Manifesto for a Relational Practice Movement

Currently, narrow industrialised models of public service interventions ignore many factors in the wider system, including the need to take a broader approach to the complexity of relational working. The powerful effect of managerialism and market competitiveness combine to produce a milieu in which human values and relationships are not explicitly prioritised: the experience of public services is increasingly impoverished and alienating for those providing or receiving them. In the current situation, professionals face the risk of losing their capacity to maintain a relational basis to the work.

 

This chapter outlines the process that led to the recognition of this ‘relational practice’ deficit, its definition and recognition, the change needed, the intention of the campaign and the underlying theoretical framework. We call for change in the training and practice of all professional and ancillary staff working in public services. Service commissioning will need to drive these changes if future public services are to be fit for 21st century requirements. To implement this, an active campaign is needed.

 

Introduction

The English Department of Health’s National Personality Disorder Programme (2003 – 2011) was launched with the publication of ‘No Longer a Diagnosis of Exclusion’ (NIMHE, 2003) and closed with the publication of a practice handbook (Winifred Bolton et al., 2014), and a qualitative service evaluation (Wilson and Haigh, 2011). The whole process became a vehicle for the identification, research, and development of ‘relational practice' (Haigh and Benefield, 2020).

 

This was achieved through establishing a range of different pilot projects across the country (Haigh, 2007), studying them with a mixed methods research programme (Crawford et al., 2007), and implementing a ‘training escalator’ to develop a workforce with suitable knowledge, understanding and attitudes (NIMHE, 2003). The programme also supported the development of a rigorous but relational and values-based process for identifying, measuring and ultimately accrediting best practice, through the Royal College of Psychiatrists Centre for Quality Improvements ‘Enabling Environments’ programme (Haigh et al., 2012).

 

This was all to provide innovative solutions to what was seen as the ‘burden’ of ‘personality disorders’ in community and inpatient mental health services (Soeteman et al., 2008).  This was traditionally seen as a traditionally ‘hard-to-reach’ population who were often excluded from mainstream services;  these people were often disliked as ‘patients’ and working with them was seen as difficult and inappropriate by many staff – as they did hot have ‘proper mental illnesses’ (Lewis and Appleby, 1988).

 

Rationale

When human development is disrupted, the psychological, social and economic consequences can reach into every area of an individual’s personal and social world, resulting in alienated and chaotic lives and repercussions throughout their communities. The causes and consequences are largely relational. They may include child abuse, inadequate parenting, failed attachment, trauma or emotional deprivation. The causes can also be social: material poverty, or the poverty of expectation that leaves individuals feeling powerless to have any impact on the world in which they live.

 

Over-riding differences in class and educational advantage confer some with strong constitutions - or a range of poorly understood ‘protective factors’ – which may be sufficient to enable them to withstand the impact of these environmental failures and emerge from their early experience to live what appear thriving and healthy lives (Bellis et al., 2016). However, very many end up in a situation where they are excluded from mainstream society, rejected by those who might be able to help them, and destined to live lives of unremitting frustration, without the happiness and fulfilment that most of us would consider just - and expect for ourselves and our families.

 

These individuals, and often their families, have little psychological sense of their place amongst others or where they fit into society. School, working lives and almost any pro-social relationships are difficult or impossible to establish and sustain. They experience the world as a hostile, unhelpful, threatening or undermining environment, living in a marginalised underclass with high levels of substance misuse, self-harm, criminality, and suffering severe, enduring and disabling mental distress (Horn et al., 2007). People in this situation will often use a considerable range of statutory services to little benefit (Coid et al., 2009).

 

If our systems could respond in a relational way, our experience in working with ‘personality disorder’ services and systems shows that many obstacles, obstructions and conflicts could be prevented. This applies at the individual level (when those seeking service input feel respected and not overpowered by the professional they consult); the service level (where those working in the service have meaningful engagement with their task, believe in what they are doing and can operate from a position of authenticity and wanting to help – rather than by just following a rulebook); at organizational level (these principles need to be prioritised and not over-ruled by role hierarchies or inflexible procedures); at political level ( so that policy makers in different areas can develop a shared understanding of how changes in this direction will lead to greater efficiency and satisfaction, for both service users and providers).

 

Contextual History

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 (Kent County Council, 2006). This led to what became known as the DSPD (Dangerous People with Severe Personality Disorder) programme (Maden, 2006). The political objective was the research into improved management of high risk offenders whose risk to others was linked to their diagnosis of personality disorder.  The outcome was the piloting of new assessment and treatment services base in prisons and forensic NHS secure services and community forensic teams. This programme provided a joint financial investment by the Department of Health and Home Office. As part of the policy plan it made a commitment to improve mainstream community mental health and social care services for those failed by existing services because of their identified ’personality disorder’ presentation.  This then became established as the National Personality Disorder Programme in 2003.

 

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 was, and still is, considerable controversy about use of the ‘personality disorder’ label itself. In terms of provision, many anguished voices claimed unhelpful and harmful treatment from statutory services (Castillo, 2003; Robinson and Cox, 2006; Sibbald, 2020).

 

These comments were gathered by Borderline UK’s 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.

 

Recognising these unmet needs, the Department of Health set up two working groups to prepare a policy implementation document on strategic changes that might help. In 2003 Personality Disorder, No Longer a Diagnosis of Exclusion (NIMHE, 2003), with clear evidence on what service users were asking for, was published alongside the Breaking the Cycle of Rejection: Personality Disorder Capabilities Framework (NIMHE, 2003), which was a guide on workforce development and establishing a training escalator relevant to all disciplines and levels of seniority. A National Personality Disorder Development Programme, for services in the community, was established. The three stated aims of the national programme were (1) to produce innovative service developments, (2) to have a national evaluation of the new services, and (3) to implement national regional training developments.

 

The new services were established in 2004. There were five medium secure services and 11 (non-residential) community one (Haigh, 2007); 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.

 

In 2006, the national learning network was established as a forum, which was attended by service users, staff and managers from all 11 community pilot projects. The discussions were 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 (Crawford et al., 2007).

 

An important part of the program was the extensive involvement and partnership with service users, also now also known as ‘experts by experience’ (‘XBXs’ or ‘EBEs’) or ‘people with lived experience’. This partnership started by developing a relationship with those who ran 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 Gallery 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 with the National Personality Disorder Programme.

 

The most influential product of the partnership, and of the cooperative and trusting relationship between professionals and those with lived experience, was the Knowledge and Understanding Framework (‘KUF’) training. It was set up in 2008, 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 delivered across four centres.  The principle of the KUF training is that it is co-produced at all levels - from writing the material, to recording videos, the online content, and the delivery. For example, the three face-to-face days on the awareness training are always delivered by a lived experience practitioner partnered with a sympathetic clinician, who had been through a train-the-trainers programme together.

 

Three important government documents were published in 2009: The ‘Recognising Complexity’ commissioning guidance for personality disorder services (Department of Health, 2009), and the NICE guidelines on Borderline Personality Disorder (NICE, CG78, 2009) and Antisocial Personality Disorder (NICE, 2009b). These strengthened the understanding of how different presentations would need specifically designed services, and provided commissioners with a model for developing services for people with complex emotional needs. At its peak, the new community PD services were only covering 12% of the English population: questions were being asked about what existed for the other 88%. Even within the 12%, the work undertaken was done in very different ways, by services that had different outcome targets, 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. At a similar time, the ‘Improving Access to Psychological Therapies’ (IAPT) programme, was able to 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. Consequently, the lion's share of any new government funding available for national programmes was 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 (Bradley, 2009), much of the learning from the community programme was incorporated into the joint Ministry of Justice/NHS Offender Personality Disorder Programme in 2011. This programme has seen the biggest development of sustainable services within the criminal justice pathways for high-risk offenders.  These assessment and treatment services include prison based Therapeutic Communities (Shuker and Newton, 2008), specialist Psychologically Informed Planned Environments (PIPEs) (Benefield et al., 2017) and numerous prison units joining the programme to become ‘Enabling Environments’ (Haigh et al., 2012).  For these men and women, who have complex needs and have histories of relational difficulties, we have provided innovative interventions and improved relational environments. In doing so we have developed our understanding of relational practice and the need to focus on the provision of reliable, consistent longer-term relational experience.

 

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’ (Wilson and Haigh, 2011) 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’, a handbook for 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 (Winifred Bolton et al., 2014). Linked work at the Royal College of Psychiatrists Centre for Quality Improvement, from 2007 onwards, these publications led to an accreditation process for ‘Enabling Environments’, which was based on ten relationship-based values. The ten standards represented the core features of any relational practice environment together with a process through which they could be established, recognised and sustained (Royal College of Psychiatrists, 2016).

 

Intention for a ‘Relational Practice Movement’

Widespread understanding and implementation of relational practice is required in order that future delivery of public services involves due attention to the quality of relationships necessary to satisfy basic human requirements for effective and meaningful exchange. It is likely that the health of all involved, support for their resilience, and effectiveness of the work, is contingent upon the quality of the relational environment in which they work. In any pathway of engagement between an individual and the services they use, the foundation of that engagement is a relational one. This requires that the exchange is respectful and personalised, and takes account of the previous experience and present position of all participants. The intention is to build a productive relationship between those who use services and those who provide them, in the context of shared ownership and effective personal agency, with understanding of any intrinsic power differences.

 

This is important because the provision of education, good mental and physical health, social and criminal justice care and support is not provided for purely by the system of delivery, but also by the quality and collective understanding of those professionals engaged with this delivery. A healthy workforce must not be stressed to the point of burn-out, lost to sick leave, or to leaving their various professions. Rather, a healthy workforce is one in which people enjoy their relational contacts with clients and colleagues, and feel valued and directly involved in a shared endeavour that is inherently meaningful, worthwhile, and interesting. However, relationships cannot be prescribed, or pre-determined, to be positive. Relational practice is not a definitive solution, and working in this way must acknowledge how future relationships are often determined by the quality and problems of participants’ previous relationships. Managing, or just enduring, difficult relationships is an unavoidable part of the work.

 

For too long public services have pursued an increasingly narrow, managerial performance framework with the unintentional consequence of distancing service users and having an unhelpful impact on accessibility to help, support and intervention. Public services need a new vision to ensure that the best psychosocial environment is reliably and consistently available in all interactions between providers and recipients. This should aim to make services more accessible and effective; more helpful than harmful.

 

We now have 18 years’ clinical practice, lived experience and evidence from the developing field of personality disorder, meaning it is now possible to identify and deliver the service design and workforce development needed for relational practice.  As yet there is only an established policy in specialist areas of criminal justice and mental health services. What is required is a movement whose campaigning objective is to make the case for designing, staffing and developing relational practice, at all levels, in a range of public service settings.

 

Expectation of reasonable human rights in a public service system are all based on a relational understanding that there should be:

•                     Access to meet need

•                     Respect and dignity

•                     Understanding and empathy

•                     Empowerment and participation

•                     Consistency and informed choice

This requires all staff to be trained, skilled and supported to understand and provide a meaningful relational response.

 

Definition of Relational Practice

Relational Practice gives priority to interpersonal relationships, in both external and internal aspects. It is the foundation upon which effective interventions are made, and it forms the conditions for a healthy relational environment. It requires relationships based on reliability, consistency, curiosity, flexibility, and authenticity; an enabling and facilitating attitude; and an understanding of the conscious and unconscious lives of individuals and groups in their social field. Depending upon the setting, there will be variations in the balance between these various elements.

 

Research and Evidence Supporting Relational Practice

Although the research does not use the term ‘relational practice’, there is a growing evidence base that these approaches have positive benefits and outcomes in prison populations  (see for example (Auty and Liebling, 2020). A relevant NIHR-funded study of service user perspectives on current provision clearly identified the central importance of relational practice, and labelled it thus (Trevillion et al., 2021). Further studies are underway including a literature search and systematic review; a Delphi-exercise is planned.

 

Training for Relational Practice

For the government sponsored ‘personality disorder’ pilot projects and the wider dissemination of suitable working practices it was essential, from the very beginning, to consider workforce development and increasing capacity. The plans were published alongside ‘No Longer a Diagnosis of Exclusion’ as the ‘Capabilities Framework’ (NIMHE, 2003) which proposed a ‘training escalator’ which started at ground level (people with interest and aptitude but no specific training) and went up through various tiers to an MSc suitable for leaders and pioneers in the area. It was open for anybody to get onto the escalator wherever they were and get off wherever they wanted. Importantly, the whole process was to be co-produced with people who had themselves been through the system as clients, patients or service users. When commissioned, this was the Knowledge and Understanding Framework (KUF) and in its first decade it delivered awareness-level training to over 80,000 people, and produced numerous graduates of its MSc programme. It is has been recommissioned and redesigned following the pandemic, and now has a clear strand of ‘relational practice’ running through it (KUF Hub, 2022).

 

Other training activities, specifically focused on using relationships in clinical practice, have been developed, mostly in the voluntary sector. Specific examples are

·           A three day immersive residential therapeutic environment from the Mulberry Bush Organisation (The Mulberry Bush, 2023)

·           Hope in the Heart is a National Lottery-funded social enterprise which “inspires change through compassionate connection” (Hope in the Heart CIC, 2023)

·           Community Housing and Therapy is a charitable provider organisation which runs specific relational practice training (CHT, 2023)

 

Recognition of Relational Practice

Figure 1 shows some of the current activities in four areas of relational practice: policy, training, research and campaigning. The initiatives with most anticipated impact are those outlined in bold.

Figure 1: Organisations and activities identified as involved in Relational Practice (mid-2022)

The ’Enabling Environments’ programme is based on ten values which reflect the quality of relationships in a working or social environment, operationalizing them with relational quality standards, and recognising them through an accreditation process. It is operated in a process of engagement and collaboration.

Figure 2: The ten values by which the Enabling Environments project recognises relational practice

 

The ten values and standards are as follows.

BELONGING: The nature and quality of relationships are of primary importance

BOUNDARIES: There are expectations of behaviour and processes to maintain and review them

COMMUNICATION: It is recognised that people communicate in different ways

DEVELOPMENT: There are opportunities to be spontaneous and try new things

INVOLVEMENT: Everyone shares responsibility for the environment

SAFETY: Support is available for everyone

STRUCTURE: Engagement and purposeful activity is actively encouraged

EMPOWERMENT: Power and authority are open to discussion

LEADERSHIP: Leadership takes responsibility for the environment being enabling

OPENNESS: External relationships are sought and valued

Details of how services using relation practice principles can be recognised and accredited, and more details, are available from the Royal College of Psychiatrists (Royal College of Psychiatrists, 2016).

 

This framework has been most extensively used in criminal justice settings, with services from various other sectors also achieving accreditation – as a quality mark to demonstrate, amongst other valuable characteristics, that they have relational work at the heart of their operations.

 

Theoretical Framework underpinning Relational Practice
This specification is based on a model of human development (Haigh and Benefield, 2019) which draws on a wide range of basic concepts with relevance to ‘relationship’ and explicit theories of need and causation of behaviours and emotions. This embraces the fields of education, life-course development, social sciences, psychoanalysis, neurosciences, management and organisational dynamics. 

 

The underlying premise is a very simple one, that a vast range of internal and external factors determine the lives we will all lead. The whole range of factors is almost impossible to precisely define, and the fixed and continuous interactions between them all creates an almost infinite number of paths for personality development, as well as life outcome and what we all leave behind. The ‘outcome’ perhaps defined as ‘what our life is like’ is an emergent property of a complex and possibly chaotic system.

 

The model was developed over several years by an iterative consultation process with experts-by-experience, clinicians and academics at a UK-based annual conference. It starts before birth and finishes after death; major areas between the two are emotional development, life experience and life outcome. All these areas can be influenced by adversity – by omission or commission – and modified by a range of ‘bio-psycho-social’ factors. All these elements and interactions are seen to exist in a relational field, part of which is experienced consciously (and therefore subject to a degree of rational understanding); but much is unconscious (or autonomic) and therefore not explicable by the straightforward logic of cause and effect.

Figure 3: The complex interplay of numerous variables in human development

 

Levels of Relational Practice

As clearly identified ideas, principles and values emerged, the concept of relational practice gained greater definition, and a framework for how it could be implemented across a wider field of public and human services emerged. It can be argued that the root of many prominent breakdowns in delivery of public services can be seen as a failure of relational practice – at individual, practice or organisation levels

 

Relational Practice is predicated on the recognition of the fundamental importance of the relational field, and that all professional work requires good quality relationships. For this to happen, we must:

·           Use a model which is based on a biopsychosocial approach.

·           Facilitate the development of healthy psychosocial life.

·           Understand the relationship between the personal, the professional and the social in all domains.

·           Promote a psychoanalytic understanding of unconscious and irrational processes as they affect feelings, attitudes and behaviours.

·           Ensure professional work is based on developing knowledge and understanding of essential relational capabilities.

·           Engage with wider social change that supports relational values and meaning.

·           Facilitate informed leadership that recognises relational principles and practice which includes being compassionate, tolerant, adaptive and available.

 

More specifically, relational practice needs to happen at several levels: the individual one-to-one encounter; the group or team within which practitioners are working; the wider organisation which is responsible for delivering that work – and the relationship between it and other organisations, as well as the political or commissioning structures within which the organisation exists.

 

Personal Qualities/Capacity

Each individual’s capacity to participate in good quality relationships requires consideration of their personal and emotional capabilities in delivering professional tasks. Failure to do so can undermine the effectiveness of their professional role and risk burnout or harmful mental health consequences, and can have a negative impact on others, including service users. Although all interpersonal work requires relational understanding, recruitment to roles requiring specific relational skills need to consider criteria to identify relevant vulnerabilities and capacities in more depth.

 

One to One Relationships

The Quality of Relationship is a measure of the way in which relationships are established, maintained, developed, and concluded. Establishing a one-to-one relationship requires an attitude of genuineness and authenticity, based on a consideration of how it must feel to be in the other’s place. It is often helped by behaviour demonstrating openness and informality; understanding any power differential and the intended purpose is essential. Speaking from a script, or working purely from a decision tree, are not sufficient in themselves. Developing the relationship is important in relationships which will endure across time. This requires different actions depending on the intervals between contacts, and the duration of engagement. The intention is to produce a feeling of safety within which confidence can be established. A sense of playfulness may help. Maintaining the relationship needs both reliability and flexibility. The experience of being fully heard requires a particular quality of listening, and willingness to hear. It must include an understanding of the conscious and unconscious impact of the emotional content, and our way of processing it. The purpose of the relationship is kept in mind, and boundaries are understood. Cancelled appointments or change of personnel, particularly at short notice, are harmful to relational continuity and organisational trustworthiness. Disagreements, breakdowns and ruptures in the relationship need to be mended wherever possible. Ending all relationships has significance which needs consideration, particularly those of longer duration or importance. Endings are best when agreed and accepted, and should be based on principles of reliability and consistency.   Endings are transitions which may have problematic associations for those who have had earlier difficulties with attachment and separations. Missing or avoiding an ending must be avoided.

 

Group Culture

One-to-one relationships always exist in the context of a wider group. The group environment needs to facilitate the conditions for healthy one-to-one relating while recognising the constraints of different settings. Belonging and connection form the basis of engagement and identity; involvement and inclusion are needed to feel part of something and to take a participating role; boundaries and limits are required to provide an experience of psychological containment, within which thinking together is more possible; safety and confidence arise from a psychosocially designed environment; authenticity and communication provide a way to give behaviour meaning; openness and transparency reduce suspiciousness, support honesty, and allow the development of trust. Spontaneity and flexibility can provide an opportunity for exploration of imaginative and innovative ideas and thinking; ownership, responsibility and power create conditions for mutual control, shared accountability and self-determination; personal agency and freedom allow individuals to maintain their own mind and have freedom to make choices. All relational environments require clarity of purpose and leadership to ensure that a relational environment is maintained.

 

Organisational Culture

Service pathways involve a range of organisational settings. Each organisation will have its own culture relating to its primary purpose, but it will need to establish an environment in which relational practice can be sustained. For services and teams, the setting requires physical facilities and organisational conditions to optimise interpersonal relational life; the leadership needs to understand and be committed to establishing and maintaining a relational environment as central to healthy working conditions and staff wellbeing, as well as improved effectiveness and satisfaction, with fewer complaints. Arrangements for support and supervision must be integral to the organisation’s design. An atmosphere of curiosity ensures a reflective approach to all aspects of the service environment and enrichment of the organisational culture reaches beyond the primary task by providing experience and allowing access to imaginative and creative experience.

 

For workforce development, all organisations and teams in public sector pathways need to have a relational practice training strategy. This will cover awareness, understanding, skills, and the recruitment and selection of staff, which needs to continue as part of professional growth. Service-specific elements of relational practice training will be required in different contexts. Depending on the organisational context, this may include the risk to self and others, attitude to rules, and issues of discretion.

 

Conclusion

Relational Practice is a way of working that was identified and highlighted through the implementation of the Department of Health’s ‘National Personality Disorder Programme (2003-11). It’s relevance is much wider than ’personality disorder’, or mental health, or indeed all health services. Human development is something we all experience (Haigh and Benefield, 2019), and healthy development forms the basis of requirements needed to produce suitable therapeutic cultures and working practices (Haigh, 2015; Royal College of Psychiatrists, 2016). An understanding of the relational field provides a working understanding of human exchange that should guide the daily practice of public sector tasks.

 

This work must continue, develop and extend as research and evidence emerges to demonstrate improved professionals’ working culture, and increased effectiveness - with improved user outcomes. This is relevant across all sectors of public service, and the manifesto’s strategic plan is shown in figure 4.

Figure 4: Process for embedding relational practice across the public sector

 

There is now a need for an active campaign to bring about change. The movement that has happened to date has raised professional awareness and found a high level of support amongst those with lived experience of services. The next step needs to be widespread consultations - across all organisations, professions and sectors – and coordination of an effective campaign to bring about these changes. A draft of a ‘rallying call’ manifesto, taken from the text of this chapter, is presented in figure 5.

Figure 5:  Statements from this chapter incorporated into a draft ‘manifesto’.

 

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