Still Learning from Basaglia

So, back to Italy - Catania this time - while our bags got stuck in Rome and didn't catch up with us till after the conference. This was for the fifth Annual Forum of the Sicilian Visiting Project - where therapeutic communities, group living apartments and therapeutic housing projects visit each other and demonstrate that they are following the therapeutic model and deserve to be accredited - then all get awarded grand certificates, clapped, and have many smiling photographs taken. 

But before all that were the talks. It was with not a little apprehension that I had prepared mine this time to include some of my own thoughts about Italian (and British) psychiatry since Basaglia and Law 180. Coals, and eggs, and Newcastle, and sucking grandmothers, come to mind. But I was armed and enthusiastic, having just finished John Foot's gripping tale of 'The Man who Closed the Asylums'. And amongst friends, so unlikely to be mauled and publicly humiliated as in the not particularly fond memories from the academic psychiatry meetings of my junior doctor days. 

Amelia and Laura - students of Jervis

And indeed, it was to be. The reception to the talk, and the discussion, was friendly and stimulating - and it was quite exciting to ind that Laura (our translator) and Ameila (one of the main organisers) had both been taught by Giovanni Jervis when they were psychology students in Rome. He was a key member - and ultimately dissident - from Basaglia's equipe; they remember him as rather austere and laconic, and not much fun - as well as being quite old by then. Maybe that's the delayed effect of playing second fiddle in one of history's major psychiatric revolutions... 

Another interesting revelation was the different nature of the soil in which the Italian and British 'antipsychiatry' and therapeutic community movements grew. The Italian one in the post-resistance communism of day-to-day officialdom - and the British one (for TCs, at least) from the wartime group therapy experiments, largely isolated from the explosion of 1960s youthful rebellion. The Italian TC work over the last decade or so suddenly made sense. Why the main TC problem in Italy is that hundreds or thousands of places call themselves TCs - when very few really are; and the main problem in the UK is that there is almost no support in health or adult social services - and often vigorous opposition - to funding TCs, and almost nobody wants to claim to be one. 

Worth some more thought.    Anyway, here is the talk:

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TCs and Critical Psychiatry

Rex Haigh

Interpreted by Laura Liverotti

Catania, 25 May 2018

In democratic therapeutic communities, we need to work in ways that are not the same as the institution of biomedical psychiatry. I have recently read a detailed book about Franco Basaglia – by a British historian called John Foot. There is so much more to the story than I thought – and the Italian experience of what they call ‘antipsychiatry’ continues to have modern relevance in a way that the work of Laing does not any more, in the UK. When I read about Mario Tomassini in Parma and Giovanni Jervis in Reggio Emilia, I thought ‘that is like we are now trying to do in Slough, and in Oxford'. We are closer to the principles coming from Gorizia than those from Kingsley Hall. So in this talk, I am going to try and draw some themes together about what we do in therapeutic communities – and enabling environments – using some of the critical thinking of postmodernism. But also, why postmodernism is not enough to explain what we do.

We all now live in systems that are highly managed, with many policies and procedures and protocols. But in therapeutic communities we need flexibility and spontaneity and creativity. That is hard to maintain in the face of requirements for manualised and standardised protocols. One way we are currently describing this in  the UK is as ‘relational practice’ rather than ‘procedural practice’. In the modern world, where people expect technical solutions to all problems, many regulations, and zero tolerance of risk, something very human and ordinary has been lost. And we are saying that what has been lost is central importance of the relationship in therapy – not necessarily the expertise of a psychoanalyst, but the ordinary and human way people are with each other. Or how it is not now possible for people to be relaxed and informal with each other at work. Clinicians are often made to be anxious about whether they are ‘following the manual’ correctly, or whether they have ‘recorded the risk level’ on the hospital computer system. One word we use for what is missing is ‘therapeutic ordinariness’ – and the Enabling Environments project, which I have described here before, is based on these ideas of relational practice.

The first time I came across this was when I was taught social sciences as a medical student by David Ingleby, in 1978. He was a radical social scientist at Cambridge University, and that was the year, of course, that Law 180 was passed here in Italy. Ingleby was writing a book at the time explaining how mental illness is primarily a political issue: he threw doubts on claims made for scientific objectivity, and uses detailed qualitative methods to reach a more phenomenological and interpretative level of meaning (he uses the term ‘depth hermeneutics’ and relates it to psychoanalytic understanding). In this way, he provided a view of mental suffering that is closer to the patient’s experience, and less contaminated by the inequality and power imbalance inherent in normal clinical practice. Although I did not know it at the time, it closely reflected what Basaglia was saying here in Italy. The book appeared in 1980 – and is called Critical Psychiatry. That importance of the subjective experience of ‘the patient’ is now a very strong feature of the ‘service user empowerment’ movement – which has been a major theme in therapeutic communities since the very beginning: a way the power balance is changed. In the last 15 years, it has also been a significant force in the British movement to re-design state services for those diagnosed with ‘personality disorders’ – in both heath and criminal justice services.

In the UK in the 1970s, Ronald Laing was seen as the champion of the British ‘antipsychiatry’ movement. But, like Franco Basaglia, he denied that he wanted to get rid of psychiatry – but he did want to change it. Laing’s focus was wanting to see deeper into the meaning of patients’ experiences; as I understand it, Basaglia and his equipé had their major purpose as, first, making a therapeutic community in Gorizia to humanise conditions for the patients there – and, later, to dismantle all the large institutions. This was all in the context of the 1960s youth revolution, which made everything much more intense, and political, and confusing. But both Laing and Basaglia were showing us how social, political and cultural realities play a vital role in helping us to understand the suffering and experience of madness, and how we should and should not response to it.

Although all the large institutions have been closed for many years, in Italy as well as the UK, the problem of ‘institutional thinking’ has now come out in different ways. Nobody is now tied up with chains or treated as animals, but they still suffer from degradation, disempowement and disrespect – and feel oppressed, alienated and as second-class citizens. It does not need large old buildings to have unhelpful and destructive relationships with those in need. I call this ‘institutionalisation in the head’. The processes that support this are the modern ones of regulation, standardisation, and social control – which make the process of care more like an industrial procedure, than a human one based on hope, and trust, and real relationships. The modern job of psychiatry, at worst, is to make a diagnosis and prescribe the correct medication, and avoid any risks. There is no real recognition that the best way reduce risk is to develop and maintain a therapeutic relationship.  

This is one of the ideas at the heart of ‘Critical Psychiatry’ – following on from the ‘antipsychiatry’ of fifty years ago.

At the end of the last millennium, in 1999, Greenhalgh and Hurwitz wrote about what was being lost:

At its most arid, modern medicine lacks a metric for existential qualities such as the inner hurt, and indeed constitute, the illnesses from which people suffer. The relentless substitution during the course of medical training of skills deemed “scientific”—those that are eminently measurable but unavoidably reductionist—for those that are fundamentally linguistic, empathic, and interpretive should be seen as anything but a successful feature of the modern curriculum.

Bradley Lewis, an American psychiatrist, makes the case for greater prominence of narrative methods in psychiatry (Lewis 2011):

This is a time of soul searching for psychiatry. Despite the investment psychiatry has made in rigorous classification and neuroscience, the field is currently meeting resistance and critique reminiscent of the 1960s and 1970s. Investigative journalists, consumer and recovery activists, academics in the humanities, social sciences and disability studies, and critical psychiatry networks all express increasing concern that the field has lost its way.

Much of the therapeutic work in our TC is concerned with constructing narratives, both of the historical reasons why members have ended up there, and the story of their time as a member of the community - and how it affects and changes them and those around them. The admission group (which is part of our TC’s joining process) is the point at which the ‘why I need to be here’ narrative is crystallised into a half hour session with the whole community. This has a profound therapeutic purpose – of establishing belongingness and attachment – as well as the communicating important information. The periodic reviews of progress, with a similar format, work in the same way: they are not merely hurdles to jump or administrative formalities, but an unavoidable exposure of feelings about one’s progress in the TC, to everybody there – as well as an opportunity of other newer members to see what sort of narrative they may be able to make for themselves.

(ironic)

A different angle on this ontological problem is how the role of doubt, complex narrative and the gradual development of conclusions and action is now eclipsed by a digital, 0/1, yes-or-no, view of what is correct. It is as if there is zero tolerance of uncertainty. Hermeneutic and qualitative methods, relational factors, contextual variables and other distractions which allow uncertainty are seen as noise in the algorithm, and denied serious relevance. This quest for certainty lies behind the dominant research paradigm, most clearly seen in the hierarchy of evidence.

In order to demonstrate evidence that is acceptable in making national treatment guidelines, a therapy requires the best evidence, meaning that it has a place that is as high as possible in the hierarchy. The ‘gold standard’ evidence is a meta-analysis of high quality randomised controlled trials. Amongst competing psychological treatments vying for recognition and funding, the quest for acceptable evidence leads to a ‘beauty contest’ mentality - where treatments are defined, operationalised, advertised and marketed as easily replicable ‘products’. These therapies can then be manualised and put through the process of gathering suitable evidence.

Steve Pearce, a colleague in Oxford, who is also a medical psychotherapist working in TCs, has taken up this challenge and published the results of his randomised controlled trial of non-residential TCs in the British Journal of Psychiatry in 2016. In a way, I think he has done the impossible – and perhaps helped the survival of British TCs. I think the organisers of this meeting are wanting to invite him to Rome next year, to explain his study.

Some of my reservations about this research process are about how closely analogous it is to drug trials in the pharmaceutical industry, and how inappropriate that fixed and inflexible model is. I also see it as part of a neoliberal commercial project to package and market psychotherapy treatments as if they were commodities that can be purchased from a store. I think this is market economics being used in a place they should not be, and are supported by a positivist type of science which is being used in places where it is not appropriate.

However, there are signs of a more sophisticated and flexible approach emerging, with the ‘quality of evidence’ becoming a more complex concept. In 2016, Steenkamp argued that treatment choices, in line with the founding principles of evidence-based practice, should be based on the three principles of

·         best evidence,

·         patient choice, and

·         clinical experience

As well as facilitating shared decision-making, she argues that a better fit is possible - between specific patient factors and available treatments. This represents a significant departure from the inflexibility of algorithmic treatment choices, based only on standardised treatments and ‘standardised patients’.

Another factor limiting the value of competitive studies is the finding that many different specific therapies can be successful, and the effectiveness is more dependent on ‘non-specific therapeutic factors’ than on the type of therapy itself. This has been demonstrated many times, and goes back to the ‘Dodo-Bird verdict’ (‘everybody has won and everybody should have prizes’). This was first claimed in 1936 by Rosenzweig, then demonstrated by Luborsky’s research in 1975, and elaborated in several ways since then.  For example, Lambert gave proportions for the relative importance of different factors in psychosocial treatments in 1992:

·         therapeutic relationship 30%,

·         external factors 40%, and

·         expectancy/placebo effect 15%, leaving

·         specific therapy techniques accounting for the remaining 15% of effectiveness 

My main contention is that this is a matter of angels dancing on the head of a pin. We all know that human health and happiness involves how we relate to other people, and modern research does not give this simple a-priori fact enough priority.

The considerable and contested literature critiquing ‘evidence based practice’ is beyond the scope of this discussion, but the trend towards accepting only larger and larger standardised and aggregated research is one that is moving in the wrong direction, away from understanding the importance of relationships. Therapeutic communities themselves are likely to suffer from this. Instead of being uniformly applicable across a wide population, TCs are fundamentally complex, and possibly chaotic. This is in the strict sense of the terms where ‘complexity’ leads to the development of ‘emergent phenomena’ (which were not intended) - and a chaotic system is like the weather, which cannot be predicted by deterministic statistics, however sophisticated they might be. In this system, every individual is recognised for their differences – their uniqueness and specialness -  rather their diagnosis. And at the next level, every therapeutic community is necessarily, and proudly, different from every other, making uniform research specifications almost impossible. We therefore need a different type of research – and I don’t think we know exactly what that is, although there are certainly some interesting non-biomedical research projects going on.

A more coordinated research effort would of course require organisational support and serious funding. The sociologist Nick Manning has pointed to a ‘politics of data’ in this field, which has resulted in TCs not having been researched or funded by those in the biomedical or psychological ‘research establishment’. Because the data is not collected in the approved format, this research does not receive government funding – and those who review ‘dissident’ papers for scientific journals are unlikely to accept them. So there is very poor visibility of therapeutic communities in the mainstream research literature.

However, there may be some room for optimism in recent service-user led research. This can pay serious attention, in rigorous and systematic ways, to the experiences of those in disempowered positions, and tackle subjects that clinicians and academics have previously avoided. This is alongside disillusionment in psychotherapy research with efficacy trials, because their results are only valid under conditions that don’t exist in the real world. TCs are well-placed here – and have been for some time. Multiple explanations of everything that happens are discussed (our colleagues in Open Dialogue call this ‘polyphony’) with none of them having the status of ‘absolutely truth’; individuals’ different perspectives give different experiences which can be worked in to the therapy; choices and decisions are made by some sort of ‘emotional democracy’.

So I have asserted that relationships, particularly the sort we have in TCs, can’t be “modernised” into precise manuals, regulations or compliance checks. They will remain irrevocably messy, difficult and uncertain – and perhaps colourful, exciting and fun as well. That is certainly one of the reasons that I would not want to work in ordinary clinical settings after a working life in therapeutic communities.

This is all about postmodernity. So for the last part of this dicussion, I want to propose that TCs are an excellent example of thoroughly postmodern practice, and we should be able to use that to our benefit. The best sort definition I know of postmodernity is Jean-Francois Lyotard’s: “NO GRAND NARRATIVES” (Lyotard, 2001). Traditionalism and modernity both have their own grand narratives: overarching explanations that intend to explain everything, predict all that will happen, and have everything neat and orderly - sanitised, contained and anxiety-free. Postmodernism acknowledges that this is impossible.

Clinically, it produces paradoxes such as the ‘overconfidence’ phenomenon: if, as a member of staff, you are quite sure that you are ‘doing it right’ – you are probably ‘doing it wrong’! Perhaps this is through a relational mechanism where you appear to others as ‘not willing to be open’ (because you’re so sure that you are correct). But it leads to the uncomfortable realisation that ‘it is not right to always be right’.

Another clinical aspect of “no grand narratives” is how members of our communities, particularly those who have gained a degree of self-empowerment, are just not willing to be told what is good for them, or how they feel. These people can now make up their own minds from a vast range of inputs – including their own experience, the internet, self-help books, the arts, intimate and detailed accounts from friends, and from experts. But experts don’t have the only say, or the last say, any more.

In an era of ‘the New Public Management’ we live in a world dominated by modernity. All publicly funded organisations – from health services to universities and social care – now need to have demonstrable accountability and transparency with particular governance structures, and systems of regulation. This is a very dull and uncreative world – and I hope that therapeutic communities can offer something different, to our members, our staff and the organisations we work in.

Let us divide mental health care approaches into traditional, modern and post-modern. ‘Traditional’ is the old-fashioned world of asylums and institutions, with strict hierarchies and the power all being in the hands of the professionals – usually doctors. ‘Modern’ is like this ‘New Public Management’ – some call it ‘performativity’ -  where everything is exactly specified and controlled, there are written protocols for any variation or exception or non-compliance. The effectiveness, performance and results can be exactly measured and audited. The power is in the system, which is democratically accountable. ‘Post-modern’ is much more awkward and critical – very much like the features of therapeutic communities I have described. But, being relationship-based, it is also to some extent unmanageable, creative and spontaneous: with a little anarchy in it. Perhaps the sort of characteristics that make life worth living, or a job worth doing. Power here is fluid – but needs to be held within a containing framework.

Finally, I want us to celebrate this way of working. It follows the ‘moral treatment’ of the 18^th century – when a few enlightened people recognised that mental health patients needed to be treated as human beings. That returned in the 1960s, with the Italian and English ‘antipsychiatry’ movements.

Now, here we are fifty years later, trying to do the same thing. In modern therapeutic communities and enabling environments – and the Visiting Project here in Sicily -  we are still doing it. I believe that we know how to construct that ‘containing framework’, within which psychiatric power can be exercised with compassion and humanity.