The Golden Thread

Having gone to many places, before covid, to talk about 'The Golden Thread', but never writing it down or publishing it anywhere, I thought that it should at least go in this blog. 

I'm well aware that many hard-nosed scientific colleagues and even friends think it is rather fluffy, soft, and perhaps woo-woo - but I stand by it (relational practice) as an idea whose time has come - or is just round the corner.

This is an edited version of a fairly concise version that Nick Benefield and I included in a chapter of a book due to come out in 2023. It is the section called 'Contextual history: The English National Personality Disorder Development Programme 2002-2011'  (though I rather prefer 'The Golden Thread'.

 The phenomenon of ‘personality disorder’ first caught public and government attention following the 1996 murders of Lin and Megan Russell, and the attempted murder of Josie Russell, by Michael Stone in Kent. This caused a public disagreement between Jack Straw, the then home secretary, and Robert Kendall, the then President of the Royal College of Psychiatrists.

Robert Kendall said Stone “was suffering not from mental illness, but from a psychopathic personality disorder”. And under the law such people could only be admitted to hospital for treatment against their wishes "if treatment is likely to allievate or prevent a deterioration in their condition". He went on: "We are not very pleased with him (Jack Straw), but even more important we are appalled by his ignorance. There may well be a place for some form of preventative detention for men like this, but that is an issue for parliament. The Home Secretary cannot expect psychiatrists to do his dirty work for him when it is at present excluded by the law". Straw responded: "Quite extraordinarily for a medical profession, they've said they will only take on those patients they regard as treatable. If that philosophy applied anywhere else in medicine there would be no progress whatsoever." Conor Duggan, a senior forensic psychiatrist, later reflected: “The government provided specialised units with generous (some might say overgenerous) funding."

This is what became known as the DSPD (Dangerous People with Severe Personality Disorder) programme. It is the crumbs from the table of this program that funded ‘community personality disorder programme’.

At about the same time a self-help organisation called Borderline UK was set up with a Millennium lottery grant; it was headed and run by people with lived experience of personality disorder, with some support from sympathetic professionals. There were many anguished quotes gathered by its members and organisers, for example:

·         How can the experts really treat it seriously and with any degree of compassion, when they define it as attention, seeking or manipulative?

·         Had I been helped when I was younger, I would not have got this bad

·         We cannot call ourselves a civilized society when so many people are outcasts and are simply not understood?

·         Specific services for this are helpful – but general mental health services are not helpful and can be abusive.

Having some recognition of unmet needs, the Department of Health set up two working groups to prepare ‘policy implementation documents’ on strategic changes that might help. In 2003 Personality Disorder, No Longer a Diagnosis of Exclusion, with clear evidence on what service users were asking for, was published alongside the Breaking the Cycle of Rejection: Personality Disorder Capabilities Framework, which was a guide on workforce development and establishing a training escalator relevant to all disciplines and levels of seniority. The three stated aims of the national programme were to produce innovative service developments, to have a national evaluation of the new services, and to implement national regional training developments.

The new services were established in 2004. There were five medium secure services and 11 community (non-residential) ones; the programme was also allied to 12 multi-systemic therapy projects for children and the four existing DSPD units mentioned above (which received the lion’s share of the funding, but were only set up for 300 patients).

 A deliberate feature of the 11 commissioned community programmes is that they were all different. Bids were invited, emphasising the value of novel thinking and bringing together different elements, services and sectors - to bring fresh thinking to a largely unsolved problem. The four largest projects were Thames Valley, Leeds, Nottinghamshire, and Coventry. The Thames Valley Initiative, brought together democratic therapeutic community programs that were adapted into coherent region-wide care pathways. In Leeds, a major focus was to coordinate a range of services between health and other sectors, with particularly strong cross-agency working. Nottinghamshire provided three coordinated services for levels of severity, with a drop-in advice centre, a ‘stop and think’ psychoeducation programme, and a non-residential democratic therapeutic community.

Coventry’s project was tightly coordinated with local mental health services, through a community mental health type arrangement. The small ones included a preventative one seeing adolescents working from a shopfront in Plymouth, and an ‘itinerant therapeutic community’ which, for example, met in a rugby club in near Carlisle, using set-top box technology (cutting edge at the time) to provide 24/7 continuity by using the internet. In Cambridge and Peterborough, the pilot project was integrated with inpatient psychiatric services. There were three projects in different areas of London: one in the Camden and Islington project, with a focus on employment and primary care consultation; in North East London the service specialised in dual diagnosis using a dialectical behaviour therapy model; the one in southwest London was a particular way of managing risk using therapeutic community principles, ‘the service user network’. One, in Essex, was not directly connected to the NHS and was set up as a social enterprise (a Community Interest Company, or CIC) with strong service user co-production and provision of a community ‘Haven’ with a therapeutic environment.

In 2006, the national learning network was established as a forum at which all 11 community pilot projects, met in different venues (at each of their locations) and attended by service users, staff and managers from the other projects. The discussions were very fertile ground for sharing best practice, and new knowledge as well as the inevitable obstructions and difficulties.

The formal research project with the national program was called ‘Learning the Lessons’ which was conducted by Michael Crawford at Imperial College in London. It included (1) an organisational evaluation; (2) a user-led qualitative evaluation; (3) a cohort study; and (4) a Delphi study of the views of academics, service users and providers – about the integrity of the diagnosis. All the results are available online.

An extremely important part of the program was the extensive involvement and partnership with service users. This was initially through the Borderline UK organisation, which later merged with an arts organisation called Personality Plus to become Emergence. As part of the merger, Emergence and Personality Plus held a major arts inclusion event at Tate Modern, sponsored by the Tate and the National Programme, on 29 October 2007. Emergence became a community interest company run by those with lived experience of ‘personality disorder’, with some board-level support from established professionals. It ran various consultation, training and research projects, the largest of which was the National Personality Disorder Program.

The most influential product of the partnership was the ‘KUF’ training in 2008 (Knowledge and Understanding Framework) with Emergence plus three partners: the Open University, Tavistock and Portman NHS Trust and Nottingham’s Mental Health Institute. There were three levels of training on the ‘career escalator’: the awareness level training - which had been delivered to nearly 200,000 people by the end of the mid 2010s; a stand-alone BSc course which later became CPD modules; and an MSc with four centres delivering.

The principle of the KUF training is that it is co-produced at all levels - from the writing the material, to the recording and videos, the online content, to the delivery of it. For example, the three face-to-face days on the awareness training are always be delivered by a lived experience practitioner partnered with a sympathetic clinician, who had been through a train-the-trainers programme together.

2009 saw the publication of two important government publications: The ‘Recognising Complexity’ commissioning guidance for personality disorder services, and the NICE guidelines on Borderline Personality Disorder (CG78) and Antisocial Personality Disorder (CG77).

At its peak, the new community PD services were only covering 12% of the English population: questions were being asked about what exists for the other 88%. Even within the 12%, the work undertaken was done in very different ways, by services that were had different outcome targets, had different populations, and very different methods. Despite the clear need for expansion, the anticipated growth of the programme - to implement the government policy guides - never came to fruition. This is probably because the complexity of training needs and wide-open scope of the programme unearthed large areas of unmet need, and many more problems, than it was feasible to address at that time. Interestingly, the ‘Improving Access to Psychological Therapies’ programme, which could reassure ministers that relatively simple solutions to common mental health problems were possible, and measurable – in terms of ‘return to work’ and other politically attractive outcomes. The lion's share of any new government funding available for national programmes was therefore allocated to Talking Therapies (IAPT), and by 2011 the effects of the economic crisis led to the community programme being closed.

However, following the recommendations of the 2009 Bradley Report, much of the learning from the community programme was incorporated into the joint MoJ/NHS ‘Offender Personality Disorder Programme’.

The programme itself finished with two publications, and a number of other indirect developments. The first is a qualitative evaluation of all eleven community pilot projects, ‘Innovation in Action’ which recognised the importance of the quality of relationships, and described many common factors and whole-system features (‘general therapeutic factors’) of what was to become ‘relational practice’.

The second publication was ‘Meeting the Challenge, Making a Difference’, which is a handbook for be working in various settings where mental health is a factor (from homelessness hostels and social care settings to psychiatric hospitals, for example). It is a user-friendly, accessible and practical guide, based on all that had been learnt from the pilot projects.

Linked work at the Royal College of Psychiatrists Centre for Quality Improvement, from 2007 onwards, led to an accreditation process for ‘Enabling Environments’, which was based on ten relationship-based values. 

These were all amongst the processes that started to more rigorously define 'relational practice'.

 

Extreme Greencare: it blew my mind, twice a day

 This was the return of the Compassionate Mental Health ‘gatherings’. I think this was the tenth one ever held, as they started in the twenty-teens - but it was certainly the first since Covid https://tinyurl.com/CMHatCoed. I first heard of them a couple of years ago, when some of us were putting feelers out in our networks for things that appeared to be based on ‘relational practice’. At that time, I got the impression they were a cross between arts-based festivals and professional conferences.

Well, now I have been to one – as a guest presenter – I can say that has some truth to it, but misses something out that is much more engaging, experiential and (for me) existentially challenging. Relational, they certainly are - with the dial set to at least eleven – for intensity, intimacy, challenge, and sheer counter-cultural alternative-ism! The closest thing I can compare it to is when I went to a week in Italy, in July 2014, to see how Disagio Diffuso is treated by the method (see previous blog https://greenshrink.blogspot.com/2014/07/a-strange-holiday.html and following entries).

But instead of Italian style (with Italian food in a nice hotel and quite a bit of chaos) this was quintessentially Welsh (set in a commune in a forest with yurts and a stone circle, and vegan food). However, because of the deeply personal and confidential nature of so much that was shared I am not going to describe what went on in our various groups in any more detail here. Suffice to say that although I was expecting something a little like our LLE weekends, this had boundaries (that were well held by the staff and structure) that are so much more complex than ours, that I don’t trust myself to try writing any details in this blog. Here’s one comment I heard over lunch on the last day ‘In that last session it was like we went as far in a couple of hours as usually takes years in therapy’. I have heard similar things said about psychedelics, Ketamine and MDMA – but I can assure you that none of that was going on here!

At a tangent – but less of one than most people think about for a conference-type event – was our set and setting. The set was that I think over half the people there had been to CMH gatherings before, and all the others (like Neil and myself) were at least trying to be as open as possible to whatever was happening. The two of us had our own anxieties, as we were presenting stories about our last 25 years’ training work and running ‘mini-versions’ of it as workshops, to an unknown audience - that was completely different from the mix of people that come to sort of conferences we usually go to. But more than that, there was an intangible quality in the air that I have no words for – it is something about numinosity, spirituality, transcendence and - dare I say it – cosmic consciousness. (Again, no psychedelics, I promise). There was a team of about ten running it, which included supporters for those in need, explainers, chairs of sessions, MCs and practical helpers. Those, plus the people who had been before were well ‘set’ to experience it again, and knew what to expect.

The link with the setting was powerful and extraordinary – and I think I can allow myself to be more descriptive here, as Coed Hills (the venue) is an entity with a set of values and activities which were explained eloquently to us, as one of the optional activities on the last day.

The setting, Coed Hills, and its people, do not seek to be hidden or confidential about its meaning and purpose. The way I explain it to people back home who are unlikely to be sympathetic is to say ‘it is a Welsh commune run by people who look like old hippies, but who have been doing it for many years and have become experts in many of the local-based things that are clearly needed for long-term sustainability’. Such as production of energy, food and craft products all done in-house, with as low a carbon footprint or ecological impact as possible, and by running a conference / wedding venue to raise funds with utterly unique and mostly beautiful architecture and design. If people I’m describing it to are likely to be at least a little sympathetic, I go further – which I will do here.

The afternoon session on the last day was called ‘Introducing the Bottega Project’ with John Whitehead and Rawley Clay. John is the resident ideas guru with outward-focussed intentions to expand the principles of sustainable living on a city scale – specifically Cardiff, where he describes collaboration with the architecture department at the university, for example, as well as many other networks of influence. Rawley, primarily an artist I think, is the main person looking inward to sustaining and developing the community at Coed – with many aspects familiar to us in the TC world, such as weekly community meetings, sharing of resources / emotions / food / life in general, and of course democratic operating - and a flat hierarchy.

We met outside the circular barn (in which most of the CMH gathering events took place) for a brief introduction. Rawley started by triggering my circular and Jungian resonances, all about the space with no corners, and their use of yurts and curves rather than rectilinear design with hard edges and all that goes with them. Coed Hills is blessed with a beautiful piece of land in a beautiful place. Here is a quote from the website:

Coed Hills (pronounced Coyd) is a unique, off grid sustainable community just outside Cardiff in South Wales.  The on-site residents still work the land using ancestral methods and manage the 180 acres of unspoilt ancient Woodland, man-made lakes and beautiful summer meadows. With elevated views reaching as far as the Jurassic coastline of Wales, yet just a stones throw from the Welsh Capital, Cardiff, Coed is a hidden Utopia from modern life.

Coed has been the leading centre for low impact living in Wales since it was established in 1997. It has hosted many international events including the UK Permaculture Convergence, and has been internationally identified as a place for those who want to embrace an off grid way of living in harmony with nature or to explore and evolve their connection with themselves in tranquil and peaceful surroundings.

John then gave a few minutes of spirited and often non-verbal communication of how Coed and its principles look well beyond the mundane necessities that most of us are immersed in. A sense, perhaps, that even though the world is in a complete and utter pit of despair at the moment, there can be different ways of looking at it. Then he introduced us to some simple exercises. The first was interpersonal, and after agreeing on pairs (six, as we were altogether a dozen) we would each spend three minutes communicating to the other, without any words, how we were feeling about being in nature and all the elements of it all around us (and it was a very rich natural environment, which included the built environment and numerous artistic pieces). We could use any physical means, such as posture, movement, facial expressions, breathing, vocalisations without words and anything else we wanted. At first, I think most of us felt– to say the least – like complete chumps. But once we got started, and could feel that we were in a trusted space, it was extraordinary how much we could communicate and mutually understand; it was in a very fluid and boundless way that is never usually possible in conversations with strangers who you only met ten minutes ago.

John then led us out of the immediate environs of the centre, up a slight grass-covered hill, to a circle of 28 standing stones. Again, he persuaded normally decent and rational people to do something they had never done before – to go up to one of the stones and commune with it for a few minutes (those weren’t his exact words, but it is the gist of it). As I write this, it sounds silly and woo-woo – but as we were there, experiencing it together, I think we all got something peaceful – and perhaps personally meaningful – out of it. There was no need to explain, or defend, or judge; we were simply doing what felt OK at the time. A few jokes and bits of warm playfulness mixed well with the sombre and serious tone of the moment.

Next we went deep into the woods – to hear from one of Coed’s oldest members, who had a fire burning strongly under an open shelter. This was a true woodsman, as in the novels of Thomas Hardy, but he also showed us some survival skills and tricks – with bangs and flashes – that I remember from school chemistry lessons.

The last port of call on our introduction to the Bottega Project was to an extraordinary structure which I thought should be the biggest yurt in the world (I asked, and apparently, it is not).

Not the biggest yurt in the world - but must be close!

There we had a rich discussion about how much, of deep psychological meaning, we have lost in modern social living, and how aspects of it could be restored – at least on a city scale. I stayed so long talking to John about it, that I was the last one there – and ended up lost in the woods as dusk was falling, and the Welsh rain was starting. But, needless to say, I soon found one of the locals who pointed me in the right direction – back to something a bit more like normal life, with tea and cakes, at the CMH gathering.

In the final session, we had a go-round to check out with our reflections about the whole experience. Mine, amongst much more emotional ones, was that I had found or come across something that I wasn’t expecting but know that I might need – and that it had blown my mind, at least twice every day.

I think that’s a good result…