Why 'compassionte mental health' matters

Arriving at the gate

As recorded here before, the Compassionate Mental Health 'gatherings' are important events that need recognising as part of the groundswell of voices that are arguing for fundamental change in mental health services. This one was in a wonderfully wacky ancestral home - Trevor Hall, near Llangollen in North Wales. Three of us had intended to present TC workshops on both full days - but sadly we were down to two (Anando and myself) and had to get there on lovely long slow trains across the length of Wales. 

But the event, as usual, was extraordinary. A powerfully thoughtful, emotional and relational space for people to come together from utterly different places - but who all wanted to pull in the same direction. 

This included several unforgettable talks and events. An utterly immersive talk and worshoop from Martin Martin Kalungu Banda - with tales of his time as chief of staff to the president of Zambia and as a professor of business studies at Oxford - as well some beautiful sung music from his family. 

Martin describes true communication

Scientific results and promise for 'neuro-feedback' from two pioneers of the field, Sebern Fisher (USA) and Mirjana Askovic (Australia). Helping NHS services to prevent unhelpul practices from Kier and Holly. 

Kier and Holly describe a different way for the NHS

Reflections on surrealism and psychosis from Pat Bracken, one of the world's leading critical psychiatrists. An extraordinary talk about the numinous personal experience of psychosis from a wannabe Swiss nun Andrea Zwicknagi, which was an immersive experience in Christian mysticism. 

Andrea takes us to a different level of experience

Then all the usual things as well - intimate compassion exercises, a powerful experience of community amongst like-minded people, excellent food, shared understanding and passion for change, and a loving relational respect for each other - wherever we were coming from. 

We must have more of this stuff! 

 More parochially, and my own interest in Therapeutic Communities and Relational Practice, I was very interested in Martin's experience of our TC workshop on the first day - almost as an live example of what he was describing in his talk a couple of hours before. 

Work in progres...

Happy Fluffy Bunnyland

After ten years of the relational practice movement: 

• There will be much less violence in prisons, and being a prison officer will be a much more satisfying job. Applications from heavies and thugs who wanted to legitimise their misanthropic world view will dry up. 
• Nurses will be able to us their own initiative to creatively and compassionately care for the people they are looking after 
• Social workers will be able to explore individual and family dynamics, and reduce risk by the quality of relationships they have with children and families. There will be far fewer child protection cases. 
• Residential care homes will all be enabling environments (though not necessarily Enabling Environments) and residential care work will be an attractive and reasonably paid job. 
• Employment and Housing offices won’t need heavy duty screens to protect staff from the public; nor will they need security guards. 
• Nowhere will need ‘zero tolerance of ….’ notices on the wall. 
• General Practice will be an attractive career option for medical graduates; ditto general and CAMHS psychiatry 
• Teachers won’t be frightened of OFSTED and children at school will enjoy a much richer, more artistic and cultural curriculum. SATs will have been replaced by improvement of standards by collaborative learning (and results will improve most where there is more collaboration) 
• Health service managers won’t game the system to get better metrics, but will all spend much of their time in staff sensitivity groups with clinicians, and sometimes service users too. 
• CQC inspections will be exploratory and supportive, with co-produced peer review and an emphasis on improvement rather than judgement. 
• In mental health services, coroners will be seen as helpful people rather than a faceless authority to be utterly feared. 
• Everybody in hospitals will be more worried about loneliness, emotional safety, single use plastics, food waste and UPF than ‘dangerousness’, floridly expressed emotion, ligature points or knives in kitchens. 
• Architects will be experts on relational as well as physical environments in all public service buildings and facilities; nature will always be a primary consideration. 
  
  
• Dixon of Dock Green will be back on telly, everybody will talk to each other at bus stops or on trains, there will be no wars or need for an army, 
• Social media will use AI to exclude anybody being horrid to anybody else, and we will all live in fluffy-bunnyland in good health till we die at 105 and Boris Johnson will be our happy jolly PM again.
  
  
•  Well, maybe not all of those.

Four of them all at once, like the proverbial buses...

1 Tim Makower and Homestead. 

We’re in the middle of Tim’s firm’s participation in LFA (London Festival of Architecture) – which is 3 Wednesday evenings just near Tate Modern. They are all part of the networking and cross-fertilisation needed to get the project - for better designed (fabric, psychosocial and occupational) residential mentl health facilities - under way.
Brigid, Neels and I slightly subverted the first one, last Wednesday, by turning it into into a TC-style democratic community meeting - after the panel of four experts had presented their own contributions. It was very interesting to see how the 'design' of the social space - in a circle rather than rows with pre-defined  boundaries and democratic facilitation, changed the nature, participation and openness of the conversation. The next one is on TCs anyway… 

The overall structure of Homestead is still evolving – but looks like being a collaboration of like-minded organisations overseeing ‘franchised’ projects in different places. Hopefully not like McDonalds, though – and allowed to ‘grow in their own soil’, as good therapeutic communities always should.

 It’s great working with architects rather than health services – I just love the way they think big and scattergun their ideas out there… When we had the 3-day meeting at Tim’s Wiltshire house in April it felt to me like most of the clinical people were rather preoccupied with risk and what’s not possible, while Tim and others were wanting to make a plan for a whole new way of reforming mental health. One of my joys of retiring from clinical work is that I am free to think more like an architect! (But need to be surrounded by some sensible clinicians so I don’t just have a manic meltdown). 

 2, 3 & 4 North American initiativess 

... in the addictions TC tradition – sometimes called ‘Classic’, ‘Addiction’, ‘Hierarchical’ or ‘Behavioural’ TCs, or ‘Concept Houses’ - as opposed the UK’s ‘Democratic’, ‘Maxwell Jones-type’ or ‘Mental Health’ TCs. The things they have in common and how they differ is a question with never-ending answer – but all the Americans and Canadians we’re working with come from the addiction tradition, and quite a hard-line version of it. They also have a never answered question about choosing between harm-reduction and recovery +/- abstinence 

They have come across the democratic model in different ways, but both interestingly involving dear old Steve – the Canadians by having their reding groups go through our TC book, and the Utah people being put onto us by George DeLeon – who is the main addiction TC researcher in USSA (and probably everywhere); Steve Pearce and I both knew George quite well, and he helped Steve get started planning his RCT research in Oxford. 

 But they see some of the addiction TC tradition as perhaps old-fashioned, or maybe just not quite compassionate enough who are more vulnerable or less robust (it’s the original ‘tough love’ I think), so want to learn about the democratic TC tradition and probably end up using elements of both. 

2 Vancouver and British Columbia 

(for BCARA – BC Addiction Recovery Association) The dates and place for the LLEs are set now – 13-18 and 15-20 September at Manning Park, BC. They have read the book (several times I think – they know it better than I do!) and are planning to train staff from 12 pilot projects with the two LLEs. For that, there are 2 from Bangalore (Shama and Anando), one from Portugal which is current president of INDTC (Joao) and two of us coming from UK (Veronica and myself). Maybe one or two others too – I think Joao has a trainee with him. Maybe others too – it is always interesting to have extra people there as researchers/social therapists/general extras. We have a monthly zoom community meeting with them all at the moment. The pilots are mostly in or near Vancouver, but a wide variety of types of places – and the project lead Rob Turnbull is calling them ‘Adapted TCs’., an excellent term. They’re also planning some serious research and evaluation. 

 Map: https://www.google.com/maps/d/u/0/edit?mid=1_YMdE1sYB3FesACwIIxostqkCEkNu44&ll=52.125476640480954%2C-121.22534945000001&z=6 

3 The Other Side Village, Salt Lake City, Utah 

The plan is for a newly built village of tiny houses for 400 people who would otherwise be living rough – through the various entangled factors that lead to homelessness. Once settled in, residents will be expected to work in one its connected social enterprises, pay rent and be abstinent. Addiction isn’t the main problem here, but amongst them: they know that Classic Addiction TC methods are too severe, or just aren’t right, for this vulnerable population. They have been running ‘The Other Side Academy’ for several years now, using that model as a fairly standard USA-type TC – pretty hard core from how they talk about it. What they now want is a DTC-based community programme as a 1-2 year induction to people living in a community of others in the same situation. BTW – they are not a Mormon-based initiative, I wondered, and did ask. 12 of them came over to London in April to see lots of TCs, CofC, Grendon Prison etc – and two of the Slough TC founders (Geoff and Natasha) are going over there lin June. We also do some online training for them. They are very determined to get it all started pretty soon! 

4 Alberta, Canada T

wo retired psychiatrists – who have worked with the Vancouver people before – are also wanting to use some DTC ideas in the next province across. It’s a very different approach, organised province-wide with provincial government support and funding. Alberta is a rich stare with its oil money, so can afford to do it well – a bit worrying maybe, but maybe ok as long as they don’t have oil or petrochemical sponsors? But that one is only in its infancy.

Just some thoughts about some interesting things going on at the moment.

Even if the NHS doesn't think much of DTCs, maybe others do!

The clockwork behind an amazing machine

 ...except it's not like a machine at all, and very friendly and human when you get through the door. But it is run inside a steely and well-oiled modernist structure called the 'Royal College of Psychiatrists Centre for Quality Improvement'. When I was first involved, in 2000, the machine did have a slightly less managerial name ('College Research Unit'), and interface (no corporate websites in those days), and worked in a friendly but slightly ramshackle old office block near Victoria, where everybody knew each other and we could hang out for a chat with the people running the new 'quality networks', and sit on teach other's desks. I don't even know where the desk are nowadays - they are probably hot.

That was the year we started the work on what was to become the 'Community of Communities'. It all came about when I was serving my time as chair of ATC - the 'Association of Therapeutic Communities'. A few years later, in 2007, ATC merged with the 'Charterhouse Trust' children's TC organisation to become 'TCTC' - 'The Consortium of  Therapeutic Communities', which is still the only professional organisation for British TCs. At the time, the mighty firm grip of 'New Public Management' (an offshoot of marketisation and quest for econmic efficiency set to bear down on those of us in the soft and cuddly public services) was starting to be felt...

Specifically, NICE was founded and had a welcoming message about helping clinicians to make decisions when it was uncertain what course of action was best. Well, that was then. But as chair of ATC, I thought we should not be left out - and wrote to NICE asking if we could be included. I received a rather formal, but prompt, reply saying that I was out of scope and should approach my relevant professiuonal body. As a psychiatrist, this was obviously the Royal College. 

And I had a very friendly and helpful response, expalining how they were just starting to develop these 'quality networks', and were we interested? Well, I was certainly interested, as it sounded like 'the good old days' (of which which I only experienced the tail end) when ATC member communities used to take it in turns to hold open days - about four times each year - to gather  together in the different TCs and swop ideas about their successes, troubles and ideas. And have a lot of argy-bargy, as rumour has it.

The hitch was that it needed money - unlike the 'good old days' ATC version, when everybody did it for free. So, as ATC had already been successful in getting a National Lottery grant for a multicente research project (in 1998), when the lottery was a fairly new thing, we thought we shoud try again - with RCPsych as the applicant and ATC as the professional organisation backing it. The rest, as they say, is history. 

The first community meeting of the Community of Communities, 25 October 2001

So we were the third of the college's quality networks, with QNIC (for children's inpatient services) and CGQN (for the emerging process of clinical governance) already established. CGQN didn't survive long - and I'm not surprised as I went on one of it's early peer review visits and was bored out of my skull. So now, in 2023, we are the second oldest amongst a whole multitude of quality networks that have been set up since 2002, in the name of healthcare quality improvement. But I still like to think that we remain the most cross-sector,colourful, and (gently) subversive of the whole lot. With a high priority to service user involvement (despite the bureaucratic hassle) and co-production (which it has taken the rest of the college 20 years to catch up with). My colleague Nick Benefield and I reckon that quiet revolutions take about 50 years, so maybe we're on track.

Today, having not been since before covid, I went to the 2023 Annual Forum (perhaps better called Jamboree - though the college public relations committee would never allow such frivolity). It was a joy. It reminded me of why I have loved this work for the whole of my NHS consultant career, and have been so lucky to be part of it. There was everything here that you could hope for in a therapeutic environment - belonging, emotional safety, fun, playfulness, growth, spirituality, 'fire in the belly', new ideas, good food, boundaries, and something that none of us have ever found a word for - except 'tc-ness'.

The team at the college who run it has included dozens of amazing people over the years (who are young project workers who often spend a year or two with us before going on to higher things, with some great tools under their belts) - and our current gang are as marlvellous as they have ever been. So many thanks are due to Bethan, Katy, Leyla and Niamh for keeping the good ship CofC on course through some wild and choppy seas!

The 2023 team - plus a few extras - winding down after this year's Annual Jamboree (Forum)

(The extras in the photo are Jane, myself, Mike and Neels - who are all involved in varous ways with the mischief we get up to)