More on Basaglia

 

Understanding and completing the legacy of Basaglia and his collaborators

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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.

 

References

Benefield, N. et al. (2018) ‘Psychologially informed planned environments: a new optimism for criminal justice provision’, in Transforming Environments and Offender Rehabilitation. Akerman, Geraldine (Editor); Needs, Adrian (Editor); Bainbridge, Claire (Editor). London: Routledge, pp. 179–197.

Clark, D.H. (1974) Social therapy in psychiatry. Penguin (Non-Classics) (Book, Whole).

Cowden, S. and Singh, G. (2017) ‘Community cohesion, communitarianism and neoliberalism’, Critical Social Policy, 37(2), pp. 268–286.

Cox, J.L. (1998) ‘Contemporary community psychiatry: where is the therapy?’, Psychiatric Bulletin, 22(4), pp. 249–253.

Evans, C. (2010) ‘Death, taxes, certainties, groups and communities or NICE and the Deathly Hallows’, Therapeutic Communities, 31(4), p. 321.

Fussinger, C. (2011) ‘“Therapeutic community”, psychiatry’s reformers and antipsychiatrists: reconsidering changes in the field of psychiatry after World War II’, History of psychiatry, 22(2), pp. 146–163.

Haigh, R. (2002) ‘Acute wards: Problems and solutions: Modern milieux: Therapeutic community solutions to acute ward problems’, Psychiatric Bulletin, 26(10), p. England.

Haigh, R. (2007a) ‘The 16 personality disorder pilot projects’, Mental Health Review Journal, 12(4), pp. 29–39.

Haigh, R. (2007b) ‘The New Day TCs: Five Radical Features’, Therapeutic Communities, 28(2), pp. 111–126.

Haigh, R. (2013) ‘The quintessence of a therapeutic environment’, Therapeutic Communities: The International Journal of Therapeutic Communities, 34(1), pp. 6–15.

Haigh, R. and Benefield, N. (2019) ‘Towards a unified model of human development’, MH Review Journal, 24(2), pp. 124–132.

Haigh, R. and Tucker, S. (2004) ‘Democratic development of standards: the community of communities—a quality network of therapeutic communities’, Psychiatric Quarterly, 75(3), pp. 263–277.

Harrison, T. (2000) Bion, Rickman, Foulkes, and the Northfield experiments: Advancing on a different front. Jessica Kingsley Publishers (Book, Whole).

Iacobucci, G. (2022) Three teenagers died after “systemic” failings in NHS mental healthcare, investigation finds. British Medical Journal Publishing Group.

Ingleby, D. (ed.) (1980) Critical psychiatry: the politics of mental health. New York: Pantheon Books.

Jones, E.G. and Mendell, L.M. (1999) Assessing the decade of the brain, Science. American Association for the Advancement of Science, pp. 739–739.

Jones, M. (1953) The Therapeutic Community. A New Treatment Method in Psychiatry. New York: Basic Books.

Maden, T. (2006) ‘DSPD: Origins and progress to date’, The British Journal of Forensic Practice, 8(4), pp. 24–28.

Main, T.F. (1946) ‘The hospital as a therapeutic institution’, Bulletin of the Menninger Clinic, 10(Journal Article), pp. 66–70.

National Institute for Mental Health in England (2003) Personality Disorder: No Longer a Diagnosis of Exclusion. Policy Implementation Guidance for the Development of Services for People with Personality Disorder. Department of Health (Book, Whole).

Rapoport, R. (1960) Community as Doctor: New Perspectives on a Therapeutic Community. London: Tavistock Publications.

Royal College of Psychiatrists (2016) ‘What is the Enabling Environments award?’ Available at: https://tinyurl.com/EEatRCPsych.

RPM Collective (2023) ‘The Relational Practice Movement and Manifesto’. Available at: www.relationalmovement.net (Accessed: 19 January 2024).

Shuker, R., Sullivan, E. and Rivlin, A. (2010) Grendon and the Emergence of Forensic Therapeutic Communities. Wiley Online Library (Book, Whole).

Wilson, L. and Haigh, R. (2011) Innovation in action.