A strange holiday.

By a long and slightly mysterious process, I have landed in Italy as part of an intensive workshop taking place in San Giovanni Rotundo. I have told friends and colleagues that I am going to join a cult for a holiday, and may never come home.

Some documents I was sent a few weeks ago might give the flavour - here are some quotes: 

Individuals have stopped having a specific and historical value in their own right; instead, their value is now decided by the financial economy according to its own strategies for accumulating money

 However, I believe the disease-based paradigm may prevent us from adequately interpreting the new forms of suffering whose emergence began in the mid 1950s, alongside the momentous and overwhelming anthropological shift seen in western societies.

Disagio diffuso. This refers to the widespread wave of deep malaise manifested by the ancient codes in response to being “estranged” from the overall governance of life and, as a consequence of which, life has been “estranged” from the two most ancient codes.

The three 'codes' are central to the theory, crudely summarised as: 

·                  Bio-organic - bodily, most ancient, particle

·                  Analogical - emotional, life-force, wave

·                  Symbolic rational - logical, most recent, becoming overwhelming

In a matter of months, an individual may go through the stages of oppositional protest, addiction to psychoactive
substances (legal or illegal, including psychiatric drugs), eating disorders and addictions to electronic and virtual reality; after which, they may move into a period of emotional dysmaturity and end up experiencing one of the many so-called delusional-psychotic syndromes that psychiatry has categorised: borderline and other personality disorders, major depression, bipolar disorder, the various forms of schizophrenia, etc.

Today, medical science has confined itself to using "disease words" to label and catalogue the various stages and symptoms undergone by individuals in the throes of disagio diffuso. In fact, medical epistemology cannot and will not be able to make sense of the continuum of today’s malaise, which requires a profounder and more structured approach than banal classification.

Given the lack of a deep-reaching diagnosis and having settled for the convenient genetic aetiology, medical science and psychiatry merely administer the same psychiatric drugs for all the various forms of malaise, tweaking the doses and prescribing cocktails of psychiatric drugs with increasingly enigmatic formulas, often dictated by current fads. Treatment is generic and non-specific, as are the diagnoses adopted. This has led growing numbers of individuals and groups to turn to alternative treatments and/or other medicines. But we must not underestimate the allure of the chemical lifestyle for the manufacturers of psychiatric drugs:  Digital Man can only be held in check, albeit temporarily, by transforming him into a Chemical Man. In fact, life, today, is to a large extent propped up by what we might call a “chemical-financial anthropology".

Watch this space – more to come…

Lords help us...

Given the Government’s commitment to parity of esteem for mental health, could the minister please explain:

1)

Why Oxford’s flagship service for personality disorder (PD), developed in response to the ‘No Longer a Diagnosis of Exclusion’ policy in 2003, is having its budget cut by two thirds now that central funding (£750K) has been devolved to local Clinical Commissioning Groups (who will only fund £250K)? It is a small service with growing demand and robust evidence of effectiveness and cost benefit. This cut will mean that about 450 patients per year will need to receive suitable treatment elsewhere in already threadbare mental health services; how will this be managed?

Back story:

"Oxford Health", the sexily-named NHS foundation trust for mental health (and community health services) in Oxfordshire and Buckinghamshire, has told its 'Complex Needs Service' that it needs to make immediate plans to cut its budget by two thirds, with almost immediate effect. The patients in the middle of their intensive therapy were informed of this earlier this month (May 2014), and are anxious, angry and determined to do what they can to fight against the cuts in service.

The service was started in 2004 with central funding (directly from the government) of £950K per year for Oxon and Bucks, plus a £200K contribution from Buckinghamshire PCT – total £1,150,000 - and this continued until this year. The intention of the National PD Development Programme had always been to carefully plan the handover of funding (over several years if necessary) – but, despite much work and detailed negotiations since 2009, this has failed. The PCTs, and now CCGs, have failed recognise the value of the service and cooperate in the orderly handover of funding, so the finances have reached the end of the line and ‘hit the buffers’: the mechanisms for central funding which existed in the days of the national programme no longer exist in the structures of NHS England. 

All the funding for the complex needs services therefore now needs to come from the local Clinical Commissioning Groups (CCGs). Oxfordshire CCG has agreed to 'find' £250K, and Buckinghamshire will find nothing extra, but continue to contribute the £200K that has been there since the beginning. The way this has been presented to the public [CEO comments - click here] is somewhat disingenuous, and tries to portray the commitment of the CCG to personality disorder services, and their generosity in providing a sum which would mean impossibly severe cuts to the service.



2)
Whether the NHS and Health and Wellbeing Boards recognise the ubiquity, severity and treatability of PD; the social and economic costs of failing to treat it; and the range of ground-breaking work undertaken by the National Personality Disorder Development Programme (NPDP) between 2003 and 2011 to work with it in new ways? Has the government effectively disowned this substantial body of ‘quality, innovation, performance and prevention’ (QIPP) orientated work? Could the government comment on clinicians’ and service users’ view that the Improving Assess to Psychological Treatment (IAPT) programme, where the development work is currently placed, is inadequate and unsuitable to manage the complexity, risk and cross-agency nature of PD and its treatment?

Back story:

In 2003, the government published ‘Personality Disorder: No Longer a Diagnosis of Exclusion’ – a policy guide that formally recognised PD as a condition deserving NHS treatment, with funding to set up eleven innovation-focussed pilot projects and to develop national training programmes to improve staff skills and reduce stigma. 

The ‘Thames Valley Initiative’ was the largest of the eleven pilot projects, covering a population of 2.1m in the then Thames Valley Region: Berkshire, Buckinghamshire, Milton Keynes and Oxfordshire. As NHS Foundation Trusts started to function as competing businesses, early hopes for a coordinated clinical network across the whole region soon faded, as Berkshire and Milton Keynes went their own way – and the separate mental health trusts in Oxfordshire and Buckinghamshire merged with each other, and with community services, to form ‘Oxford Health Foundation Trust’, in which the complex needs services were a tiny part of the budget and for which any organisational memory of the intentions of working across county borders was soon lost.

The National Programme was shut down (in March 2011) and a detailed clinical review, ‘Innovation in Action’, was commissioned and written – but never published. It describes the success of the pilot projects and was intended to be the official document marking the end of the programme, much as ‘No Longer a Diagnosis of Exclusion’ marked the beginning. The unpublished draft is available online: www.personalitydisorder.org.uk/innovation-in-action

With considerable reduction in all government budgets, the only remaining national mental health programme was ‘Improving Access to Psychological Treatment’ (IAPT, also known as ‘Talking Therapies’). This was a large, highly organised and widely implemented programme conceived to deliver cognitive behavioural therapy (CBT) at primary care level for people with mild to moderate depression and anxiety, in order to get them back to economic productivity. This programme has now been expanded to cover ‘serious mental illness’, part of which is personality disorder. However, it is much more restricted in its scope – and uses therapeutic methods and measures which fit a ‘psychological model’ of mental disorder rather than the ‘biopsychosocial’ one required for comprehensive treatment of personality disorder. Specifically, it cannot address the complexity of presentation of many people diagnosable with personality disorder, it does not have the mechanisms to engage people who are hostile to services because of previous bad experience, it cannot manage the high and randomly variable levels of risk inherent in a PD population, and it has no brief to work across agencies and sectors (most people with PD do not present in an orderly way to mental health services).

3)
How the new NHS England commissioned specialist services (tier 4) can hope to effectively coordinate with local (tier 3) services in the light of NHS England’s policy to commission ‘self-contained’ tier 4 services, with no joint working across the local/specialist divide - while the CCGs are actively disinvesting in tier 3 (as in (1) above)? Is NHS England being specifically asked to give greater priority to administrative structures which will facilitate the growth of disconnected independent sector provision, than to satisfactory service user experience, coherent clinical care and ‘joined-up’ patient pathways? If this is done without advising and influencing CCGs to provide satisfactory tier 3 services, is it recognised that serious gaps in service provision for this very risky and vulnerable population will be created?

Back story:

NHS England is responsible for all specialist services in the NHS, of which there are about 130. One of these is ‘Severe Personality Disorder’, also known as ‘tier 4 PD’ (tier 1 is primary care and voluntary sector provision; tier 2 is local mainstream mental health services, such as community mental health teams and crisis services; tier 3 is local specialist services, as described above for the NPDP pilot services; tier 4 is for non-forensic specialist services beyond the scope of local provision; tiers 5 and 6 are for rarer cases where there is significant risk to others and history of offending – tier 5 is ‘medium secure’ and tier 6 is ‘high secure’. 

The divide between tier 3 and tier 4 has always been a problem, and there have been various attempts to build a bridge across it (so patients experience a coherent pathway, clinical communication is good, staff training is comprehensive, quality is defined and improved, and integrated research is possible).

Now that the funding arrangements have an absolutely sharp division between those that are nationally funded through NHS England (tier 4 and above) and those funded by local CCGs (tier 3 and below), such bridges are more difficult to build.

However, the NHS England policy of demanding specialist service specifications which do not include any possibility of establishing formal links or joint working with locally commissioned services – in order that they are open to ‘any qualified provider’ – has made these bridges well nigh impossible to build.

It does not take a great leap of imagination to think that this could be related to the government’s intention for the new NHS to have a much higher level of private provision. It is easy to see how fragments of disconnected service are much more likely to be profitable than those which offer coherent pathways and continuity of care. 

The end of the road for radical approaches to PD

Two wasted decades?

With Ioannis Tsegos in Athens

I should have believed Ioannis Tsegos in 1995 when he said that it just wasn't possible to run a TC in a state service. As a new consultant and president-elect of the Association of Therapeutic Communities, I was invited to give a my first ever keynote talk at an international congress, in Athens. With far too much to say, and being as nervous as hell, I did the talk - and was then taken out to dinner by Ioannis and his wife.

Stained glass windows at Athens OPC

I had already heard about the 'Open Psychotherapy Centre' in Athens, as they had often presented startlingly radical papers at ATC's annual Windsor Conference, but after a visit to it the following day, I was utterly in love with their model. Group Analytic, democratic, integrated with training, economically progressive, open to all, playful yet very serious, profoundly radical, finely balanced between anarchy and control - it had everything I reckoned a TC should have.

As I left the building (an elegant three-floor block on a city-centre street corner) there was somebody storming out of one of the groups and wielding a razor blade with which she was threatening to cut herself - just like home! (Except that she was being treated with proper therapy rather than by by paperwork and risk management!).

But after twenty years of trying, as a consultant in the NHS, I have finally given up trying.This story has three layers, and I'll start with the simplest one - local. Then I'll see how it makes sense regionally, and then nationally. As I recently emailed to a longstanding colleague, I smell a rat - though I'm not yet sure whose rat it is. B F Skinner may yet be implicated, I expect!

Slumping in Slough

The local project that looks like it has bitten the dust is the 3 year long attempt to bring serious greencare to a rigorous NHS treatment programme for PD. Because the development of the intensive programme (in Slough) had hit the NHS times of austerity - it was started in 2010 - it had to be run with much less staff and other resources than would be ideal. So we tried to do it on an absolute shoestring - with volunteer staff (assistant psychologists looking for good clinical experience, or nearly - qualified psychotherapists doing clinical placements) and a hard-won lottery grant to provide afternoon greencare groups. But clinically, despite all the usual turbulence of a new TC, it was a joy to work in - and many people did fabulously well because of it.

Our therapy room - under construction

We tried our best to get the voluntary sector part of the programme (the greencare) integrated with the NHS part in several ways:

• inviting local and senior NHS managers and commissioners to see the project and explain the project (they seemed to love it, but...).
• building it into an 'alternatives to admission' programme for PD in East Berkshire (which is going very well - but would be even better if it took greencare seriously!).
• applying for NHS charitable funding (still waiting, advised that it is unlikely to bear fruit...).
• writing outlines of potential business plans, including applications for innovation monies (emails to relevant NHS officials never responded to)
• incorporating it into junior doctors' training placements (much appreciated, but never recognised as a relevant element of training)
• being a partner in a submitted application for National Institute of Health Research funding for a randomised controlled trial (decision awaited)

...But ultimately to no avail. Because of this, and other insoluble structural problems about the ways in which risk has to be over-managed in all statutory services, it has led to my retirement from full-time NHS work. I now consider it impossible to run authentic therapeutic community programmes within the health service - and will be using some of my time to develop them elsewhere. Without my role in the NHS side of the  programme, the two parts have little hope of remaining coordinated or being seen by service users as part of a coherent and emotionally containing pathway.

Thames Valley Trouble

The original patch

The 'Thames Valley Initiative' was funded by the Department of Health in 2003, as the largest of eleven pilot projects to explore and evaluate innovative ways of treating personality disorder in community mental health settings (of which, more later - see next section, below). Based on the longstanding model developed and refined over more than three decades at the non-residential Winterbourne Therapeutic Community, it modernised and adapted to model in line with contemporary requirements for equity, access and transparency.

"We had a dream" ...of services integrated across sectors, collaboration across the three counties, self-referral and no postcode exclusions to anybody, multi-centre research, integrated training programmes for all relevant agencies, free movement of staff and 'job-sharing' across the patch for personal, professional and service development, excellent service user and carer involvement with graduates of programmes having pathways into careers employed by the services, and flexibility to adapt to changing needs of service users and of the policy environment.

But what we got is:

• Separate NHS foundation trusts fiefdoms, with very little managerial collaboration possible between trusts. 
• Little appreciation of the particular needs of PD.
• Very limited genuine service user partnership.
• Commissioning with no understanding of the social and economic/political context of PD.
• Managerialism and governance writ large.
• Severe risk-aversion with a joyless culture of authoritarianism, hierarchy and compliance control.
• Remoteness from senior management and strategy decisions. 
• An increasingly biomedical framework for psychiatry.

But, to give due credit, we also got extraordinarily effective and innovative programmes from which many many people have been able to experience transformative therapeutic progress. With extraordinarily committed staff who have all been prepared to 'go against the tide' and suffer he parallel process of alienation from the mainstream.

National Personality Disorder Development Programme Dissolution

No longer a diagnosis of exclusion?

The National PD Development Programme was formally launched in 2003 at the Department with speeches by Jacquie Smith (a government minister at the time), Dale Ashman (the service user founder of 'Borderline UK') and others. Its guiding policy document was 'No Longer a Diagnosis of Exclusion' - and its key principles were (1) including the previously excluded, (2) service user involvement, and (3) working across sectors and agencies. It recognised complexity of human development - and how its disruption led to the emergent 'diagnostic entity' of PD. Its sister document 'Breaking the Cycle of Rejection: A Capabilities Framework for working with Personality Disorder', indicated how workforce development needed to include access to an escalator for all with suitable aptitude, and not just those with the correct documented experience and registered qualifications.

Its three activities were service development (the eleven pilot projects), evaluation (formally by Imperial College, and a later clinical review which was never published by DH) and training (which emerged as the Knowledge and Understanding Framework, KUF).

The training is still going strong, but seems to be increasingly disconnected from, and different to, the sort of instrumental, procedural and transactional 'training' expected in mainstream public service provision. It is delivered by service users in partnership with clinical staff, it is largely experiential rather than didactic, and it covers nebulous subjects such as the nature of relationship... This if course is exactly what makes it suitable for a radical approach to PD - but it is also what makes it like a round peg for the standard square holes of managed professional development.

The formal evaluation was undertaken early in the programme (published 2008), and provided useful information for those in the field, but the clinical outcome part of it was not a trial, and had no long-term follow-up, so it had little impact more widely. The less formal clinical review of the services (2011) gathered a great deal of very positive qualitiative data from each of the eleven pilot projects - including subtle variables such as the 'culture of a unit' and 'the quality of relationships' - and quantitative measurements that demonstrated economic and social return. However, it could not be processed and published by the Department of Health before the non-forensic part of the National PD Development Programme closed, in March 2011. All this data, and any more that has been analysed and published by the pilot projects themselves, is therefore unlikely to have any impact on the wider commissioning for local specialist ('tier 3') PD services.

Unfortunately, the large scale trials of 'alphabetti spaghetti' therapies are more likely to influence that, and lead to brand competition between therapies - inappropriately using a determinstic and commercial framework that denies human agency, the complexity of social context, and the importance of relationship.

The saddest part of this story is the pilot projects. Our own 'Thames Valley Initiative', originally covering Berkshire, Oxfordshire, Buckinghamshire and Milton Keynes,  is described above. We are fortunate in that it is likely to survive in some form, although that is likely to be different across the various areas for which it was set up. Other projects are less fortunate, and have either been closed or directly threatened with imminent closure.

More important than clinical coherence, service user views or theoretical integrity is now 'compliance' with regulatory frameworks - imposed through the Care Quality Commission (CQC) and Monitor (concerned with risk, liability, etc). This will be interpreted differently by each provider trust. This is likely to lead to 'lowest common denominator' commissioning: with the 'successful' programmes being those with lowest risk, highest replicability, easiest benchmarking and little chance of innovation through positive risk-taking.

By my reckoning, that means that 'messy' and 'complex' treatment programmes like therapeutic communities (that particularly require high tolerance of uncertainty) are going to be dead in the water. The neatly processed and packaged alphabetti spaghetti therapies (like DBT, MBT, STEPPS and numerous others) will get the contracts every time.

What has been learned from twelve years of tier 3 programmes is also unlikely to have any impact on the development of tier 4 services (commissioned as specialist services by NHS England) - as service specifications are explicitly not asked to include working across the tier 3/ tier 4 boundary (as they have different commissioning structures, and must meet Any Qualified Provider requirements).

SO... where's the rat?
I blame... the service managers for being frightened; the middle managers for being craven; the corporate risk-minded senior managers who have had all imagination and creativity squeezed out of them; the ignorance of commissioners about the unconscious; the authoritarian culture of the NHS (you-know-who that means, and I only hope his successor is better); the bankers for crashing the economy and putting intolerable screws on the public purse; the leaders of IAPT for making therapy look so measurable, predictable and controllable (back to BF Skinner); American business schools for modern managerialism and all its horrible trappings; psychiatric colleagues for losing most of their psychosocial roots and yearnings (and their will to make a fuss about what really matters - which is patient experience); politicians for failing to connect the idea of 'broken Britain' with broken people and broken services; Regan and Thatcher for rampant individualism; the Enlightenment - for letting us think that we could ever understand it all; and I suppose that man eating that apple a long long time ago.

Therapeutic Communities in Sicily

While the fortune of British 'Democratic' therapeutic communities always seems to be teetering on the brink of oblivion, it seems like the Sicilian version is going from strength to strength, and with government backing. They are expanding in all directions: adults, personality disorder, psychotic illness, homelessness, adolescents, refugees, forensic and group apartments; properties are also being repossessed by the government from convicted mafiosi and given over to social enterprises to set up as therapeutic communities.

A thriving network of community-based units already runs a sophisticated quality network (adapted from 'Community of Communities' at the Royal College of Psychiatrists) which held its first Annual Forum last year with twelve members, and is planning its second one (with many more members) at the end of this year.

The psychiatric authorities in Sicily also want to forge links with the British ‘Living-Learning Experience’ (LLE) therapeutic community training (www.livinglearningexperience.com) which has been essential TC training in the UK for nearly twenty years now. This has involved close liaison with the British ‘Living and Learning’ team, which already includes two Italians and another Italian-speaking therapist (from Uruguay).

The "regional psychiatric authorities"

Numerous LLEs have been held in Sicily since 1999, twice at Erice, in Caltanisetta, Partenico, and with two based on a converted fishing boat in Trapani  (for training new British personality disorder teams, one from Oxford and one from Nottingham). A formal one-day event, organised by the regional psychiatric authorities, was held in Piazza Armerina, for about a hundred delegates, in 2008. After much work developing their clinical model of therapeutic ‘community in the community’ practice, this was followed by the first LLE for Sicily’s new therapeutic communities at Caltagirone in 2013, and a second one last weekend at Altavilla Milicia, near Palermo.

The setting was a 50-bedroom monastery with one monk, looking out at the sea on one side and the mountains on the other, sat in the middle of a large garden filled with lemon and orange trees, and olive groves. We had the venue to ourselves: the guest rooms were converted monastic cells, and the group rooms were normally for lectures and seminars, from which we carefully removed various Catholic artifacts and set the chairs in circles.

The monastery with one monk

We started the workshop as always, with the staff (six of us this time) meeting for a team meal, the night before the participants arrived. This ensures good ‘team bonding’ and was particularly important for this workshop, as some of the staff had not worked together before. It also allows us to relax and unwind after our various journeys.

The 19 delegates started arriving a little before midday on Thursday, while the staff team was preparing lunch, Sicilian-style. This was the first of several culinary extravaganzas, subsequently effortlessly prepared and elegantly presented by various groups of delegates. The show was on the road! Apart from the usual community meetings and small groups, we were all involved in numerous games, activities and fun – although my own linguistic deficiency (non parlo l’italiano!) left me almost entirely in the dark about what we were doing until we actually did it. But everybody seemed to get a great deal out of the experience – and one of the Italian staff took a video of everybody’s evaluation and feedback – see [www.insert.link.here.it].

After we had all said our goodbyes, the team went to meet a Professor of Psychology at Palermo University – who is helping the research and development project for TCs. We learned of how all Sicilian forensic mental health facilities are to be closed, and the service users transferred to the day-to-day care of social cooperatives (while remaining under the supervision of government-employed psychiatrists). These cooperatives are to be run as TCs – about four of them residential, with fifty places, and the rest – for people less likely to be a danger to others – will be non-residential community places.

We also heard of how the TC standards for Children and Young People have been translated into Italian, and are being used for quality assurance and improvement. We left feeling excited about all the action going on in Sicily – and perhaps a little regretful that therapeutic communities back home do not enjoy the same level of formal and organisational support.

But it should give a good opportunity for plenty of future cooperation and collaboration for training, research and service development in the Sicilian sunshine! 

Is 'Open Dialogue' the new mental health revolution ...or just the latest 'big thing'?

The Round Chapel, Hackney

When they cancelled the lunches by email, the day before, I wondered if there would even be a dozen people there – but I was wrong to doubt the strength of this movement, as there were 120. It looked pretty slick – in that MBA/project management/young entrepreneur sort of way – too: QR code check-in at registration (although hardly anybody had printed out their tickets or had them available on a smart phone – these are mostly NHS therapist types, after all! – so they were just nodded in), and a folksey singer playing the grand piano. Wires, a big mixer desk and sound systems with video cameras on high tripods at both sides of the hall. Strange red lights (which turned out to be heaters) dotted about the auditorium. The auditorium itself is well-worth mentioning – it is a deconsecrated round church, elegantly restored, in Clapton, Hackney. Despite lots of stations in Hackney, it seemed to be just about the most difficult place within the M25 to get to by public transport. But was this a gig or a therapy workshop?

A musical welcome

The ‘main man’ of Open Dialogue UK was the warm-up: Nick Putman. A cross between the looks of a singer-songwriter like James Taylor and the demeanour of Ricky Gervais in The Office, he told us tales of early inspiration by Ronnie Laing’s work, and how he dropped out of clinical psychology training, travelled, qualified in psychotherapy – and more recently chanced upon Open Dialogue from Western Lapland in Finland. He is now a trainee in the Open Dialogue movement in USA. The approach is now catching on in other northern European countries, it seems, and he has set up Open Dialogue UK to bring it to these shores – and hopefully in a way that’s deeply embedded in the NHS. Of which, more later. This, he explained to us in a somewhat sleep-deprived state, is the first full six-day event in the UK to ‘spread the word’. It comprises three whole weekends held over a couple of months. A full training programme is anticipated for late 2014.

So we were introduced to the headline act:  two longstanding therapists from the original project in Western Lapland, Markku Sutela and Maria Kurtti, who worked as a ‘double act / reflecting team’ through the rest of the weekend. They explained how the approach had developed in Finland over about thirty years, much of it by serendipity. I was rather taken with how they saw it as an approach, maybe a therapeutic philosophy, rather than a brand-in-a-box (see my previous post from BIGSPD about ‘alphabetti spaghetti’ therapies for a rant about that particular point!). And also, the fundamental embracing of uncertainty that it demands, and the absolute requirements of flexibility, spontaneity and openness. But it’s also harder than that – as the method demands that you can never be certain that what you are doing is right. "The way that can be named is not the true way…". This is the sort of therapy that I have respect for...

We also did some small group work – for half an hour at a time in groups of about ten, with built in reflecting teams. One interesting stream of thought in ours was ‘what do you have to give up, as a therapist in your own favoured tradition, in order to work in this way?’. We felt that it was the ‘security blanket’ of theory, from our own long-cherished therapeutic trainings. Working in this ‘unlabelled’ way, perhaps like Laing described as ‘unlabelled living’ at Kingsley Hall, leaves us with only our selves and our relationships to work with. But it is all strictly done with shared responsibility – so one is never alone. The one question left hanging in the air for me was what we in the UK see as 'service user involvement' - not only doing the clinical work in authentic partnership with service users, but also the choice of services that people want - and the administrative clockwork (of real jobs etc) to go with it. Open Dialogue is clearly a very professionally run outfit, without the inevitable confusion and messiness we have to negotiate and hopefully enjoy when working absolutely alongside service users in planning and developing new services.

The therapeutic influences were explained – with the strongest influence being Milan-style systemic family therapy with extensive, integral and continuous use of reflecting teams. The one powerpoint slide that blew my mind was what they call their ‘Principle Number One’, dating back to 1984: “You are not allowed to talk about patients or their families when they are not present”.

I think that is sufficiently radical to stop there, and reflect on it…

Is this a gig?