Northfield flashback

GASI is the Group Analytic Society International - and it has a regular schedule of well-attended meetings, conferences and workshops, mostly in Europe. It also is reputed to have the scariest on-line email discussion forum of any professional society.

Wish you were here

Then and now

This January, its annual Winter Workshop was held at what was the 'Northfield Military Hospital' (in the Second World War) - to celebrate the 75th anniversary of the group therapy experiments that happened there - and led to all sorts of relevant things since.

What was then one of the four large psychiatric hospitals of southwest Birmingham (Hollymoor by name) is now almost entirely modern rows of housing with hedges between neat green lawns and cars in the front drive which one imagines are washed every Saturday. The mighty water tower, with its copper cupola that is a landmark that can be seen for miles - is listed and remains; a few scattered old buildings from the old site have also found modern NHS uses.

Through the work of the officers there, particularly Bion, Rickman, Foulkes, Main and Bridger, the whole field of 'Group Analysis' was founded (and thence GASI itself), the mental health Therapeutic Communities were developed, and many other spin-offs started and grew, particularly in the world of group theory, such as the Tavistock Institute of Human Relations. 

The format of the two days was thoroughly groupish, apart from the four short plenary presentations by various experts: two ninety minute median groups for eighteen people - in the very building where the wartime experiments took place, and two ninety minute large groups to close each day, with a little under a hundred people.

The median groups - or at least the one I was in - seemed to be a good place to feel the cold (the heating was broken) and imagine how much worse it probably was in the winter of 1943. Also, to have various conversations linking members' lives and work to the thoughts and feelings that arose from the other parts of the workshop. As described by Pat deMare, who worked with some of the Northfield pioneers and wrote extensively about groups:

GASI median group room.
Bion and Foulkes stalked these corridors:
did they hold groups in this room?

The avowed purpose of the median group is to encourage members to learn to talk to each other, to learn to dialogue so as to humanize society, and to transform frustration and outrage into the positive energy required to think (de Maré, 1990). Thus, the median group as socio-therapy is a tool that fosters the societal and community life of the citizen, familiarizing its members with democratic principles, while serving as a platform to practice democracy in action. 

As well as having a scary internet forum, GASI is famed for its large groups, which are well documented to be crazy places. This workshop did not disappoint. With nearly one hundred people from all over Europe and a few from beyond, assembled in two concentric circles, plus two conductors, and no set agenda, we went all over the place. Fascinating, enraging and frustrating - occasionally warm and enabling, even sexual - but powerful emotional statements from the regulars seemed to keep us newbies rather quite. I understand from some others there that some of the overt topics might now have moved from Palestine and Israel to British colonial atrocities and the Balkans. But highly recommended as a profound challenge to how you think and feel in groups, even if you can't participate much.

If only they got to understand more about modern TCs and where it is all going. But the air was full of closures, destruction and betrayal (not to mention the terrors of war) - without much space for hope, optimism and playfulness.
So be it - there are other shows in town...

Concepts for Democratic TCs

The there are usually two usual 'main types' of therapeutic community that are seen as different:

Various names	Hierarchical	Democratic
	Addiction	Mental health
	Concept or Concept House
	Behavioural	Psychotherapeutic
	Synanon-type	Maxwell Jones-type
Comes from…	New York Daytop Village in 1950s	British WW2 group experiments in 1942
Initially for…	Homeless drug addicts	Shell-shocked soldiers
Now for…	All addictions	Mental health and ‘personality disorder’
Distribution	USA and whole world. Few in UK	UK and some in Europe
Number	Many thousand	Low hundreds
Distinguishing features	‘The Concepts’ Strict rules Staffed by ex-users (usually ~50%) Stages and graduation ceremonies Always residential Initially some were punitive	Flattened Hierarchy (lately ‘fluid’) Permissiveness Mostly professional staff, plus co-creation with ‘experts by experience’ Residential, day, mini and micro Some were seen as anarchic
Sector/setting	Usually not-for-profit	Health service & hospital Prison Social care
Examples	Ley (Oxford) Coolmine (Dublin) Phoenix Futures	Henderson (closed 2008) HMP Grendon Thames Valley CNS

Coolmine has two residential TCs in Dublin, one for men and one for women - which includes their preschool children. We were there to do Community of Communities visits, the serious 3-yearly one for accreditation - and to have a think about why more addiction/concept TCs were not CofC members.

Jan - TC Specialist; Four good men from Grendon; Simon - Convenor; Rex - extra

We were received with a great mixture of high-intensity hospitality and efficiency: the welcome meetings with each of the whole communities were full on. When we each introduced ourselves, from a panel at the front, a instant loud chorus of "Thank you, Rex" (or whoever) rebounded from the assembled audience - with the precision of a military drill. This was clearly different from the soft and fluffy democratic TCs we are more used to. Several questions arose for us in our time there, so here's a quick skip through just three of them.

First Question: Why do some say that addiction/concept TCs are not 'democratic'?

...particularly as many of the procedures and goings-on were very democratic. For example, there are intricate structures for dealing with rules, and enforcing them, and changing them - all by going up through the crystal-clear hierarchy, and down again, as necessary. Well, maybe it's just that they're democratic in a different way - and, because we're dealing with addictions and powerful urges to use familiar ways of coping, the democracy must be hard-edged and have no possible loopholes or slipperiness, or shades of grey. And maybe we should stop thinking that hierarchies can't be democratic - they are completely different things, not opposites. So it's possible to be very hierarchical, and very democratic. And that's what Coolmine felt like.

Second Question: So what is it that feels so different?

Well, it's not that different a 'feel' from the prison DTCs in England - and it was useful to have a gang of four from HMP Grendon with us on the visiting team. And many of the Coolmine residents had been admitted straight from prison - over half the men, in fact. It's that old thing 'the nature of relationships' - or the 'us and them' factor that was so different. There was no balancing act that staff had to do, between being 'authentically there' and knowing the 'fluid hierarchy' underpinned it. It was quite easy and obvious to tell the difference between the way the staff conducted themselves and the way the residents did: and also between different seniorities of residents. Clear roles. BUT... it also felt a long way from that emancipatory sense that the service user / expert by experience movement generates, as in the English 'relational practice' movement. It almost certainly helps people to stop doing addictive stuff - but it doesn't necessarily make them fundamentally different inside. It's behavioural, not 'analytic' (for want of a better word). And maybe that his implications for the hybrid model we're trying to do in Slough...

Third question: Are these addiction TCs the only ones who have 'concepts'?

Indeed not: 'democratic' TCs could easily come up with a list of concepts that describe what they do. Indeed it might be a good way to summarise just what they do, and what they do differently. Here's a starter:

• Culture of enquiry / openness
• Fluid hierarchy
• No 'us and them'
• Co-creation
• Reality confrontation
• Emotional permisiveness
• Boundaries
• Belonging
• Safety and containment
• Inclusion and involvement
• Therapeutic ordinariness
• Creative chaos
• Here and now
• Relational practice
• Everything here is part of the therapy
• Tolerating uncertainty

We too could have pithy quotes about them, framed, and up on the walls - as our key 'concepts'.
Or could we? Maybe not... 

There's a paper in that, one day.

An anti-consensus statement

The day after there was a relative amount of consensus about the label of 'personality disorder' and the relational ways it is best treated, the BPS, led by Lucy Johnstone, published the product of many years' work, 'The Power Treat Meaning Framework', which has already ruffled feathers and will probably lead to anything but consensus.

What a stunning graphic - full of strangeness and intrigue, but ...?

Although I think it does say a lot of good things - many of which we have been saying in and since the National Personality Disorder Programme - I do worry about the way it has been done.

Maybe, just maybe, things might be brought back together through relational developments...

Consensus statement ...nearly

After a monumental struggle to herd the cats, Sue Sibbald, Alex Stirzacker and Norman Lamb managed to get eight felines into the bag:

• Mind
• Centre for Mental Health
• Royal College of Nursing
• British Association of Social Workers
• Royal College of General Practitioners
• British Psychological Society 
• Anna Freud Centre
• Barnet, Enfield and Haringay Mental Health Trust

One more joined the party, the next day, perhaps after being shamed into doing so - the Royal College of Psychiatrists.

Here are the links to the statement itself and the BBC webpage on it.

The gang of three - plus the Man from Mind - at the parliamentary launch of the Personality Disorder Consensus Statement

Here's the briefing from GBL, some of which is in the Consensus Statement itself, and some of which found its way into the BBC News piece:

Some key facts and figures on ‘personality disorder’

·         Though PD is most visible in forensic settings (ie linked to public safety and dangerousness), the size of the problem in general mental health settings is hardly ever recognised. It affects, at some level of severity:

o    Between a third and two thirds of all psychiatric inpatients

o    92% of homeless people

o    60-80% of prisoners

o    Up to a quarter of GP consultations in inner city London

·         Suicide rate for Borderline PD (= “Emotionally Unstable PD”) = 10%;

o    this means people diagnosed with it are 400 x likelier than the national average;

o    Epidemiology figures indicate that at least half of all suicides ‘have some PD involvement’

o    On average, people with PD live 17 years less than the general population (including other reasons as well as suicide)

·         It costs a fortune, one estimate gives

o    £34bn (yes, not million!) for general management costs across all health services

o    £14½m for inpatient stays

o    Yet only 55 beds are commissioned by NHSE for severe cases

That’s the bad news, here’s something a bit more positive:

·         17% of areas had dedicated community PD (ie non-forensic) services in 2003, now (2016-7) it is 79%

·         Since the launch of the national training programme, over 100,000 frontline staff have received awareness and attitude training

Some opinions on ‘personality disorder’

·         Although most public interest is in forensic PD, that is relatively well-resourced

·         The lack of understanding of PD in general mental health services is a public health scandal

o    That lack of understanding is at least as significant as the lack of NHS resources (especially beds)

o    Many private hospital providers make their profits by providing bed-based services which rely on this lack of understanding

·         The vast majority of people with these problems do not get help from NHS – they suffer loneliness, isolation, social exclusion and desperation without knowing that help is possible. Many kill themselves without anybody else ever knowing. Many others manage to cope with help from voluntary organisations, churches and other religious groups, and random kind people.

o    The NHS is very wary of taking people with these complex problems onto its lists – partly because they are so short of resources – but also because these conditions are often seen as ‘untreatable’ and potentially a waste of what resources they do have.

o    Also, suicides are increasingly seen as unacceptable in mental health services (eg ‘zero tolerance’ programmes), and people with these conditions are at high risk. So, without deliberate direct intent, it is ‘convenient’ to find them untreatable, so that the suicides of those unregistered people with ‘PD’ are not counted as mental health failures by the NHS.

·         Cross-departmental work is needed to address this at policy level: the National Personality Disorder Development Programme did this (across DH, MoJ, DCLG and DfE) but was stopped in 2011.

·         The only national coordination is now through the IAPT programme, which is does not have sufficient scope to be fit for the task.

Please contact me if you would like more information, or would like to be put in contact with other experts.

Dr Rex Haigh, NHS Consultant Psychiatrist in Medical Psychotherapy; Clinical Advisor to National PD Development Programme, 2002-2011. rex.haigh@gmail.com

These opinions are not necessarily those of organisations for whom I work.

Overall, a lot of work and conflict contained in many struggly months - and a worthwhile day at the end of it. Maybe it's a new start for doing something meaningful about the ghastly industrialisation and corporate fascism of public service mental health. But it's a shame...

• That RCPsych wasn't enthusiastically in there from the beginning
• The BBC piece used a rather frightening forensic case to open it
• More journalists were not at the launch - to write more about it in broadsheets etc
• The statement itself is not more slickly produced (not something I usually complain about!)
• Paul Farmer from Mind couldn't be there
• NHS England were only there in disguise - when Simon Stevens should have been
• It doesn't link up with anything else going on in the field (eg BIGSPD, specialist commissioning, innovative services, relational practice and enabling environments, great progress in the homelessness and justice sectors).
• Nothing is on the horizon for joined-up leadership of the field - and the kerfuffle with the RCPsych being left out didn't help. But thereby lie dragons.
• It was the greyest, darkest, drizzliest January day in lining memory. London at its most iconic.

The modern psychotherapies

Out of a book, a course is born

The book of the non-modern psychotherapy

One of the advantages for modern psychotherapies is that they are in keeping with the times: they are easy to understand, generally positive, low risk and populist. The processes that clone, replicate and implement them ‘at scale’ are industrialised and commercialised for maximum market penetration and efficiency. An individual or team of individuals can conjure up a ‘new’ therapy out of elements that most psychotherapists have known for years, simplify it as much as possible, define it exactly, research it, write a manual and – if they have done it well enough – hit the jackpot and become celebrity academics. A neoliberal success story – rock on!

One of the problems with the world of therapeutic communities is that they don’t fit this modern way of doing things. They have been around for decades, if not centuries, and nobody could or should claim any sort of ownership of them. They are fundamentally counter-cultural, anti-individualistic and strongly communal. Therefore, the corporate and industrial processes that work for modern psychotherapies will never be acceptable to their members or champions. These processes don’t allow for democratically incremental and reflexive change and development of the field, don’t recognise the inherent complexity and uncertainty of depth approaches, and deny the need for a critical or whole-system approach. The modern psychotherapies are managed into a state of fixed and reified sterility. Which means, since the late 1980s, therapeutic communities have been left out in the cold: in a state of moderate decline and all but forgotten by all but a few aficionados.

However, a few have adapted and modernised themselves to survive – hopefully without ‘selling out’ – although the rest have gone to the wall, and Empire is now Striking Back – with three prequels. The first has been to gather up all the therapeutic communities into a ‘Community of Communities’ and have a process to agree together what they are all doing, help each other with it, and make it accreditable. The second is to grit one’s teeth, screw one’s courage to the sticking place, and finish a research project which has been declared well-nigh impossible by anybody who has thought about it in the past. The third is to get together with everyone’s favourite friendly independent publisher, and publish a book about it all. The two people responsible for the first and second prequels are the co-authors.

The course of the book of the therapy

So now the book is there, it needs to earn its living – by making therapeutic communities, and therapeutic environments, spring up in new places, and bring the whole therapeutic communities movement back to life and rude health. It was a powerful social force in the heyday of social and emancipatory psychiatry in the middle of the twentieth century, and many feel the need for a twenty-first century version: mental health as a social movement.

One way we are starting this do this is by stealing a trick from the ‘modern therapies’ by mounting a practitioner training course. It is based on the book, and includes as many therapeutic goodies as it is possible to get into a course little over a year long. But those who complete the course will be able to call themselves ‘therapeutic community practitioners’, have confidence that they are doing something that is both age-old and evidence-based, as well as being thoroughly human. They will bring the quiet revolution to a mental health service near you. 

May the force be with them!