Relational Practice - Manifesto and Movement

This is the story of how a government mental health programme which was shut down in 2011 (following the financial crash) gave rise to a movement and manifesto, with aims to press for  wide-reaching national policy changes.

 

The ‘personality disorder problem’

The work was born out of a public argument between the then home Secretary (Jack Straw) and the then President of the Royal College of Psychiatrists (Robert Kendal): Kendal claimed that ‘Personality Disorder’ was untreatable - and Straw refused to accept that. The result was an expensive programme to treat the 300 most ‘Dangerous people with Severe Personality Disorder’ (DSPD), and a community-based ‘National Personality Disorder Development Programme’ (NPDP).

The DSPD programme was marred by adverse public opinion and professional disagreement – perhaps most strongly about detention without conviction and the indeterminate sentences given by courts for ‘dangerousness’ rather than criminal offences. The sentences continue to be an unresolved problem.

The community  NPDP work was allocated  a recurring sum of £9.8m – perhaps ‘crumbs from the table’ of DSPD. For it, the government produced and published the ‘No Longer a Diagnosis of Exclusion’ (NLDE) policy guide. This was used to set up eleven community pilot projects, a national training programme, and a formal research evaluation. The pilot projects varied considerably, and the successful applicants were chosen by a large group process led by the opinion of service users – who had themselves experienced either good services, or the lack of them. The workforce development programme became the Knowledge and Understanding Framework’s (KUF’s) ‘training escalator’.

The different projects within programme were tightly reviewed, and frequent ‘learning network’ events were held. What started to emerge was a common theme across the widely different services: best summed up as the importance of the ‘quality of relationships’ between those who delivered the services and those who received them. This was hinted at in the formal research project, ‘Learning the Lessons’, and confirmed in the commissioning team’s  end-of-project evaluation ‘Innovation in Action’.

After the funding was withdrawn, and throughout the 2010s, those involved in the programme continued to meet – usually, but not only, at the annual conference of the British and Irish Group for the Study of Personality Disorder (BIGSPD). The organisation grew from a dozen or two delegates in 1999 (taken to Jersey by Peter Tyrer) to over 600 in 2023. But there was an even more significant qualitative change: from a scientific conference only discussing pure research, to one which first included presentations on novel service designs, to one where delegates with lived experience were almost as numerous as clinician and researchers. Again, ‘a different quality of relationship’.

 

The ’golden thread’

But much of the undercurrent during these years was not about the ‘beauty contest’ or ‘horse race’ between competing ‘alphabetti spaghetti’ therapies, but what the common principles were.  This thinking has a long history – similar to the ‘Dodo Bird Verdict’ from 1975, and traceable right back to 1936. Most importantly, the people with lived experience had little truck with the finer points of distinction between different therapies – and very often mentioned that it was the relationships that mattered. These were not only the relationships between them and therapists, but included relationships between different people who were in therapy groups as well as more abstract relationships – such as those between the individuals and themselves, the system and culture they were being treated in, and wider experiences such as the natural world.

Those of us most involved (Nick Benefield, who had been DH’s commissioner for the NPDP, and myself, Rex Haigh, as his clinical advisor) produced increasingly complex diagrams for BIGSPD workshops over the years. It eventually resulted in publication of what we now call the ‘complexity model’, but which we rather presumptuously called ‘a Unified Model of Human Development’ at the time.

This was included by the Ministry of Justice as a theoretical foundation for their work in the ‘Offender PD Programme’ – which led on from the end of the NHS-funded NPDP, without the inclusion of an NHS community focus (it only concerned the NHS for those in prison or on probation). Sadly, since then, the NHS involvement in the work has been minimal – although significant progress (through research, quality standards and workforce development) has happened in the criminal justice sector.

Nonetheless, the idea that ‘relationships are key’ persisted in the growing number of clinicians, academics, commissioners and policy-makers who were aware of the continuing interest in these ideas.

Throughout the covid lockdowns, we all learned to use Zoom – and a few of us continued building a network of virtual relationships to include individuals and organisations who understood the relevance of relationships, and could see that this could be a rallying call with a wider scope than just ‘personality disorder’. Rather romanticised portrayals of the ‘Golden Thread of Relational Practice’ were promoted (often by myself, to the scepticism of my erstwhile and much-missed colleague Steve Pearce - and others who were more formal in their scientific approach).

 

Towards a manifesto and movement

But, since retirement from the NHS and escape from the dogmatism of ‘high quality evidence’, I have been energised by the idea of starting a movement pushing away from biomedical determinism towards something much more fluid, chaotic - and with unknown emergent potential. Hence, a few of us drafted a rather angry first draft of the manifesto, including demands for services that ‘are more helpful than harmful’, and asserting that that relational practice ‘is the antidote to dehumanisation, commodification  and the loss of human dignity and agency’.

Although this found much favour amongst many of the discontented, we decided it was too strident and aggressive. So we recruited a couple of young and non-clinical ‘wordsmiths’ to produce something more in tune with our times. One was a UK therapeutic community graduate and the other an Indian businesswoman running a therapeutic community-based service in Bangalore. The result was the ‘Little Green Book’ which was launched and distributed at the Royal College of Psychiatrists on 7 July 2023. It was hosted by the Enabling Environments project team and supported by the Offender PD Programme. Keynotes were given by Lord John Alderdice, Dame Clare Gerada, Professor Russell Razzaque Manifestos and others.

 

Rationale

At the launch, Nick Benefield, who commissioned the 2002-2011 No Longer a Diagnosis of Exclusion programme for DH, described the rationale in vivid terms: change happens when the sum of dissatisfaction plus vision of what is needed plus accessible first steps becomes greater than the resistance.

In his formulation, dissatisfaction is at three levels: the commodification, industrialisation and dehumanisation of public service culture; professionals’ loss of belonging, connection, communality, agency, worth and efficacy; and the emotional consequences of sadness, anger, depression, helplessness, despair and rage that results from this degredation.

The vision is for formally sanctioned but psychodynamically informed coordination of efforts across all public services - to put relational priorities above bureaucratic, legalistic and managerial ones (like risk aversion, performativity and metrication). It includes further development of services and training programmes that are manifestly relational already – such as psychologically informed planned environments (PIPEs) in prison and probation settings; psychologically planned environments (PIEs) for the housing and homelessness sector; democratic therapeutic communities for severe personality disorders, open dialogue and dialogic practice for systemic intervention in  psychosis, intentional and therapeutic living communities for long-term mental disability, therapeutic group childcare for looked-after children, and enabling environments in various settings where ‘relational practice’ is valued.

The first steps are what the Relational Practice Movement and Manifesto has started to do: bring together the many individuals and organisations who are doing it already, with a structure of networking based on geographies, sectors and professions – through meetings and consciousness-raising events for anything between three and three hundred people – either as stand-alone events, or as part of existing conferences, workshops, courses and various other gatherings. The founding group of the relational practice movement incudes senior policy-makers and commissioners as well as clinicians, academics and people with lived experience – and next steps will draw on these networks and relationships.

The resistance that needs to be overcome, for the changes to happen, comes from a widespread lack of public awareness of the nature of the problem, with little professional or political commitment to recognise it. Personal and professional responsibility for demanding change is lacking. Commissioning mechanisms are mostly unhelpful, often obstructive and almost always without any real understanding of the whole range of unmet needs. There is no funded strategic vision or positive regulatory intent; in short, no work towards developing a robust 21^st century public service ethos is possible.

 

After the manifesto launch

One of our first tasks after the launch was to agree a formal ‘strategy plan’, defining the movement, its intention, and its methods. This was sent out for widespread consultation last autumn; encouraging responses and offers for assistance followed – and a final version has been published on the website. Since then, many individuals and organisations have given their time and energy to help, and five areas of activity have developed. These are networking, training, quality, research and commissioning.

The networking has been by geography, by sector and by profession. The events have included the emergence of local and regional action groups, presentations at various organisation’s conferences (online and live). Some areas and regions have been more energetic than others, and we are hoping that some national events later this year will help to recruit other areas. The voluntary sector, and groups of people with lived experience of ‘non-relational’ services have been particularly interested. The website was set up before the launch, and is kept up-to-date by volunteers. The first print run of 1,000 manifestos soon went far and wide – so 10,000 copies of a second edition is now with the printers.

In addition to the vital consciousness-raising, network, and campaigning effort, four embryonic areas of activity have been defined: training, research, development and regulation. The provisional titles of each of these areas are ‘Relational Learning Academy’, ‘Relational Research Collaborative’, ‘Relational Development Initiative and ‘Relational Assurance Collaborative’, respectively. Each will be led, largely voluntarily, by experts in the various fields who are committed to the principles of relational practice.

The ‘Relational Learning Academy’ will include the KUF programme, with its extra modules for leadership in the prison and probation services, and revive the idea of a ‘training escalator’ by gathering information on all good quality training activities, events and courses. The principle is that they are not for specific therapy or management training, and will be accessible for all professions, sectors, backgrounds and seniorities. In the future, a more formal recognition of individuals’ portfolios might be developed.

The ‘Relational Research Collaborative’ already exists insofar as that at least six senior academics in different universities are undertaking, or have published, research on ‘relational practice’. In the next year, and perhaps annually after that, a small gathering will be held to aid cooperation and collaboration between them. The hope is that research efforts by separate and unconnected teams will develop relationships that will advance the field as a whole – perhaps unlike the more usual academic culture of secrecy and competitiveness. Time will tell…

The ‘Relational Development Initiative’ will be similar to a great deal of organisational consultancy work that already happens, but will particularly focus on improving and promoting the fundamental aspects of relational practice and therapeutic environments. It will build on many ideas familiar to analytically-based psychotherapists, such as the importance pf unconscious dynamics in work settings, and over twenty years of experience in delivering programmes at the RCPsych Centre for Quality Improvement, such as ‘Enabling Environments’.

The last of the four areas of activity , the ‘Relational Assurance Collaborative’, is a longer-term aspiration to influence statutory standards and commissioning of public services in a relational direction - by educating and influencing those involved in regulation policy. Many senior managers, clinicians and academics – as well as the general public – see the downside of excessively authoritarian inspection regimes, for example in school OFSTED reporting. Alternatives exist, particularly ones which develop networks of critical (and supportive) relationships to bring about quality improvement - and need to be considered in developing policy for a robust 21^st century public service ethos, as mentioned above.

This is a brief overview of what many of us are working towards. If you want to know more, please sign up to ‘be part of the movement’ on our website: www.relationalmovement.net.