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