in Gran Bretagna.

Quando ho letto di Mario Tomassini di Parma e di Giovanni Jervis di Reggio Emilia ho pensato ‘questo e’proprio quello che stiamo cercando di fare al momento in Slough ed Oxford. Siamo forse piu’ vicini ai principi che provengono da Gorizia che a quelli proposti dalla Kingsley Hall.

Percio’ in questo mio internvento, usufruendo del pensiero critico del Postmodernismo, provero’ a raggruppare insieme alcune di quelle tematiche che riguardano il lavoro di comunita’ terapeutiche e degli ambienti abilitanti.

Attualmente, viviamo in sistemi che sono altamente gestiti da politiche, procedure e protocolli. Al contrario, le comunita’ terapeutiche hanno bisogno di flessibilita’ e di spontanieta’ (e di creativita’). Questo pero’ e’ difficile da mantenere nella scia di richieste sempre piu’ esigenti di protocolli standardizzati e manualizzati. Uno dei modi che attualmente viene utilizzato in Gran Bretagna e’ chiamato ‘relational practice’ (pratica delle relazioni) piuttosto che ‘procedural practice’ (pratica della procedura). In un mondo dove le persone si aspettano soluzioni mediali per ogni problema, numerose regolamentazioni ed una tolleranza ‘zero’ riguardo al rischio, cio’ che e’ umano ed ordinario e’ stato perso. E quello che che e’ stato perso ha un ruolo centrale nella relazione terapeutica, e qui non parlo necessariamente della conoscenza dell’analista, bensi’ mi riferisco all’aspetto umano ed all’ordinarieta’ del convivere l’uno con l’altro. O, come per esempio, le persone non trovino facile rilassarsi ed essere informali l’uno con l’altro sul posto di lavoro. Il personale clinico e’ spesso reso ansioso dal dover applicare ed aderire correttamente alle ‘prescrizioni del manuale’, o se il ‘livello di rischio’ e’ stato annotato sul computer dell’ospedale. Una parola che usiamo per descrivere cio’ che manca e’ la “therapeutic ordinariness” (ordinarieta’ terapeutica) - ed il progetto ‘Enabling Environment’ si basa prorio sui principi di questa ‘’relational practice’ (pratica delle relazioni).

La prima volta che ne ho sentito parlare fu nel 1978, quando, all’epoca studente di medicina, attendevo le lezioni di Science Sociali condotte da David Ingleby. Lui era uno scienziato sociale radicale all’Universita’ di Cambridge, e quello era proprio l’anno in cui la Legge 180 fu passata qui in Italia. A quel tempo, Ingleby stava scrivendo un libro dove spiegava come la malattia mentale fosse primariamente un problema politico e getto’ dubbi riguardo le affermazioni fatte circa l’oggettivita’ scentifica, proponendo metodi qualitativi piu’ precisi con l’obiettivo di ottenere un maggiore livello di significato dai punti di vista fenomenologico ed interpretativo (David Ingleby usa il termine ‘depth hermeneutics’ e lo relaziona alla comprensione psicoanalitica). In questo modo ci propone una visione della sofferenza mentale che e’ piu’ vicina all’esperienza del paziente e meno contaminata dall’ineguaglianza e dal divario di potere intrinsechi alla pratica clinica. Nonostante al tempo non ne fossi a conoscenza, cio’ e’ molto vicino a quello che Basaglia promuoveva in Italia. Il libro fu pubblicato nel 1980 e si intitola “Critical Psychiatry”. L’importanza di questa esperienza soggettiva del paziente e’ diventata un aspetto centrale nel movimento dei ‘service users empowerment’ (responsabilizzazione degli utenti), ed e’ stato uno dei principi fondamentali delle comunita’ terapeutiche sin dai suoi albori: un modo che ha ri-bilanciato il concetto di potere. Negli ultimi 15 anni, nel movimento britannico c’e’ di forte tendenza a “ri-definire” i servizi pubblici, sia nel settore sanitario che forensico, per coloro che hanno una diagnosi di Disturbo di Personalita’.

In Gran Bretagna, intorno agli anni ’70, Ronald Laing era visto come il trascinatore del movimento dell’ ‘antipsychiatry’, ma come Franco Basaglia, anche lui negava di vuolersi sbarazzare della Psichiatria, anche se la vuoleva cambiare. L’obbiettivo di Laing era quello di voler capire piu’ approfonditamente le esperienze del paziente: per quanto ho capito, il proposito principale di Basaglia ed la sua equipe era, prima di tutto, di sviluppare una comunita’ terapeutica a Gorizia cosiche’ da offrire ai pazienti condizioni piu’ umane, e susseguentemente di smantellare le grandi istituzioni. Tuttocio’ avveniva nel contesto della rivoluzione giovanile degli anni ’60, che rese tutto molto piu’ intenso e politico e confuso. Comunque entrambi, Laing e Basaglia, ci stavano mostrando come le realta’ sociali, politiche e culturali svolgono un ruole vitale in aiutarci a comprendere la sofferenza e l’esperienza della pazzia, e di come allo stesso tempo dovremmo e non dovremmo rispondergli. 

Nonostante le grandi istituzioni siano ormai chiuse da anni, in Italia come nella Gran Bretagna, il problema legato all’ ‘institutional thinking’ (pensiero istituzionale) continua a manifestarsi in modi diversi. Nessuno e’piu’ legato con catene o trattato come un animale, ma continua a soffrire della degradazione, della mancanza di emancipazione/responsabilizzazione e di rispetto, sentendosi cosi’, oppresso, alienato e come un cittadino di seconda categoria. Non sono necessari vecchi edifici per avere relazioni deleterie con coloro che si trovano in uno stato di bisogno. Io chiamo cio’ ‘institutionalisation in the head’ (l’istituzionalizzazione nella testa). I procedimenti che sostengono questo sono quelli  moderni delle regolamentazioni, della standardizzazione e del controllo sociale che rendono l’assistenza sociale simile ad una procedura industriale invece di essere umana e basata sulla speranza, la fiducia e le relazioni vere. Il lavoro attuale della Psichiatria, nel peggiore delle ipotesi, e’ quello di diagnosticare e prescrivere i farmaci necessari, e di evitare rischi. Purtroppo l’idea che il miglior modo per limitare i rischi sia quello di sviluppare e mantenere rapporti terapeutici, non e’ riconosciuta come valida. Questa e’ una delle idee alla base della ‘Critical Psychiatry’ (Psichiatria Critica), che a sua volta segue la scia dell’ antipsychiatry (anti-psichiatria) di 50 anni fa.



Alla fine dello scorso millennio, nel 1999, Greenhalgh e Hurwitz scrivevano proprio riguardo a quello che e’ stato perso:

“All’apice piu’ arido, la medicina moderna scarseggia di una metrica per misurare le qualita’ esistenziali come il dolore interiore, e che certamente costituiscono le malattie di cui le persone soffrono. Durante la formazione medica, la continua sostituzione di quelle abilita’ considerate “scientifiche” - quelle che sono eminentemente misurabili ma inevitabilmente riduzionistiche - con quelle che sono fondamentalmente linguistiche, empatiche ed interpretative, dovrebbero essere viste come aspetti vittoriosi del curriculum moderno.



Bradley Lewis, uno psichiatra americano, promouove il metodo narrativo nella Psichiatria (Lewis, 2011):

“Questo e’ il momento della ricerca dell’anima per la Psichiatria. Nonostante gli investimenti che la Psichiatria ha fatto in creare classificazioni rigorose e nella Neuroscienza, il campo attualmente sta riscontrando opposizione e critiche reminescenti quelli degli anni sessanta e settanta. Il giornalismo investigativo, i consumatori ed gli attivisti della riabilitazione, gli accademici nelle Scienze Umanistiche, Scienze Sociali e gli studi sulla disabilita’, ed i networks della ‘Critical Psychiatry’, esperimono tutti  una crescente preoccupazione sul fatto che questo dsciplina abbia smarrito la sua strada.”



La maggior parte del lavoro all’interno della nostra comunita’ terapeutica riguarda i costrutti narrativi , sia per ragioni storiche, che guardano alle ragioni per cui i suoi membri sono ‘finiti li’, sia per la storia del loro percorso come membri di comunita’ e di come cio’ abbia un impatto sia su loro stessi che su coloro a cui vivono insieme. Il gruppo di ammissione (che e’ parte del nostro processo di ammissione all’interno della comunita’) e’ il momento in cui la narrativa circa il “perche’ ho bisogno di essere qui” diviene cristallizata in una sessione di mezz’ora con il resto della comunita’.  Cio’ ha una profonda valenza terapeutica, e cioe’ quella di creare il senso di appartenenza  e di attaccamento, insieme a quello di comunicare informazioni importanti. Obbiettivi simili sono ottenuti anche quando, usando una modalita’ simile a quella descritta, si vanno a valutare i progressi raggiunti dai residenti della comunita’; cio’ infatti non deve essere vista soltanto come un ostacol o una formalita’ amministrativa, bensi’ un’ esposizione inevitabile, difronte al resto del gruppo, di quei sentimenti legati ai propri miglioramenti ottenuti all’interno della comunita’ terapeutica; nonche’ un’opportunita’ per i nuovi arrivati di vedere il tipo di narrativa che potrebbero essere in grado di generare per loro stessi.

Questo problema ontologico puo’ essere osservato da un angolo diverso e cioe’ come il ruolo del dubbio, di una narrativa complessa ed il graduale sviluppo delle conclusioni ed azioni siano oscurate da una visione digitale - 0/1, si’-o-no - di cio’ che e’ corretto. E’ come se ci fosse una tolleranza zero riguardo all’incertezza. I metodi ermeneutici e qualitativi, i fattori relazionali, le variabili contestuali ed altre distrazioni che permettono all’incertezza di emergere, sono viste come un’interferenza nell’algoritmo, e percio’ negate di ogni rilevanza significativa. Questo bisogno di certezza si nasconde dietro ai paradigmi dominanti della ricerca, e piu’ chiaramente nella gerarchia delle evidenze.

Al fine di trovare quelle prove che siano accettabili cosiche’ da influenzare le direttive nazionali sui trattamenti, una terapia deve far si’ che le sue evidenze trovino un posto, il piu’ alto possibile, all’interno di questo ordine gerarchico.  L’evidenza ‘gold standard’ e’ una meta-analisi dei randomised control trials di alta qualita’. Tra una vasta gamma di trattamenti psicologici che competono affinche’ vengano riconosciuti e finanziati, la richiesta di evidenze accettabili porta ad una mentalita’ tipo quella dei concorsi di bellezza, dove i trattamenti sono definiti, attuati, pubblicizzati e messi sul mercato come prodotti facili da replicare. Queste terapie, allo stesso modo,  possono essere cosi’ trascritte sottoforma di manuali ed essere passate attraverso il processo piu’ adatto di raccolta di dati. Steve Pearce, un collega di Oxford, che e’ anche uno Psicoterapeuta medico che lavora in comunita’ terapeutiche, ha intrapreso questa sfida e, nel 2016 ha pubblicato nel British Journal of Psychiatry, i risultati del suo studio sui gruppi randomizzati all’interno di comunita’ terapeutiche non-residenziali. In un certo senso penso che abbia fatto l’impossibile, ed allo stesso tempo forse ha anche aiutato la sopravvivenza delle comunita’ terapeutiche britanniche. Penso che gli organizzatori di questo incontro, lo vorrebbero invitare a Roma l’anno prossimo, cosiche’ possa parlare del suo studio.

Ho comunque delle riserve circa questo processo di ricerca; la prima riguarda la stretta somiglianza con gli studi sui farmaci condotti dalle industrie farmaceutiche; la seconda riguarda l’inadeguatezza di questo modello cosi’ rigido ed inflessibile. Inoltre lo vedo come parte di un progetto commerciale neoliberale con l’intento di confezionare e promuovere i trattamenti di psicoterapia come se fossero comodita’ che possono essere acquistate in un negozio. Penso che questo sia un esempio di economia di mercato usata in un ambito nel quale non dovrebbero, e vengono sostenute da un tipo di scienza positivista che, a sua volta, e’ usata in contesti in cui non e’ adeguata. 

Comunque, segnali di un metodo piu’ sofisticato e flessibile stanno emergendo, in cui la ‘qualita’ della prova’ sta divenendo un concetto piu’ complesso. Nel 2016, Steenkamp sostiene che le scelte di trattamento, in linea con i principi fondamentali della pratica clinica basata sulle evidenze, dovrebbe essere basata su tre principi:

·        La prova migliore
·         
·        La scelta del paziente, e
·         
·        L’espereinza clinica
·         
Inoltre, sostiene che, a parte il facilitare una processo decisionale condiviso, una sceta piu’ adatta e’ possibile; per esempio quella tra i fattori specifici legati ai pazienti ed i trattamenti disponibili. Cio’ sta a simbolizzare uno spostamento significativo da quella che e’ l’inflessibilita’ delle scelte del trattamento algoritmico, basate solamente sui trattamenti standardizzati ed ‘pazienti uniformati’.

Un fattore che limita ulteriormente il valore degli studi competitivi e’ la scoperta di come terapie specifiche diverse possono essere ugualmente efficaci e che la loro efficacia dipenda maggiormente da ‘fattori terapeutici non-specifici’ che sul tipo di terapia in se stesso. Questo e’ stato dimostrato molte volte, e risale al verdetto del ‘Dodo-Bird’ (dove tutti hanno vinto ed ognuno dove avere un premio). Questo fu sostenuto per la prima volta nel 1936 da Rosenweig, poi  dimostrato con la ricerca di Luborsky nel 1975, e da allora continua ad essere elaborato in modi diversi. Per esempio Lambert, nel 1992, mostra le percentuali relative ai diversi fattori presenti nei trattamenti psicosociali:

·        La relazione terapeutica 30%
·         
·        I fattori esterni 40 %, e
·         
·        L’aspettative di/l’effetto placebo 15%, lasciando
·         
·        alle specifiche tecniche terapeutiche il rimanente 15% di impatto sull’efficacia
·         


La mia preoccupazione e’ che questo e’ un po’ come la questione degli angeli che danzano sulla capocchia di uno spillo. Sappiamo che la salute e la felicita’ dell’ individuo consiste nella capacita’ di relazionarsi agli altri, e la ricerca moderna non da’ a questo aspetto - l’ ‘a priori’ - la priorita’ necessaria.

La considerevole e contestata letteratura che critica la ‘evidence-based practice’ va aldila’ dello scopo di questo intervento, comunque voglio dire che la tendenza verso l’accettare solo ricerche standardizzate ed aggregate di campioni sempre piu’ grandi sta dirigendosi nella direzione sbagliata, in quanto si sta allontanando da quella che e’ la comprensione dell’importanza delle relazioni umane. E sono proprio le comunita’ terapeutiche che rischiano di soffrirne di piu’ di questo. Al contrario di poter essere applicabili in modo uniforme su una vasta popolazione, le comunita’ terapeutiche sono fondamentalmente complesse e, in un certo senso, hanno anche in che di caotico. Questo pero’, nel vero senso della parola, e’ dove la sua complessita’ porta allo sviluppo di ‘fenomeni emergenti’ (spesso non intezionali) e di un sistema ‘caotico’ che, come il tempo, non puo’ essere previsto da statistiche deterministiche, aldila’ del loro grado di sofisticazione. In questo sistema, ogni individuo e’ riconosciuto per le sue differenze - la sua unicita’ e specificita’ per esempio - e non per la sua diagnosi. Cosi’ come, ad un livello successivo, ogni comunita’ terapeutica e’ orgogliosamente diversa l’una dall’altra, rendendo la specificita’ della ricerca uniformata quasi impossibile. Per questo motivo abbiamo bisogno di un tipo di ricerca diverso, ed anche se credo che ancora non sappiamo esattamente di come questo sia, al momento ci sono progetti di ricerca non-biomedica molto interessanti.

Una ricerca piu’ co-ordinata richiede un maggiore sforzo in quanto ha bisogno di sostegno sia organizzativo che di quello finanziario. In questo campo, il sociologo Nick Manning ha evidenziato una ‘politics of data’ (politica dei dati), il cui risultato e’ stato quello di non prendere le comunita’ terapeutiche come oggetto di studio di ricerca e, che di consequenza non hanno ricevuto finanziamenti da parte di quelle ‘istituzioni di ricerca’ appartenenti al campo biomedio o psicologico. Questo tipo di ricerca, siccome non raccoglie i dati secondo le modalita’ previste, non ottiene finanziamenti governativi; e senza tenere in considerazione coloro che revisionano articoli per riviste scientifiche, i quali probabilmente non accetterebbero articoli considerati ‘dissidenti’. Per questo motivo, la visibilita’ delle comunita’ terapeutiche nella letteratura di ricerca convenzionale e’ scarsa.

Comunque, c’e’ da dire che grazie ai recenti progetti di ricerca portati avanti dagli utenti (service users led research) forse c’e’ spazio per un po’ di ottimismo. Questi studi, seguendo metodi rigorosi e sistematici, pongono una notevole attenzione all’esperienza di coloro che si trovano in posizioni svantaggiose, e fanno fronte a quei temi che, sia i clinici che gli accademici, hanno in precedenza evitato. Questo va di paripasso con la ricerca in psicoterapia e gli studi sulla sua efficacia, secondo cui i risultati sono validi solo in certe condizioni che non esistono nel mondo reale. Questo e’ un buon momento per le comunita’ terapeutiche ed e’ cosi’ da un po’ di tempo. Qui, tutto cio’ che avviene - i nostri colleghi di ‘Open Dialogue’ chiamano cio’ ‘polyphony’ (polifonia) - e’ visto come un’opportunita’ per dialoghi che offrono spiegazioni molteplici ma dove nessuna di queste ha lo stato di verita’ assoluta; e dove, le opinioni di ogni individuo offrono esperienze differenti che a loro volta possono poi essere usate cone spunto di lavoro in terapia; e dove, le scelte e le decisioni sono prese secondo una specie di ‘emotional democracy’ (democrazia emotiva).

Tutto cio’per dire che le relazioni umane, ed in particolare quelle che si formano all’interno delle comunita’ terapeutiche, non possono essere “modernised” (modernizzate) secondo protocolli precisi, regole e controlli di conformita’. Queste rimarranno inevocabilmente complicate, difficili ed incerte, ma allo stesso tempo variopinte, emozionanti e divertenti. Questa e’ sicuramente una delle ragioni per cui non vorrei mai lavorare in ambienti clinici tradizionali dopo aver lavorato una vita all’interno di comunita’ terapeutiche.

Questo e’ tutto sulla Postmodernita’. Adesso invece, per la parte conclusiva di questo mio intervento, vorrei proporre l’idea che le comunita’ terapeutiche sono un esempio eccellente di pratica clinica post-moderna e dovremmo essere in grado di usarlo a nostro favore. In un certo senso, la miglior definizione della postmodernita’ che conosco e’ quella di Jean-Francois Lyotard: “NO GRAND NARRATIVES” (Lyotard, 2001). Sia il tradizionalismo che la modernita’ hanno le loro “grand narrative”, fatte di spiegazioni onnicomprensive che hanno l’obbiettivo di giustificare il tutto, predire cio’ che accadra’ ed avere tutto chiaro ed ordinato – igenizzato, contenuto e senza stati anziosi. Il Post-modernismo riconosce che cio’ e’ impossibile.

Da un punto di vista clinico, questo produce paradossi come quello del fenomeno della ‘overconfidence’ (presunzione/eccessiva sicurezza). Per esempio, come quando un membro del personale, e’ sicuro di fare la cosa giusta, probabilmente ‘sta sbagliando’! E forse, cio’ che accade secondo un meccanismo relazionale, e’ che lo stesso membro del personale appare agli altri come se non fosse intenzionato ad aprirsi emotivamente (perche’ cosi’ sicuro di essere nel giusto). Cio’ comunque conduce alla inevitabile conclusione che forse non e’possibile ‘essere sempre nel giusto’.

Un altro aspetto clinico del “no grand narratives” e’ come i membri delle nostre comunita’, specialmente coloro che hanno ottenuto un certo grado di autonomia, non sono molto propensi ad ascoltare quando gli viene detto che cos’e’ meglio per loro o che tipo di sentimenti stanno provando. Queste persone possono farsi idee da una vasta gamma di stimoli che, per esempio, includono le loro esperienze personali, l’internet, i libri di auto-aiuto, l’arte, i racconti dettagliati e profondi degli amici ed infine gli esperti. Comunque c’e’ da dire che adesso gli esperti non hanno piu’ l’ultima parola.

In un’era caratterizzata dalla ‘New Public Management’ (Nuova Gestione Pubblica), viviamo in un mondo dominato dalla modernita’. Tutte quelle organizzazioni finanziate dal pubblico, dai servizi sanitari alle universita’ ai servizi sociali, devono dimostrare sia responsabilita’ che transparenza rispetto alle specifiche strutture e sistemi di regolamentazione governativi. Questo e’ una modalita’ monotona che manca di creativita’, e spero che le comunita’ terapeutiche possano offrire qualcosa di diverso ai nostri membri, al personale ed all’organizzazione in cui lavoriamo.

Allora, proviamo a dividere i vari approcci verso la salute mentale in tre categorie:  tradizionali, moderni e post-moderni. L’approccio ‘Tradizionale’ che e’ il vecchio sistema del manicomio e delle grandi istituzioni con gerarchie rigide e dove il potere e’ tutto nelle mani dei professionisti, di solito i dottori. L’approccio ‘Moderno’ e’ quello del ‘New Public Management’ o, come alcuni lo chiamano, ‘performativity’ (la migliore performance), dove tutto e’ stabilito e controllato con esattezza, dove ci sono protocolli scritti per ogni variazione/divergenza od eccezione fatta o per qualsiasi inadempienza, e dove l’efficacia, la performance ed i risultati possono essere esattamente misurati e verificati. Qui il potere e’ nel sistema che e’ democraticamente responsabile. Infine, l’approccio ‘Post-moderno’ che e’ molto piu’ difficile e critico, e molto piu’ simile alle caratteristiche delle comunita’ terapeutiche che ho descritto. Ma siccome e’ basato sulle relazioni umane, nonstante la sua creativita’, spontaneita’ ed anche forse un po’ di anarchia, e’ in un certo senso il piu’ difficile da gestire. Ma forse sono proprio questi gli aspetti che rendono la vita degna di essere vissuta o un lavoro degno di essere fatto. Qui, il potere e’ fluido anche se deve essere contenuto all’interno di una struttura contenitiva.

Per concludere, vorrei che tutti noi celebrassimo questo modo di lavorare che segue il ‘Moral Treatment’ (il trattamento morale) del 18esimo secolo quando pochi illuminati riconobbero che le persone con disturbi di salute mentale avevano bisogno di essere trattati come esseri umani. Questo stesso pensiero fu ancora una volta rivisitato negli anni ’60 con il movimento italiano ed inglese dell’antipsychiatry.

Oggi, 50 anni piu’ tardi, cerchiamo di fare la stessa cosa. Lo stiamo ancora facendo nelle comunita’ terapeutiche e negli Enabling Environments (ambienti abilitanti), ed anche qui in Sicilia con il Visiting Project. Credo che adesso sappiamo come costruire la struttura contenitiva all’interno della quale, il potere dello Psichiatra puo’ essere esercitato con compassione ed umanita’.