The Kindergarten of Democracy

Breakfast at 0715 for a 0800 start – on a Sunday! – but absolutely worth the effort.

The first session was presented by two extremely articulate and erudite Austrian psychiatrists, on the long-term consequences of war. Not only was their methodology presented to us in a way that made complex research easily understandable, but their humanity and compassion shone through. They also showed their  political understanding when talking about how core funding for NGOs makes coordinated action almost impossible, and the lack of leadership leads to a miasma of fragmented services.

A very interesting clinical point was about how ‘low intensity warfare’ could lead to a more complex form of PTSD, or personality change, suggesting the mechanism was not unlike that of childhood trauma and abuse: while still mentally recovering from one adversity, another happens and has a complex interaction with it. They also spoke movingly about how children and families being ‘repatriated’ from Germany to Kosovo showed very high rates of disturbance, and how the family disturbance would probably be passed onto the next generation. The terrible consequences of public policy on mental health – thorough adjustment, loss and emotional insecurity.

An odd random thought came across me during this: ‘we must do an RCT of greencare in Afghanistan’. Based on Steve’s methodology, and the vast disparity between the capacity of a single greencare TC and the unmet need there. Yousuf was soon interested in the idea, and we started thinking about the practicalities of genuine randomisation – and partnership with a respectable academic institution in the UK.

The second session – about the psychological aspects of the Arab Spring - was even more passionate and rousing. We learned how the Arab Spring, started by a single suicide, was sprung by years of pent-up and severe emotional disturbance simply being tolerated no more. We learned of Ghaddaffi’s longstanding severe disturbance and mental health treatment, following hospitalisation in 1971, and how it included the rape of many thousands of under-age virgins: sometimes five per day. And how Burgita of Tunisia was hospitalised in Geneva and later assessed by two psychiatrists, who were under duress themselves, to be found unfit to rule for reason of insanity. 

The exciting headlines, perhaps relevant for the future of the world, were:

·       “We are in the kindergarten of democracy” – which is never a fully attained goal, only ever a process and direction of travel (much as we say in TC practice)
·       Citizens – in a socially-networked world – can no longer be considered as ‘owned’ by single country or organisation. The fear of ‘them’ has disappeared. Again, like a TC?
·        ‘The cancer of multinational corporations’ with the dominance they have from their immense power and financial resources, can only be balanced by the power of the population – talking to each other. Just like they do in groups.

The closing ceremony was just four serious men in suits on the stage – and an interesting presentation of an elegant glass award to the young psychiatrist who asked the best questions and had the best discussions in the ’meet the experts’ sessions throughout the congress. We were also treated to a travel agent’s advert of all the wonderful forthcoming locations you could go to with the next year or so’s meetings of the WPA: Bucharest, Istanbul, Vienna, Melbourne, Ljubljana.

A final bit of wheeling and dealing to be done: Yousuf already knew him, but the rest of us introduced ourselves to the WPA Secretary-General to tell of our ideas for skills training, our links to IMH in Nottingham and the work we will do to work across the WPA sections - maybe for the Istanbul congress. He encouraged us to get information published on the website, promised us his wholehearted support, and would arrange meeting rooms for us. Watch this space…

Post Script. We started the process with two snag-ridden journeys; we had another on the way back. After we had gone through to the gate, Andrea noticed her mobile was missing: desolation and panic. But we phoned it, and, amazingly, it was answered by somebody who understood English – our mini-bus driver. After a complicated sequence of coordinating phone calls, he arrived back at the airport with it to meet Olivia (who had a later flight, and who had not gone through passport control). 600CKr (~£20) later, and with a handover in the back streets of Liverpool tomorrow, it will be back in Andrea’s possession. Hallaelluja!

Windsor tomorrow.

Wheeling, Dealing and Scheming

Sadly the psychodynamics session was mediocre at best, but bumping into Bulent over coffee, I suggested what a good member of the Edcuation Section committee Yousuf would be, and he warmly agreed. Soon after this, I found Yousuf, and he invited me to a grand pow-wow of the heads of all the 67 sections of WPA, to which he had already been invited to be a gatecrasher. Enthusiastic at the smell of new blood (maybe) we were actively included in the discussions to promote cross-sectional working. So Yousuf agreed to be on the Education Section, and apply to be on Developing Countries Section – for which I fully expect him to be chair or secretary within a year.

For my part, I made contact with the Psychotherapy Section chair, and want to explore their interest in collaborating with the Education Section in promoting the importance of experiential learning and our KUF-style ‘quality of relationships’ training - which of course was the subject of our symposium on Thursday. I also recognised the potential that might come of joining the Social Psychiatry Section, to perhaps promote the new breed of TCs we are developing in the UK, and hope to do in culturally congruent ways in Afghanistan (and maybe elsewhere).

So, much as an autocthanous delusion crystallises out of thin air, here’s the game plan that Yousuf and I have cooked up:

1. Following our symposium, we do what we can to promote experiential learning through the psychotherapy and education sections. Use our presentation as a springboard for the idea.
2. Join that with developing countries section (hopefully under Yousuf’s leadership!) to develop training programmes such as we were planning for Kabul last year (see previous blog entries)
3. See if this could be done as an activity of Putting People First, maybe in collaboration with IMH.
4. See if IMH would be interested in developing cross-cultural KUF-type online material as part of the training effort.
5. Suss out whether the psychotherapy section is interested in TCs.
6. If so, plan a congress symposium in the next year or two as part of the section’s work. To include the Thames Valley TC model, Steve Pearce’s RCT, the cultural and economic benefit of adding greencare, and plans for Afghanistan. Maybe also including the Social Psychiatry section.
7. If not, take that symposium to next June’s separate Social Psychiatry congress in Lisbon.  Maybe do this anyway.
8. See if there is any other interest in such a symposium from people at the TCTC Windsor Conference this coming week.

Maybe they should keep us two apart!

Footprints on the pavement

In some need of an antidote to wheeling, dealing and scheming, I followed the antipsychiatry footprints on the pavement to the travelling film exhibition put on by the American ‘Citizens Commission on Human Rights’. Slick but extremely shrill,  I presume it is something they put on all over the world for events like major psychiatric congresses, to ‘put the other side of the story’. Although I was sympathetic with much of what they were saying, the message was drowned out for me by the high intensity invective and ‘hard sell’ – populist maybe necessary to transmit messages like this, but dumbing-down to this level patronises everybody and just insults most people’s intelligence.

Dumbed down

 The other footprints – much more numerous and continuous – led to a sinister black lorry identifiable by only a pharmaceutical logo. Inside, we were promised an frightening experience of what schizophrenia was like. As close as a theme park ride is to something really frightening, tabloid tales are to truth, or Hollywood is to real life. Lavish and clever – but that’s all most people expect nowadays isn’t it? Like the antipsychiatry roadshow, I suspect it treks round the globe to follow international congresses and events – although with very different purposes, intentions and values, with equal shallowness and lack of integrity.

A sinister lorry

Then I just caught Paul Moran presenting the rather counter-intuitive results of a feasibility RCT for crisis plans in BPD: the trend, without statistical significance, was to increased self-harm when engaged with a well-shared crisis plan. The economics data, and qualitative ‘successful engagement’  result, pointed the other way, but nothing was conclusive. Rather disappointing. Let’s hope Steve Pearce’s RCT of TCs isn’t as damp a squib…

More importantly personally, and in a whole-system way of thinking, was a few minutes conversation I had with Paul. Our unsubstantiated conclusion widened out the one that Yousuf and I reached yesterday morning: many psychiatrists in the NHS are being systematically devalued, disempowered and demoralised. In other countries, in other and kinder times, this would be a public mental health problem.

The day finished with a dinner cruise on the Vlatva River, which cheered us all up and was an almost perfect combination of music, food, fun and utterly beautiful scenery. With the added bonus of one of our team getting engaged in a deep and meaningful conversation with an e-psychiatrist , who presented papers on the power of cyber relationships, proposing a serious reversal of his professional practice – and requesting uncharacteristic hyper-proximity. She told him to buzz off, and the rest of us formed a human shield around her for the rest of the evening.

In wandering back to our hotel through the streets of the ancient quarters of the city, we chanced upon the dear old astronomical clock.  The midnight performance was a few minutes away, so we regained our favourite spot in the street café, and tried a few adventurous cocktails, all wrapped in bright red blankets against the chill of the night. Only to be sorely disappointed at the witching hour: no apostles, no Jesus, no lust, sloth, greed or even rattling death. Our waiter told us that silent night lasted from the last performance at 11pm until the first at 7am. 

And so to bed.

Ulysses or lithium?

A slightly later start for a more leisurely day: leisurely breakfast with Yousuf and an interesting conversation about the ways in which the anti-medical regime, in place at Winterbourne (and subsequently the Complex Needs Service) in Berkshire since 2002, has undermined and ended the careers of several senior medics there, and destroyed the culture of excellence for  training junior doctors. Determined not to be that latest victim, I am very unsure about what I need to do next.

Onto “Cultural Psychiatry, Empowerment and Best Practices in Europe” which was mostly rather dry and about the sizes and needs of people of different cultures - until the final presentation by Professor J Achotegui from Madrid. He told of the terrible desperation economic migrants felt, and the often fatal lengths to which they went, to land on the Spanish coast. There were severe psychiatric consequences of the displacement, alienation and rootlessness – as well as rejection, worthlessness and helplessness they subsequently experienced (not unlike life for doctors at Winterbourne since 2002!). In a crescendo of emotion, he described how their mental conditions, a sane response to an insane situation, were not well-captured by any current psychiatric diagnosis. With the help of Homerian poetry, anthropological reflections , a little economic analysis and a public education campaign, he had coined the term ‘Ulysses Syndrome’. Not everybody in the audience took to the cut of his jib, but nobody could deny him his fervour and passion for humanitarian responses to international civic bureaucracy.

From Spain to Germany – and one of the plenary lectures, on mapping care pathways, by Heinrich Helne. After a vaguely interesting preamble about principles and examples from Italy, Japan and USA he got thoroughly dug-in to the intricacies of the German system. Losing the will to stay awake, a walk in the fresh air through the ancient streets of the Old Town was called for. I caught up with Kath, Andrea, Emma and Olivia and we ambled from our hotel to the astronomical clock – arriving a few minutes after it had struck noon. With five ringside seats available in the pavement café next to the Old Town Hall, there was little choice but to sit down and enjoy the rare luxury of a lunchtime beer - while waiting for the disciples, Jesus, lust, sloth, greed and death to appear or jiggle for the one o’clock show.

We then ascended the tower in the tardis lift to see the two o’clock show from aloft, next to the lone trumpeter. Most impressive – as was the walk across Charles Bridge ominously watched by the  looming statues.

Back to the congress centre for the committee meeting of the Education Section – which I had recently been coopted onto. What were they on about, I wondered – and I simply had the intention to find that out, and whether any of them were friendly to psychotherapy and experiential training. Very friendly and welcoming, we heard of a couple of international surveys, proposals to have new psychiatrist educational seminars at future meetings, NY Cornell’s outpost in Doha (Qatar), and our free use of a Harvard project manager.

The extremely affable chair, Bulent Coksun from Turkey, took us over to dinner at the nearby Holiday Inn – but was profuse in his apologies for having to attend a form dinner elsewhere himself. The remains of us had a fairly raucous time being rude about each other’s countries and customs, and our own. Suffice to say that one dinner guest had to be restrained and told to be more compliant with his Lithium!

More than 17 (just)

Arriving for breakfast at 0632, I was surprised (and very pleased) to see I was the last one there. We ate rather silently and nervously, and got the metro to arrive in our presentation room just after 7am. We put up our display posters either side of the stage, and leaflets on all the seats; we adjusted Yousuf’s powerpoints a few more times, and finally handed it over to the technicians. Then we waited…

Emma and Olivia - with the tree of hope

Nearly 17 by now...

Although there were only 3 attendees there on the dot of 0800 (our official starting time), somebody did say that lots more were outside the congress centre, just arriving – so we waited a few minutes before starting. Soon there were 17 and by the end we had about 30, though there was some coming and going. The talks went pretty well exactly to time and to plan, and are available on the LLE website www.livinglearningexperience.com  .  Afterwards, we breathed a sigh of relief and had the freedom to enjoy the rest of the congress.

C B Nemeroff (USA) gave the first plenary lecture – on Neurobiology of Child Abuse and Neglect – and gave a dazzling exposition of the genetic, neuroimaging and pharmacological bases of adult consequences of childhood trauma and abuse, and how the people with histories of maltreatment had different brains. Although he seemed to deliberately avoid the PD label, it was almost a return to the days of ‘endogenous v reactive’ depression – except over a life course, rather than weeks or months. Quite reassuring to those of us who fear being eclipsed by the biomedical juggernaut driven by the economics of the pharmaceutical industry.

Then to the posters – hundred of them from all over the world; interestingly all of those from latin countries bearing a prominent ‘no conflict of interest’ declaration, none of which would have suggested any such suspicions. Is this an international version of the UK ‘health and safety’ culture, used to destroy trust and spread persecutory anxiety? And next to the poster, a display of restraint cages through the years, and straitjackets exhibited like a fashion display. Was this deliberate irony?

Bed shortage?

PICU?

C&R?

straitjacket couture?

Next to a heart-warmingly reassuring session by Czech psychiatrists and therapists from The International Centre for Integrated Psychotherapy (Knobloch). Heart-warming because it was human-scale and clinical, reassuring because it is a TC by any other name. Although they only briefly referred to TCs, I asked if they recognised the British TC tradition, with Maxwell Jones and all, as their work seemed so familiar: and indeed they did. Somehow, we should be making friends with groups like this.

Towards the end of the afternoon, were workshops. The title of ‘Innovation in Psychotherapy Education’ was catchy enough to attract me, but for some reason, my heckles were soon raised once there. It was a sharply commercial presentation of an elegant and well constructed Moodle website for training in basic psychotherapy – not unlike KUF in its design, but lacking the radical ‘relational’ edge that I think is essential in any therapeutic engagement. A sales pitch, I suppose, when I was looking for realttitude change, I suppose – tackling ‘us & them-ness’ – ever seeking that dear old ‘quality of relationship’ again.  After an initial altercation which Yousuf and I had with the presenter – about the viability of hard evidence-based rules for all psychotherapies – I meekly shut up and watched nigh on a dozen video clips of very self-assured therapists teaching how to do CBT…

The final session was much more cheering, though. Professor R S Murthy was being presented with a special prize. The purpose, structure and committee for this prize was explained at great length before the ceremonial  exchange of gifts and flowers and the lecture could begin. Professor Murthy is recently retired Dean of the NIMHANS – ‘the Maudsley of the Subcontinent’ in Bangalore – and I explained to him before the talk about our link with ASV and the intention to do an LLE there in the next year or two. Maybe we should do a second one for NIMANHS residents! But he was great – talking our language like few others did here. 

Here’s the points from two of my favourite slides of his. This one gave seven criticisms of the current ways of psychiatric thinking and practice:

1. 1.       Medicalisation of suffering
2. 2.       Vague diagnosis
3. 3.       Mainly pharmacological interventions
4. 4.       Doubtful outcomes
5. 5.       Insensitivity to local customs and practices
6. 6.       Loss of personal context
7. 7.       Psychiatric imperialism

And this one gave three points for the ‘paradigm change’ that’s needed for world mental health to improve:

• ·         Recognition of the central role of people and families
• ·         Information and interventions for them
• ·         Professional development to share this

Back for a celebratory meal of stroganoff with dumplings and Czech beer at a cosy little restaurant just near the hotel. But rock on Professor Murthy – you’re my main man!

The Yerkes-Dodson test

First there were seven, now we are six. Sadly Lou, from Emergence, who was going to present the KUF model with Andrea, has to pull out a couple of days before we left. Then, just to test the rest of us for our ability to cope with anxiety, four of us nearly didn’t make it to the airport. Emma was coming from a village outside Norwich by train – and she had allowed for trouble by getting one train earlier than she strictly needed. But, with one train cancelled because the driver had a cold and the next one missing its connection, this was not enough. The next train from Norwich was running ten minutes late – but the airport passengers were relieved to be told that the connecting train to the airport would wait. But it didn’t, and sadly unsurprisingly to those of us who often use British trains, the staff at Ely were inflexible and unhelpful. One very expensive 50 mile taxi ride at breakneck speed did eventually ensure that Emma did manage to get to the airport in time. My own resolve was severely tested when I looked up the M4 on Google Traffic about half an hour before going to pick up Kath then Yousuf at different points along it, en route for Stansted. I usually prefer trains, but I had been watching the M4 at that time of day for the previous week, including going to work that way one day to check it would be okay for the airport run. But random events are much less forgiving than careful planning can always cover: Google Maps (bless it for its amazing technology!) showed a string of black with a few red beads along the M4. Black is stationary and red is very slow. Radio Berkshire was on in the kitchen and the Breakfast Show presenter was getting quite excited about it all – getting people to phone in from the stationary traffic jam and tell their stories of why it was so important to get to where they were going this morning. Purleez! – as they say. But Kath was going to on the train to Theale by now – so I had to go and pick her up. She and I discussed the various cross country routes and she much calmed my jangling nerves by pointing out that, although we had no idea of whether we would get to the airport on time, there were no more decisions to be made, once we decided to head up through Wallingford, and meet Yousfuf at Lewknor on the M40 near Oxford. Thankfully, Yousuf had emailed me his new mobile phone number about an hour beforehand… We made it. Not being at all superstitious, I did hope that those three (Lou, Emma’s train and the M4) were going to be our full measure of troubles. Well, there was the slight matter of being charged about double what we should have for the people-carrier taxi from the airport – ‘it’s on the meter, guv’ would be the London cabbie translation. But, reading the guide book, I just took that as NPP (normal for Prague).

The opening ceremony was what you expect – a long table full of civic dignitaries and big cheeses on a grand stage in a plush but three quarters empty auditorium, interspersed with Czech folk dancers and local musicians. Just an hour: quietly dignified, and quite good fun. But not exactly setting the soul alight with passion, imagination or fire-in-the-belly!

The ‘cocktail reception’ afterwards had a funny idea about cocktails – red wine, white wine, beer and tea. But with some interesting canapés – in good quantity – pressed upon us by friendly waiters. An hour or two there gave us time to do carpet bombing of hundreds of copies of our ‘come to our session’  leaflets we had brought with us, because we feared absolutely nobody would come to our session at 8am the next morning. My guess was 17 people.

The flier for our symposium (front)

The flier for the Kabul paper

But distributing the leaflets was quite interesting in itself – as most of the reception was in the congress’s exhibition area, which was dominated by a few vast and elaborate pharmaceutical company pavilions (eg ‘redicovering trazodone’), and a few small stands for organisations and future congresses. I rather enjoyed putting our leaflets on the Big Pharma tables, smiling and saying ‘maybe this is the antidote to too much psychopharmacology and neuroscience’. Yousuf and I took over one of the small non-drug company tables and finished our powerpoints, as everybody else’s were long done by then. We tried to check out our room, but it was chained up – although we did ask a technician how big it was, and were not exactly relieved to be told it seated 200. I kept my estimate at 17, others were more optimistic. Another glass of wine and back to the hotel for a rehearsal…

Because we had paid for the hotel in advance, we couldn’t get any refund for Lou’s room – though one of our number (I shan’t say who) had suggested we sub-let it on a half hourly rate basis as an income generation proposition. Instead, we decided to use it as our rehearsal room, and we all gathered there when we had done the four metro stops from the congress at Vysehrad to our hotel at Florenc. But once there, in the knowledge we had an early start, we had run out of steam – so we just discussed how we would coordinate the 4 talks. Then all went to bed, with the intention to be together again at breakfast, at 0630 sharp (5.30am UK time).