The promise of Bristol greencare

 

How exciting and refreshing it was to go to Bristol today and see some of the potential developments with what might be their first ever self-described 'Nano-TC' at Bedminster City Farm. And I thought we were winning the shrinkage game at Slough with our two and a half hour 'micro TC'... (and as for the 'mini-TCs', with a whole day and a half together, they are positively last-but-one decade!

As a (semi-retired and increasingly grumpy) NHS medical psychotherapist I have a passionate interest in helping people to develop progressive ‘greencare’ interventions for ‘personality disorder’ in group settings. Because of this, I was intrigued to see just what the Bristol gang were up to, particularly as our  little social enterprise (Growing Better Lives CIC) won the Royal College of Psychiatrists’ inaugural sustainability award  a few years ago, and I had recently presented our Slough work to a Bristol online seminar. It seems that there is a lot of interest in these greencare-TC approaches across the country, and maybe this lot could be getting ahead of the game!

The setting for the service, in the longest-established of Bristol's three city farms, is just excellent – it represents an important and clinically meaningful departure from the usual anonymous and alienating hospital offices and rooms. It also represents a tangible example of what we expect with the forthcoming transformation of mental health services, with the NHSE funding and expectation of preventative services, asset-based community development and third sector partnership - doing mental health really and radically differently. We do a tiny example of this in Slough, but these people have so much opportunity to do it for a whole city – and where better than Bristol, with it’s proud green reputation?

Part of the transformation we all expect is also to do with what some of us are calling ‘relational practice’ – where everybody involved recognises how important ‘the relational field’ is: in terms of risk, recovery, well-being, and suicide prevention. Co-production requires a high order of relational practice, and its central role in the work – and wider systems in the local mental health services – makes me feel that it is fine form. Although there are the usual inter-professional rivalries, I think it is important to always stress the need for a psychiatrist who can work outside a strict biomedical model, and yet have the skills and experience necessary for matters such as deprescribing (specifically for ‘personality disorders’), which will almost certainly become a major part of psychiatrists’ work in years to come, and the huge overlap with physical health.

My only reservation is that this sort of service needs to ‘grow in its own soil’, and establish its identity and relationships - as connected and contributing to, but distinctive from, its parent organisation. This sort of development cannot be manualised or ‘rolled out’ across a large area: it needs to be nurtured and treasured – like a garden or allotment. If done well, many benefits beyond the immediate clinical gains will come. 

Unfortunately, these organic and flexible requirements are sometimes against the modern methods of project management and service standardisation, as are now almost universal in the NHS - one of the ghastlier and more dehumanising aspects of 'The New Public Management', I fear. However, there are excellent standards-based quality assurance tools which have been developed at RCPsych – such as the Community of Communities and Enabling Environments - that recognise, measure and accredit the things that accountancy firms can't, and that matter most to real people.

Answering Jo's three tricky questions

I'll keep this confidential and not reveal Jo's identity - suffice to say she is what I see as an energetic and dynamic force for really improving Gloucestershire's mental health services. I'm sure that for anybody reading this who knows the Gloucestershire set up, it will immediate click!

During a on online seminar today, she described the three problems with TCs that influential people in NHS management and local commissioning usually quote to discredit or oppose TC-based developments. They are:

• TCs only treat small numbers of people
• They are expensive
• They are old-fashioned

We had some useful discussion about it all, but I thought it would be a worthwhile exercise to record some thoughts in this blog about these three 'questions'  - as I think many people elsewhere, who are trying to set up progressive, democratic and relational services, will also face them.

1    Small numbers who benefit

Yes, the numbers in any single TC are small (not usually more than 20), and the throughput is often slow (perhaps one or two new people per month) but they can often help the people who bounce around other services and cannot find what they need in any of the mainstream therapies.  Their problems are often of a severity and complexity that means standarised and manualised treatment services and pathways are of no help at all, and can actually be experiences as harmful and even abusive. 

If these people are effectively engaged and helped, not only will that be of great personal benefit to them, but it will prevent a great deal of pressure on hard-pressed staff in mainstream services to 'do something' when they do not have the facilities or training to do so.

There are also indirect benefits of TCs that extend beyond helping the people who are in them for treatment. A therapeutic community that is well-integrated into a local mental health system can be hub activities that has profound effects on staff attitudes and working culture. This can be by directly providing training placements and experience for staff, but also by getting involved in wider initiatives beyond the clinical base - and spreading best practice in areas such as co-production, asset-based community development, stigma reduction, relational practice and democratic techniques in mental health.

The assertion that those with more complex problems, who often reject or may become worse in standard therapies, need more involved and complex treatments is supported by the Royal College of Psychiatrists' Position Statement on 'Services for People Diagnosable with Personality Disorder', PS01/20  

2    Expensive

Non-residential TCs are very much cheaper than repeated inpatient admissions. The cost for people who do not receive a treatment that they can engage well with is often considerably increased by demands on other parts of the health service (such as ambulance calls, and A&E attendances) as well as for pervasive impact across public services (such as child protection, criminal justice, housing and others). Numerous economic reports and studies have found large cost savings when comparing the time before admission to a therapeutic community and the time afterwards. For example, the micro-TC in Slough reported reduction from 4786 to 312 bed-days with its first 103 members (one year before and one year after the programme - nominal savings of £1.5m on beds alone).

The 2017 Oxford randomised controlled study also found significant reductions. See

Pearce S, Scott L, Attwood G, Saunders K, Dean M, De Ridder R, et al. Democratic therapeutic community treatment for personality disorder: randomised controlled trial. BrJPsychiatry 2017; 210: 149–56.     

3     Old-fashioned

This would be true if it were referring to the common misconception that therapeutic communities still work as they did in the twentieth century. In those times some could be characterised as insular, resistant to change and somewhat arrogant. However, much has changed in the last twenty years: new models have emerged that bring maximum cost effectiveness (by using less hours of clinical staff input), and sophisticated integration across health and social care ecosystems (through coproduction and asset-based outreach). 

See Haigh R. The New Day TCs: Five Radical Features. Therapeutic Communities 2007; 28: 111–26 and Pearce S, Haigh R. Mini therapeutic communities: A new development in the United Kingdom. therapeutic communities 2008; 29: 111–24.

The therapeutic philosophy behind therapeutic communities, particularly that of relational practice and democratic mental health, is congruent with many progressive movements in mental health that have arisen in the last century - from Psychiatrica Democratica in Italy, to user empowerment and the recovery movement today. The preventative nature of the treatment meets a public health need, and will be increasingly relevant as the damage to supportive relationships wreaked by covid becomes apparent. Also, the cross-sector integration that is possible with modern forms of TC can provide a 'social glue' foreshadows forthcoming developments in NHS community mental health provision.

Therapeutic communities are not just a treatment modality - they are a post-post-modern social movement. See Haigh R. Charismatic Ideas-Coming or Going? Therapeutic Communities 2005; 26: 367–84.

Thoughts about Forensic TCs

After escaping from having to write a chapter for them, Richard and Geraldine twisted my arm to knock out a thousand word Foreword for their forthcoming book - at extremely short notice.

The book is 'Forensic Therapeutic Communities: A Global Perspective' from the Issues in Forensic Psychology series, edited by Geraldine Akerman and Richard Shuker.

It's to be published by Wiley-Blackwell - and I'd expect it to be out towards the end of the year, knowing how slowly these things go. As a bit of pre-publicity to whet appetites, here is my Foreword...

As most people who have spent time in them realise, therapeutic communities a largely hidden jewel in the panoply of modern interventions for complex mental health needs. As one of those people, with many hours of time inside, I know that extraordinary things can happen in them, that people’s lives are often transformed (staff members as well as client members), and that there is a quality of relationship between the participants that simply does not exist in other settings. But this is not good enough for the modern thirst for a specific type of evidence: we must work harder. This book is part of that effort.

A major problem with therapeutic communities is that nobody really knows just what kind of animal they are, and there is no universally accepted definition. Perhaps this is one reason why they are largely hidden from wider understanding and acceptance. I believe it is entirely reasonable to describe them in at least seven different ways – all of which come from widely different frames of reference.

Most simply, they are treatment units – brick walls containing prison wings, custodial units, hospital wards, clinics, hospitals, day centres, schools, or whatever. People go into them, something happens, and they come out.  There are several different histories and types of these; they have a great deal in common but so many differences that no single definition would fit them all. Secondly, they are a theoretical model of care, with explicit therapeutic principles based on established psychological and sociological theories. This is the main tradition from the British version of ‘social psychiatry’ following the wartime Northfield Experiments, which continues to this day in different sectors. Thirdly, they are an intensive form of group psychotherapy defined and recognised by democratically co-produced quality standards. The ‘Community of Communities’ network at the Royal College of Psychiatrists uses this approach.  Fourthly, they constitute an evidence-based treatment “brand” with an extensive qualitative evidence base going back many years, and at least one recent, modern, randomised controlled trial. This is a difficult area, particularly because their status as a recognised ‘treatment’ has recently been denied. Fifthly, they could be described as programmes which are delivered by staff who have certain competencies, gained through suitable selection, training, support and supervision. The systemic nature of the resultant team cohesion and common sense of purpose delivers a unique sort of therapy. Sixthly, they arise from a technology of planned environmental engineering which results in a milieu which is conducive to personal growth and self-actualisation or individuation. This is akin to the work of ‘Enabling Environments’ and what I have called the ‘TC in the Head’ or the ‘TC without walls’. Finally, and somewhat related, they could be seen as a radical and subversive ideology: a social movement demanding a social movement a different way for humans to relate to each other. This is beyond post-modernism, as there is a clear ‘grand narrative’ – of relationship. This means that relationality has priority over individuality, as with the ‘foundation matrix’ in Group Analytic Psychotherapy – or waves and particles in physics. This way of thinking recognises the duality of individual minds and the relationship between them, but focuses on the waves. It is in tune with modern consciousness studies, and progressive ideas about how radical change is needed if humanity is to survive – particularly concerning the relationship we have to our natural environment. 

Perhaps these could be called the ontological (what are they?) and epistemological (how can you know what they do?) problems. But if the definition of therapeutic community is does not include all these angles, and possibly others, we will be losing something of their essential, and edgy, nature. Similarly, if we irrefutably prove that one type of therapeutic community leads to a reliable change in one variable, we risk losing the breadth and depth of the approach, through standardisation and regulation. This wide scope of this book ensures that it does not make those reductive oversimplifications.

 Then there is the problem of history, and what is usually called ‘baggage’ – and how it affects the political context of therapeutic community work. In some countries, different sorts of wildly diverse units, clinics and facilities all call themselves ‘therapeutic communities’. Some do this proudly, with high clinical standards, transparent and accountable published processes, university collaborations, and highly trained staff. Others have little understanding of the meaning of the name or the depth of history in therapeutic communities and simply think of the term as a useful name with which to market their services. In other countries, the name itself carries an unspoken stigma that conveys a whiff of disreputableness, tainted history and deliberate failure to face the reality of modern life. Here, only the most confident therapeutic communities can proudly assert their identity. The communities described in this book are amongst these, and can perhaps offer encouragement and support to those wanting to tread a similar path towards excellence – and membership of the extended family.

 It is a paradox that the type of therapeutic communities that have always appeared to be most secure in their continued existence are those that are growing in what might be considered the stoniest and inhospitable soil – the criminal justice system. It is a paradox because it is extremely difficult to see how it is possible to give people in state custody a sense of openness, empowerment and personal dignity in settings which demand almost total social control and lack of freedom. Perhaps it is the very rigidity of the system – security over therapy – that ensures that, once therapeutic communities become part of the establishment, it is almost impossible to get rid of them all (though individual ones may have insurmountable local difficulties, of course), however counter-cultural they may appear. But it happens, and often in innovative and effective ways: this book gives a wide range of examples of what is possible.

 

Green Cloud

 After a long gap, filled with random hassle and poor excuses, my good friend Anando has told me that I should not give up on my greenshrink blog. To be fair, a lot of interesting things have been happening - and there is a sort of therapeutically useful processing to be had from putting some of the frustrations and excitements down in words. So here we go again.

A cute little thing that we have been growing for a year or so now is the 'Green Cloud' group - a Covid 19 response, but something that might develop a life of its own in future. If so, that will surely be th esubject of a future blog.

Here's the first section of a paper we're hoping to publish about it - watch out for the full thing in the TC Journal, hopefully/probably in 2022. 

A greencare TC goes online

Introduction

‘Greencare’ is a principle which includes nature as part of therapeutic programmes: the term and its scope were defined in the ‘conceptual framework’ as part of a European Union EU COST Action (Sempik et al., 2010). The evidence base for the mental health benefits of greencare has grown substantially in the last few years (Farmer, 2014; Natural England, 2016). Its use in therapeutic communities is particularly apt (Pearce and Haigh, 2017; Sempik and Haigh, 2008), and has a long and distinguished history of including horticulture (Sempik, 2008), agriculture (Artz and Bitler Davis, 2017; Hine et al., 2008), animal care (Loue, 2016) and permaculture (Hickey, 2008) in its programmes.

 

Our local service is a National Health Service (NHS) ‘micro TC’ called, ‘EMBRACE’, which is a hub for various therapeutic activities across the town (Haigh, 2017); the greencare therapeutic community was one of these activities . It ran as a one-day-per week non-residential TC programme in a yurt at a local environment centre in 2013 (Thrive, 2014; Langford, 2015). Its intention was to provide a safe space in which nature, playfulness and therapeutic support were available to all its members, without the formal and conflictual psychotherapy elements that are often present in TCs.

 

However, when the Covid-19 lockdown prevented any face-to-face therapy groups from taking place, a replacement for this ‘dose of nature’ was required, particularly to help retain and sustain the relational field, and relational practice (Haigh and Benefield, 2020), that had emerged in the original group. This paper is an explanation and evaluation of the online programme that replaced the therapy in the environment centre, with some action research considerations about how it might be developed as an international, and sustainable, therapeutic activity that would not be possible as a face-to-face therapeutic community.

 

Methodology and creation

As soon as the UK Covid-19 lockdown was announced, in March 2020, the existing therapeutic community was forced to stop meeting. As the NHS slowly moved towards a weekly online group on MS Teams, two part-time members of the staff team who are greencare practitioners (RG & VJ) decided to start a more ‘light-hearted’ and playful weekly group on Zoom, run by Growing Better Lives CIC (a greencare social enterprise), in close collaboration with the NHS service’s peer mentors. Peer mentors are akin to experts by experience or lived-experience practitioners: they have completed the EMBRACE programme, and chosen to train and work in a role between service user and clinician (Lees et al., 2019).

 

Its design was not as a psychotherapy group, but a more socially focussed group which all its members (members, staff and peer mentors) would find therapeutic; it included all the elements of the previous face-to-face greencare group, except growing food, preparing meals and eating together.

 

Initial discussions with the peer mentors covered the need to establish safe boundaries, and a quality of ‘belongingness’ (Pearce and Pickard, 2013). The initial and closing community meetings were condensed into a ‘check-in’ at the beginning  and the end of the session (using planticons, see below); the morning activity is to share and discuss our experiences of nature over the past week; lunch was shortened to a quick snack or beverage at home; the afternoon activity is usually a game or quiz; lack of time prevented the co-production of a weekly blog, so this was taken on by staff members. After some initial variability, the group settled into a 90 minute time frame. 

 

Routine evaluation took place by use of planticons to register members’ feelings at the beginning and end of each group, and the blog which documented various aspects of the group and members’ experience of it. Staff and peer mentors all participated equally with the other group members.

 

References

Artz, B., Bitler Davis, D., 2017. Green care: A review of the benefits and potential of animal-assisted care farming globally and in rural America. Animals 7, 31.

Farmer, P., 2014. Ecotherapy for mental health. Journal of Holistic Healthcare 11.

Haigh, R., 2017. A New Biopsychosocial Programme for Emotional Instability: the Slough Model. The Psychotherapist 66, 27–29.

Haigh, R., Benefield, N., 2020. Personality Disorder: breakdown in the relational field, in: Working Effectively with Personality Disorder: A Paradigm Shift. p. in press.

Hickey, B., 2008. Lothlorien community: A holistic approach to recovery from mental health problems. therapeutic communities 29, 261–72.

Hine, R., Peacock, J., Pretty, J., 2008. Care farming in the UK: contexts, benefits and links with therapeutic communities. Therapeutic communities 29, 245–260.

Langford, A., 2015. Growing Better Lives: peace, quiet, and yurts. The Lancet Psychiatry 2, 685–686.

Lees, J., Lomas, F., Haigh, R., 2019. The Third Position. Therapeutic Communities: The International Journal of Therapeutic Communities.

Loue, S., 2016. CooperRiis Healing Community, in: Therapeutic Farms. Springer, pp. 69–78.

Natural England, 2016. A review of nature-based interventions for mental health care (NECR204). Natural England, London.

Pearce, S., Haigh, R., 2017. A Handbook of Democratic Therapeutic Community Theory and Practice. JKP, London. p341

Pearce, S., Pickard, H., 2013. How therapeutic communities work: Specific factors related to positive outcome. International Journal of Social Psychiatry 59, 636–645.

Sempik, J., 2008. Green care: A natural resource for therapeutic communities. therapeutic communities 29, 221–227.

Sempik, J., Haigh, R., 2008. Special Edition: Greencare. Therapeutic Communities 29.

Sempik, J., Hine, R., Wilcox, D., 2010. Green Care: A conceptual framework, a report of the working group on the health benefits of green care, EU COST Action.

Thrive, 2014. Making Borders Bloom: pioneering project for borderline personality disorder. Growth Point 14–17.