Understanding and completing the legacy of Basaglia
and his collaborators
..........................................................
4.3 Related Trends in Mental Health Treatment in the
UK
Each decade of since the middle of the 20th century can be used to the
dominant ideas, trends and approaches in British mental health. Of course, this
is only a partial account, and this section an informal collation from various ‘critical’
viewpoints over the eighty years since the Second World War. The viewpoints
included here are social psychiatry, therapeutic communities, antipsychiatry
(fleetingly), democratic mental health, depth psychology and psychoanalysis, social
justice and human rights, medical anthropology, the ‘service user movement’ and
the field of personality disorders.
1940s: Second World War, and the Northfield Experiments, which produced
the first hospital-based therapeutic community which was described and defined
as such (Harrison, 2000). The normal
professional power dynamic was disrupted, laying the foundations for later ‘Democratic
TCs’. The surrounding context was of the urgent needs of war, followed by victory
celebrations, and rebuilding the extensive damage.
1950s: The social psychiatry movement starts, including widespread
adoption of ‘open doors’ policies for the asylums and the foundation of
Henderson Hospital plus many other therapeutic communities, supported by
anthropological research (Rapoport, 1960). A time of
optimistic rebuilding amidst austerity, with phoenix-like ideas flourishing.
1960s: Anti-psychiatry flourished under RD Laing, and gained widespread popular
support and publicity (Ingleby, 1980). Some deliberately
anarchic TC experiments were seriously implemented and studied. Grendon prison was
founded as the first Democratic Therapeutic Community (DTC) in a prison, with
more to follow (Shuker, Sullivan and Rivlin, 2010). Youthful leaders promised
social revolution, through consciousness-raising and ‘all you need is love’.
1970s: A fairly even balance of social and medical approaches to mental
health allowed progressive policies to spread, and the steady incorporation of DTCs
as part of that in most large psychiatric hospitals (Fussinger, 2011). The surrounding
economic and political milieu was of recession, stagnation and pervasive gloom.
1980s: Collectivist and progressive approaches lose support, DTCs start
to close and mental health services are not given priority; much mainstream
care is moved from hospitals to the community without the necessary resources. Major
western political changes are towards the right with individualistic policies
and increasing economic inequality (Cowden and Singh, 2017).
1990s: Declared as ‘the Decade of the Brain’ by the US president George
H W Bush. Many DTCs close, major interest in neurobiology channels funding
towards biomedical and pharmaceutical research, the balance of interests in
psychiatry tilts strongly away from psychosocial therapies (Jones and Mendell, 1999). Many DTCs close, others are
required to reduce services – for example by moving from residential to day
care. Generally experienced as an affluent though increasingly unequal decade
in the UK.
2000s: The Community of Communities is started at the Royal College of
Psychiatrists (Haigh and Tucker, 2004) and the government’s national
Personality Disorder Programmes recognises the need for novel approaches (NIMHE, 2003). New models
of non-residential DTCs are developed (Haigh, 2007b). ‘Enabling
Environments’ (Royal College of Psychiatrists, 2016) becomes a quality mark for services
providing recognised therapeutic environments, mostly in the forensic sector. In
the wider British culture, initial millennial optimism fades.
2010s: All mainstream services are subject to regulatory pressures, often
to conform to narrow ‘evidence-based’ criteria (Evans, 2010). Together
with severe financial cutbacks, this leads to service developments being
severely constrained - and only allowed under tight managerial and political
control. An exception for psychosocial developments is the ‘Offender PD
Programme’ in the prison service, which develops Psychologically Informed
Planned Environments (PIPEs) and other innovations (Benefield et al., 2018). Several voluntary sector
groupings of critical and dissenting professionals and people with lived
experience of services gain numbers and strength. The background national mood
is primarily of austerity.
2020s: Although DTCs in the NHS system remain under severe pressure and
threat, the well organised ones prove their worth and survive well. Most of those
in the third sector (both adults and children) continue, and some start to gain
more recognition; those in prisons are well-supported. Post-pandemic, a loose
alliance of individuals and organisations with determination to push for
significant change launch the ‘Relational Practice Manifesto’ and associated
movement (RPM Collective, 2023). At the time of writing
(2024) the prevailing national mood is pessimistic, but wanting change.
Unlike the situation in Italy, in the UK there has been a noticeable
lack of political engagement – which was always a central feature of Basaglia’s
work and influence. Some emancipatory and progressive changes have happened over
these decades (often coming and going), but they have never been grounded in a coherently-articulated
vision for whole system change with wider ramifications. However, this is
hopefully now happening in the Relational Practice Movement – which is
advocating a fundamental change in the nature of professional relationships in
mental health and beyond.
4.3.1 Deinstitutionalisation and the First Democratic
Therapeutic Communities
The term ‘Therapeutic Community’ was coined by Thomas Main in 1946 (Main, 1946), following
the Northfield Experiments; it came to prominence after Maxwell Jones established
Henderson Hospital in 1947, and soon became a place of pilgrimage for those from
all over the world who were interested in progressive mental health (Jones, 1953). After decades
of administrative reorganisations, it did not survive the increasingly harsh
conditions in the NHS, and closed in 2008.
David Clark (1920-2010) was medical superintendent of Fulbourn Hospital
in Cambridge from 1953 to 1983. Like Basaglia, he demanded that the traditional
methods of treatment, including deprivation of liberty, dehumanisation and
assumption of incompetence, were unacceptable. With the authority of his role
there, he managed to unlock the doors for all 1,000 patients by 1958 (Clark, 1974). He later
went on to set up what would now be recognised as DTCs, and was instrumental in
making this into a national movement by being one of the founders of the
Association of Therapeutic Communities. He
is recognised as a main leader of British social psychiatry in its heyday between
the 1950s and the 1970s.
4.3.2 Mental
Health Policy, Psychosocial Interventions and Human Rights
The first governmental move to deinsitutionalise the Victorian asylum
system arose following the famous ‘Water Tower Speech’ by the Minsister of
Health, Enoch Powell, in March 1961.
'This is a colossal undertaking, not
so much in the new physical provision which it involves, as in the sheer
inertia of mind and matter which it required to be overcome. There they stand,
isolated, majestic, imperious, brooded over by the gigantic water-tower and
chimney combined, rising unmistakable and daunting out of the countryside - the
asylums which our forefathers built with such immense solidity to express the
notions of their day. Do not for a moment underestimate their powers of
resistance to our assault.’
The ‘Hospital Plan’ followed and the move to ‘care in the community’ was
started, although slowly at first, and probably never with sufficient resources
to actually improve the experience of those moved out of the hospitals.
As the national programme of closure moved towards the end of the
twentieth century, a breed of ‘closure managers’ was recognised. They were seen
to be unwavering in their determination to empty the hospitals then sell the
land and buildings; the requirement to provide a dignified transition for very
vulnerable people to individually suitable accommodation with the required
support services, for many thousand people, was a largely unrealised
aspiration. True informed consent was never an issue, and the process probably increased
stigma, alienation and loneliness – as well as premature death – for many
people who did not want to, or could not, live so independently.
In practical and strictly legalistic terms, the intentions of
deinstitutionalisation were met and the project seen as a success. Although many
ex-asylum residents were probably satisfied, or even delighted, with the change
of their living arrangements, this belies the possibility of as many of them –
or more – who experienced it as a profound loss, of cherished relationships
that could never be replaced. John Cox, president of the Royal College of
Psychiatrists at the time, wrote a paper called ‘Contemporary community
psychiatry: where is the therapy?’
for the first Maxwell Jones Memorial Lecture (Cox, 1998).
In psychotherapeutic terms, a fundamental human right is seen to be that
of secure attachment – without which satisfactory emotional development is
impossible (Haigh, 2013). For those living
the majority of their lives in an asylum, this is a complex attachment to the
asylum, its systems and the people in it – however dysfunctional some of them
may be (Haigh, 2002). It is hard
to see the wilful destruction of this deep attachment as anything but a severe denial
of dignity and abuse of human rights.
4.3.3 Stagnation,
lack of progress and regression in the statutory (NHS) services
For the last decade there has been increasing public awareness of severe
problems which currently occur in NHS mental health services. These often
feature in investigative television reporting, and are sometimes substantiated
by adverse conclusions of coroners’ inquests (see for example Iacobucci, 2022). Blame is most commonly
attributed to inadequate ‘systems’ or ‘communication’, or insufficient resources,
and rarely recognises the authoritarian and aversive practices demanded by
hospitals’ policies and the dysfunctional ward environments where patients
often cannot feel physically, let alone emotionally, safe. Seeing this situation, many professionals,
from all the mental health disciplines (psychiatry, nursing, psychology,
occupational therapy and social work) as well as general practice feel that many
mainstream mental health services are no longer fit for purpose.
Two main sources of blame are often identified; both are systemic. The
first is that the regulatory framework for services is based on ‘safety’
principles that strive to eliminate any source of risk. This is
counterproductive and prevents much necessary therapeutic ‘positive
risk-taking’, and therapeutic growth. The second is the biomedical model of
clinical practice that is demanded through structural processes such as NICE
guidelines as well as the powerful impact of the pharmaceutical industry. Drugs
are very often the primary treatment, and little else is considered
cost-effective.
Recipients of these services often feel that their responsibility for
themselves and their personal agency has been removed; they have no sense of
informed collaboration of their treatment. The understandable emotional
reaction to this situation often makes people ‘worse’ by acting in ways which
lead to greater restriction, coercion and doses of medication. Iatrogenic harm
has been done through a systemic power imbalance, which neither recipients nor
providers of care can change.
4.3.4 The
origin of the Relational Practice Movement and wider aspirations
At the beginning of the twentieth century, when ‘Dangerous People with
Severe Personality Disorder’ was high on the public agenda, the government
started to produce policy for it (Maden, 2006). Although
the lion’s share of the funding was allocated to new the four ‘DSPD’ units in
prisons, high security hospitals and in medium secure and community programmes,
the ‘Community PD Programme’ was started in 2002. The bold tactic of using
co-produced selection and commissioning (Haigh, 2007a) to spend £9.8m
of revenue led to a range of services being developed, along with a
nationally-funded training programme and an evaluation strategy.
A quality assurance programme was developed and is accredited at the
Royal College of Psychiatrists: the ‘Enabling Environments’ award (Royal College of Psychiatrists, 2016). It is based on ten values
derived from various sources, with many from DTCs, and standards for each of
them. It requires submission of a detailed portfolio of evidence and its evaluation
by an expert committee.
Through subsequent years the developing National Personality Disorder
Programme was discussed, analysed and evaluated. The formal centrally-funded
programme ended in 2011, with several of the pilot projects continuing – and
others evolving on similar lines. What started to emerge in the ‘Innovation in
Action’ final report was a ‘Golden Thread’ which highlighted ‘the Quality of
Relationships’ at various levels (Wilson and Haigh, 2011).
This led to a ‘relational model’ being written and published (Haigh and Benefield, 2019). Through the pandemic years,
many links were made with interested individuals and organisations. This
culminated in a ‘call to action’ – which resulted in the creation of a Manifesto
to start the Movement. The ‘Relational Practice Manifesto’, and the ‘Relational
Practice Movement’, were hosted by the ‘Enabling Environments’ project and
launched at the Royal College of Psychiatrists in July 2023.
This is the definition used for the Relational Practice Manifesto and
Movement (RPM Collective, 2023):
Relational Practice gives priority to
relationships, with ourselves, with each other and with the planet. 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, curiosity, flexibility, authenticity and responsibility
● an
enabling and facilitating attitude
● an
understanding of the inner and outer lives and external relationships of
individuals in their social field
The ambitious intention is to have relational practice as a fundamental requirement
of all work in the public sector. To quote the introduction from the Manifesto
itself:
The Relational Practice Movement is a
response to the isolation and dehumanisation of people across our public
services, both staff and users. Our mission is to replace the current
financially-motivated and disempowering practices across the sector with revitalising
and enabling ones that put humans and interpersonal relationships at the centre
of each intervention. The movement unites people across education, criminal
justice, charities, health and social care to build a more humane and connected
world. The call for Relational Practice in all areas of public service is a
rallying cry for a deeper connection with ourselves and others.
This
reminds us of the two Italian Manifestos written in 2008 and 2023 (see section 4.1.3):
the underlying intention of all this work is to bring about a more respectful
and compassionate way of working, without destructive power relations. It is,
of course, counter-cultural and will always meet resistance and opposition. But
we need to remember that Basaglia’s work was never finished, and indeed is now
more needed more than at any time since his heyday. The modern forms of
institutionalisation are more covert and subtle than they were in the old
asylums – but still rob many people of their right to feel safe and act as free
citizens.
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