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'.
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).
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'.
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