The Golden Thread

Having gone to many places, before covid, to talk about 'The Golden Thread', but never writing it down or publishing it anywhere, I thought that it should at least go in this blog. 

I'm well aware that many hard-nosed scientific colleagues and even friends think it is rather fluffy, soft, and perhaps woo-woo - but I stand by it (relational practice) as an idea whose time has come - or is just round the corner.

This is an edited version of a fairly concise version that Nick Benefield and I included in a chapter of a book due to come out in 2023. It is the section called 'Contextual history: The English National Personality Disorder Development Programme 2002-2011'  (though I rather prefer 'The Golden Thread'.

 The phenomenon of ‘personality disorder’ first caught public and government attention following the 1996 murders of Lin and Megan Russell, and the attempted murder of Josie Russell, by Michael Stone in Kent. This caused a public disagreement between Jack Straw, the then home secretary, and Robert Kendall, the then President of the Royal College of Psychiatrists.

Robert Kendall said Stone “was suffering not from mental illness, but from a psychopathic personality disorder”. And under the law such people could only be admitted to hospital for treatment against their wishes "if treatment is likely to allievate or prevent a deterioration in their condition". He went on: "We are not very pleased with him (Jack Straw), but even more important we are appalled by his ignorance. There may well be a place for some form of preventative detention for men like this, but that is an issue for parliament. The Home Secretary cannot expect psychiatrists to do his dirty work for him when it is at present excluded by the law". Straw responded: "Quite extraordinarily for a medical profession, they've said they will only take on those patients they regard as treatable. If that philosophy applied anywhere else in medicine there would be no progress whatsoever." Conor Duggan, a senior forensic psychiatrist, later reflected: “The government provided specialised units with generous (some might say overgenerous) funding."

This is what became known as the DSPD (Dangerous People with Severe Personality Disorder) programme. It is the crumbs from the table of this program that funded ‘community personality disorder programme’.

At about the same time a self-help organisation called Borderline UK was set up with a Millennium lottery grant; it was headed and run by people with lived experience of personality disorder, with some support from sympathetic professionals. There were many anguished quotes gathered by its members and organisers, for example:

·         How can the experts really treat it seriously and with any degree of compassion, when they define it as attention, seeking or manipulative?

·         Had I been helped when I was younger, I would not have got this bad

·         We cannot call ourselves a civilized society when so many people are outcasts and are simply not understood?

·         Specific services for this are helpful – but general mental health services are not helpful and can be abusive.

Having some recognition of unmet needs, the Department of Health set up two working groups to prepare ‘policy implementation documents’ on strategic changes that might help. In 2003 Personality Disorder, No Longer a Diagnosis of Exclusion, with clear evidence on what service users were asking for, was published alongside the Breaking the Cycle of Rejection: Personality Disorder Capabilities Framework, which was a guide on workforce development and establishing a training escalator relevant to all disciplines and levels of seniority. The three stated aims of the national programme were to produce innovative service developments, to have a national evaluation of the new services, and to implement national regional training developments.

The new services were established in 2004. There were five medium secure services and 11 community (non-residential) ones; the programme was also allied to 12 multi-systemic therapy projects for children and the four existing DSPD units mentioned above (which received the lion’s share of the funding, but were only set up for 300 patients).

 A deliberate feature of the 11 commissioned community programmes is that they were all different. Bids were invited, emphasising the value of novel thinking and bringing together different elements, services and sectors - to bring fresh thinking to a largely unsolved problem. The four largest projects were Thames Valley, Leeds, Nottinghamshire, and Coventry. The Thames Valley Initiative, brought together democratic therapeutic community programs that were adapted into coherent region-wide care pathways. In Leeds, a major focus was to coordinate a range of services between health and other sectors, with particularly strong cross-agency working. Nottinghamshire provided three coordinated services for levels of severity, with a drop-in advice centre, a ‘stop and think’ psychoeducation programme, and a non-residential democratic therapeutic community.

Coventry’s project was tightly coordinated with local mental health services, through a community mental health type arrangement. The small ones included a preventative one seeing adolescents working from a shopfront in Plymouth, and an ‘itinerant therapeutic community’ which, for example, met in a rugby club in near Carlisle, using set-top box technology (cutting edge at the time) to provide 24/7 continuity by using the internet. In Cambridge and Peterborough, the pilot project was integrated with inpatient psychiatric services. There were three projects in different areas of London: one in the Camden and Islington project, with a focus on employment and primary care consultation; in North East London the service specialised in dual diagnosis using a dialectical behaviour therapy model; the one in southwest London was a particular way of managing risk using therapeutic community principles, ‘the service user network’. One, in Essex, was not directly connected to the NHS and was set up as a social enterprise (a Community Interest Company, or CIC) with strong service user co-production and provision of a community ‘Haven’ with a therapeutic environment.

In 2006, the national learning network was established as a forum at which all 11 community pilot projects, met in different venues (at each of their locations) and attended by service users, staff and managers from the other projects. The discussions were very fertile ground for sharing best practice, and new knowledge as well as the inevitable obstructions and difficulties.

The formal research project with the national program was called ‘Learning the Lessons’ which was conducted by Michael Crawford at Imperial College in London. It included (1) an organisational evaluation; (2) a user-led qualitative evaluation; (3) a cohort study; and (4) a Delphi study of the views of academics, service users and providers – about the integrity of the diagnosis. All the results are available online.

An extremely important part of the program was the extensive involvement and partnership with service users. This was initially through the Borderline UK organisation, which later merged with an arts organisation called Personality Plus to become Emergence. As part of the merger, Emergence and Personality Plus held a major arts inclusion event at Tate Modern, sponsored by the Tate and the National Programme, on 29 October 2007. Emergence became a community interest company run by those with lived experience of ‘personality disorder’, with some board-level support from established professionals. It ran various consultation, training and research projects, the largest of which was the National Personality Disorder Program.

The most influential product of the partnership was the ‘KUF’ training in 2008 (Knowledge and Understanding Framework) with Emergence plus three partners: the Open University, Tavistock and Portman NHS Trust and Nottingham’s Mental Health Institute. There were three levels of training on the ‘career escalator’: the awareness level training - which had been delivered to nearly 200,000 people by the end of the mid 2010s; a stand-alone BSc course which later became CPD modules; and an MSc with four centres delivering.

The principle of the KUF training is that it is co-produced at all levels - from the writing the material, to the recording and videos, the online content, to the delivery of it. For example, the three face-to-face days on the awareness training are always be delivered by a lived experience practitioner partnered with a sympathetic clinician, who had been through a train-the-trainers programme together.

2009 saw the publication of two important government publications: The ‘Recognising Complexity’ commissioning guidance for personality disorder services, and the NICE guidelines on Borderline Personality Disorder (CG78) and Antisocial Personality Disorder (CG77).

At its peak, the new community PD services were only covering 12% of the English population: questions were being asked about what exists for the other 88%. Even within the 12%, the work undertaken was done in very different ways, by services that were had different outcome targets, had different populations, and very different methods. Despite the clear need for expansion, the anticipated growth of the programme - to implement the government policy guides - never came to fruition. This is probably because the complexity of training needs and wide-open scope of the programme unearthed large areas of unmet need, and many more problems, than it was feasible to address at that time. Interestingly, the ‘Improving Access to Psychological Therapies’ programme, which could reassure ministers that relatively simple solutions to common mental health problems were possible, and measurable – in terms of ‘return to work’ and other politically attractive outcomes. The lion's share of any new government funding available for national programmes was therefore allocated to Talking Therapies (IAPT), and by 2011 the effects of the economic crisis led to the community programme being closed.

However, following the recommendations of the 2009 Bradley Report, much of the learning from the community programme was incorporated into the joint MoJ/NHS ‘Offender Personality Disorder Programme’.

The programme itself finished with two publications, and a number of other indirect developments. The first is a qualitative evaluation of all eleven community pilot projects, ‘Innovation in Action’ which recognised the importance of the quality of relationships, and described many common factors and whole-system features (‘general therapeutic factors’) of what was to become ‘relational practice’.

The second publication was ‘Meeting the Challenge, Making a Difference’, which is a handbook for be working in various settings where mental health is a factor (from homelessness hostels and social care settings to psychiatric hospitals, for example). It is a user-friendly, accessible and practical guide, based on all that had been learnt from the pilot projects.

Linked work at the Royal College of Psychiatrists Centre for Quality Improvement, from 2007 onwards, led to an accreditation process for ‘Enabling Environments’, which was based on ten relationship-based values. 

These were all amongst the processes that started to more rigorously define 'relational practice'.

 

Extreme Greencare: it blew my mind, twice a day

 This was the return of the Compassionate Mental Health ‘gatherings’. I think this was the tenth one ever held, as they started in the twenty-teens - but it was certainly the first since Covid https://tinyurl.com/CMHatCoed. I first heard of them a couple of years ago, when some of us were putting feelers out in our networks for things that appeared to be based on ‘relational practice’. At that time, I got the impression they were a cross between arts-based festivals and professional conferences.

Well, now I have been to one – as a guest presenter – I can say that has some truth to it, but misses something out that is much more engaging, experiential and (for me) existentially challenging. Relational, they certainly are - with the dial set to at least eleven – for intensity, intimacy, challenge, and sheer counter-cultural alternative-ism! The closest thing I can compare it to is when I went to a week in Italy, in July 2014, to see how Disagio Diffuso is treated by the method (see previous blog https://greenshrink.blogspot.com/2014/07/a-strange-holiday.html and following entries).

But instead of Italian style (with Italian food in a nice hotel and quite a bit of chaos) this was quintessentially Welsh (set in a commune in a forest with yurts and a stone circle, and vegan food). However, because of the deeply personal and confidential nature of so much that was shared I am not going to describe what went on in our various groups in any more detail here. Suffice to say that although I was expecting something a little like our LLE weekends, this had boundaries (that were well held by the staff and structure) that are so much more complex than ours, that I don’t trust myself to try writing any details in this blog. Here’s one comment I heard over lunch on the last day ‘In that last session it was like we went as far in a couple of hours as usually takes years in therapy’. I have heard similar things said about psychedelics, Ketamine and MDMA – but I can assure you that none of that was going on here!

At a tangent – but less of one than most people think about for a conference-type event – was our set and setting. The set was that I think over half the people there had been to CMH gatherings before, and all the others (like Neil and myself) were at least trying to be as open as possible to whatever was happening. The two of us had our own anxieties, as we were presenting stories about our last 25 years’ training work and running ‘mini-versions’ of it as workshops, to an unknown audience - that was completely different from the mix of people that come to sort of conferences we usually go to. But more than that, there was an intangible quality in the air that I have no words for – it is something about numinosity, spirituality, transcendence and - dare I say it – cosmic consciousness. (Again, no psychedelics, I promise). There was a team of about ten running it, which included supporters for those in need, explainers, chairs of sessions, MCs and practical helpers. Those, plus the people who had been before were well ‘set’ to experience it again, and knew what to expect.

The link with the setting was powerful and extraordinary – and I think I can allow myself to be more descriptive here, as Coed Hills (the venue) is an entity with a set of values and activities which were explained eloquently to us, as one of the optional activities on the last day.

The setting, Coed Hills, and its people, do not seek to be hidden or confidential about its meaning and purpose. The way I explain it to people back home who are unlikely to be sympathetic is to say ‘it is a Welsh commune run by people who look like old hippies, but who have been doing it for many years and have become experts in many of the local-based things that are clearly needed for long-term sustainability’. Such as production of energy, food and craft products all done in-house, with as low a carbon footprint or ecological impact as possible, and by running a conference / wedding venue to raise funds with utterly unique and mostly beautiful architecture and design. If people I’m describing it to are likely to be at least a little sympathetic, I go further – which I will do here.

The afternoon session on the last day was called ‘Introducing the Bottega Project’ with John Whitehead and Rawley Clay. John is the resident ideas guru with outward-focussed intentions to expand the principles of sustainable living on a city scale – specifically Cardiff, where he describes collaboration with the architecture department at the university, for example, as well as many other networks of influence. Rawley, primarily an artist I think, is the main person looking inward to sustaining and developing the community at Coed – with many aspects familiar to us in the TC world, such as weekly community meetings, sharing of resources / emotions / food / life in general, and of course democratic operating - and a flat hierarchy.

We met outside the circular barn (in which most of the CMH gathering events took place) for a brief introduction. Rawley started by triggering my circular and Jungian resonances, all about the space with no corners, and their use of yurts and curves rather than rectilinear design with hard edges and all that goes with them. Coed Hills is blessed with a beautiful piece of land in a beautiful place. Here is a quote from the website:

Coed Hills (pronounced Coyd) is a unique, off grid sustainable community just outside Cardiff in South Wales.  The on-site residents still work the land using ancestral methods and manage the 180 acres of unspoilt ancient Woodland, man-made lakes and beautiful summer meadows. With elevated views reaching as far as the Jurassic coastline of Wales, yet just a stones throw from the Welsh Capital, Cardiff, Coed is a hidden Utopia from modern life.

Coed has been the leading centre for low impact living in Wales since it was established in 1997. It has hosted many international events including the UK Permaculture Convergence, and has been internationally identified as a place for those who want to embrace an off grid way of living in harmony with nature or to explore and evolve their connection with themselves in tranquil and peaceful surroundings.

John then gave a few minutes of spirited and often non-verbal communication of how Coed and its principles look well beyond the mundane necessities that most of us are immersed in. A sense, perhaps, that even though the world is in a complete and utter pit of despair at the moment, there can be different ways of looking at it. Then he introduced us to some simple exercises. The first was interpersonal, and after agreeing on pairs (six, as we were altogether a dozen) we would each spend three minutes communicating to the other, without any words, how we were feeling about being in nature and all the elements of it all around us (and it was a very rich natural environment, which included the built environment and numerous artistic pieces). We could use any physical means, such as posture, movement, facial expressions, breathing, vocalisations without words and anything else we wanted. At first, I think most of us felt– to say the least – like complete chumps. But once we got started, and could feel that we were in a trusted space, it was extraordinary how much we could communicate and mutually understand; it was in a very fluid and boundless way that is never usually possible in conversations with strangers who you only met ten minutes ago.

John then led us out of the immediate environs of the centre, up a slight grass-covered hill, to a circle of 28 standing stones. Again, he persuaded normally decent and rational people to do something they had never done before – to go up to one of the stones and commune with it for a few minutes (those weren’t his exact words, but it is the gist of it). As I write this, it sounds silly and woo-woo – but as we were there, experiencing it together, I think we all got something peaceful – and perhaps personally meaningful – out of it. There was no need to explain, or defend, or judge; we were simply doing what felt OK at the time. A few jokes and bits of warm playfulness mixed well with the sombre and serious tone of the moment.

Next we went deep into the woods – to hear from one of Coed’s oldest members, who had a fire burning strongly under an open shelter. This was a true woodsman, as in the novels of Thomas Hardy, but he also showed us some survival skills and tricks – with bangs and flashes – that I remember from school chemistry lessons.

The last port of call on our introduction to the Bottega Project was to an extraordinary structure which I thought should be the biggest yurt in the world (I asked, and apparently, it is not).

Not the biggest yurt in the world - but must be close!

There we had a rich discussion about how much, of deep psychological meaning, we have lost in modern social living, and how aspects of it could be restored – at least on a city scale. I stayed so long talking to John about it, that I was the last one there – and ended up lost in the woods as dusk was falling, and the Welsh rain was starting. But, needless to say, I soon found one of the locals who pointed me in the right direction – back to something a bit more like normal life, with tea and cakes, at the CMH gathering.

In the final session, we had a go-round to check out with our reflections about the whole experience. Mine, amongst much more emotional ones, was that I had found or come across something that I wasn’t expecting but know that I might need – and that it had blown my mind, at least twice every day.

I think that’s a good result…

 

World Mental Health Day: INDTC moves from Italy to Portugal

Firenze Duomo at sunset

Still a bit wary about flying - from Gatwick this time, the day after a train strike - but the train round the Surrey Hills was fine. They only needed a passport at check-in, so my anxieties about not having the necessary post-covid papers was soon dispelled. But I did get given an old-fashioned boarding card - perhaps there was so much hassle and bureaucracy during the pandemic that they have now stripped it all down to the bare minimum. 

WMHD ribbon

Anyway, easy flight to Florence for two days there - a World Mental Health Day conference called 'Mental Health Marathon' on the Monday, followed by the final Italian-organised conference and workshop of INDTC (International Network of Democratic TCs) on Tuesday. 

INDTC was formed about ten years ago based by the London-based charity Community Housing and Therapy (www.cht.org.uk). After widespread networking across Europe and India, the British organisation held their final conference at the Cassel Hospital in 2019 and handed the reins over to a collective of our Italian colleagues. From then until now they have been in charge - of direction, strategy, logo, website (www.indtc.org), and (a small sum of) money.

In the midst of their time came covid - and they organised numerous events, perhaps made easier (though certainly less sociable) by the widespread and easy use of video conferencing we have all experienced. Indeed the direction and intentions of INDTC were set by a slightly chaotic and crazy day in May 2021 called the 'Zoom of Babel'. It took place in the middle of the afternoon (GMT) so people could join from the West Coast of North America (early in the morning), Europe (easy), India (evening) and Japan (very late). Although people from Australia and NZ were invited, I don't think any of them managed to come - but it would have been the very middle of the night. So, with some rather playful IT voting tricks, the long list of things that people were interested in was whittled down to three, which were held as the main areas of current interest for INDTC. Several other meetings and events followed, some Italian for their local groups, and some international. 

The first time we all got together for a real face-to-face reunion was yesterday - when the Italians' tenure ended. Interestingly, the Google Translate app has come on leaps and bounds since I last used it. If you set it to translate audio and transcribe it is amazing to watch - typing out in English what it hears in Italian. It doesn't catch everything, especially when there is background noise or more than one person talking (not uncommon in Italy!), and sometimes it comes out with weird and convoluted results - but at least you can get a sense of what is being talked about. And if you are close to the speaker and they use simple language, it gets it absolutely perfect! Never as good as dear Laura our interpreter, of course, but good when there is nobody to help us English linguistic illiterates.

 The morning topics for the conference came from the Babel event and subsequent discussions:

• Greencare
• Democratic working in non-democratic places
• Conflict and dialogue

Interesting discussions were had by all - I particularly enjoyed being in the greencare group, and hearing about how seriously greencare is being taken in various places in Italy, and that a national research study is soon to be commissioned. Also the Greencare 'conceptual framework', written by the EU COST Action 866 about twelve years ago (https://www.cost.eu/actions/866/) has been translated into Italian and is being distributed as a book (the English version sadly being out of print for several years now). 

We heard from Terra Nostra (the Caltagirone Care Farm - called Social Farm in Italy) where we have held several LLEs in the past - and the wide range of activities they are now up to. If only different funders and commissioners could get together, I thought, what a good solution it could be for some of the intractible problems in health, mental health, social care, education, criminal justice, housing and employment. But that seems an unrealistic dream at the moment - it is clearly a struggle to even survive; just like back home I suppose.

The afternoon started with a manifesto workshop - to define the forthcoming areas of interest for INDTC; each of the morning groups took it in turns to present and debate three intentions - making a total of nine areas to focus on. This is the afternoon's draft list (translated by Google again) but it will be refined and edited by INDTC's international steering group before the final version is decided.

Green Care

• communities and therapeutic services should have as a requirement to have the convention that of implementing green care practices
• training, evaluation and continuous and residential research of operators on green care
• green care as a socio-rehabilitative living environment and environmental care

Democracy in non-democratic environments

• get involved in a group and democratic way in a dialogic paradigm accepting the challenge of research
• promote formal structures and intra-institutional organizational practices that are dialogic, multidisciplinary and non-hierarchical
• cultivate an inter-institutional network of connections and collaborations

Dialogue and conflict

• recognition of differences and conflicts as constitutive parts of individuals, groups and organizations and institutions
• promote dialogic and democratic approaches based on complexity and mediation to make transformative conflicts
• accept and understand the complexity of therapeutic work in institutions through community democratic principles 

The final item for the day was for the Italian collective (Chaired by Angelita Volpe) to say 'goodbye', and the Portuguese team (chaired by João Pereira) to say 'hello, here we are'. They did this with a beautiful video of the Portuguese landscape, and a hint of what is to come. See https://www.fundacaords.org/en/videos/casa-de-alba-therapeutic-community-in-mental-health/. Intriguingly, it included human rights and mental health - something I have always claimed that TCs do rather well...

Italians hand over to the Portuguese - Angelita and Joao in the centre

Finally, a note about Parmigiano Reggiano Stravecchio. One of my rituals is always to take a big block of Parmesan cheese home, but I am starting to wonder if it is worth it. As you may know, the length of its ageing makes a great deal of difference to the way parmesan tastes, particularly the quality of umami, and what it costs. I went to a vast supermarket on the way to the airport and bought 24 month parmesan for €25/kg. Then at the airport, I looked at the prices and it was €38.50/kg for 15 months and €49.99/kg for 30 months - so at least I did right to not wait until the airport. But looking at the parmesan  prices back home - Sainsburys' ''Taste the Difference' 30 month, or organic 18 month, is £21/kg. 'Ordinary' parmesan, matured for 22 months, is £17.50/kg. At the local Costco, the 24 month matured parmesan is £15.69/kg. With the pound and euro being so close, it is looking better off waiting to get it at home, which feels a bit sad. But so does Brexit and our UK financial mess.

Selling psychedelics - to government, policy makers and a sceptical public

One of the big things on many people's horizon as 'the next big thing' in mental health is the use of psychedelics. Although the label 'psychedelic' has largely replaced the old word  'hallucinogen' (for reasons of technical inaccuracy), its literal meaning - as 'mind revealing' - is also true for Ketamine and MDMA, which are also known as a 'dissociative anaesthetic' and an 'empathogen', respectively - but they are not hallucinogens. Therefore I use 'psychedelic' to cover them all. 

To reduce it to the usual diagnostic straitjackets I will simplify the reasons for which they are thought to be therapeutic. The list that follows is in order of current and likely future legalisation. 

 

K-hole

Ketamine for 'TRD' (Treatment Resistant Depression') - a controlled drug already prescribable off-label by anesthetists and maybe others, and prescribable on-label as the absurdly expensive separated S-enantiomer called 'esketamine' and marketed as a nasal spray (Spravato). Only a handful of UK clinics exist, charging about £5000 or more per treatment, including preparation and integration psychotherapy sessions before and after the medicine dosing. There is a much wider range of formats in USA and overseas - from wholly biomedical IV infusions, through IM, sublingual lozenges and oral sustained release resin-pearls (which have imperceptible psychological effects).

Smiley

MDMA for PTSD - with excellent studies and high quality evidence, particularly from the US East Coast. There are initiatives to develop new formats of therapy in at least Europe and USA (eg couples, families and groups) but it is only legal to do so as part of fully registered clinical trials. MDMA's professional therapeutic use is nearly always as a facilitator of psychotherapy. The onerous requirements for research trials entail a great deal of burdensome bureaucracy. It is therefore likely that much informal / underground / illegal therapeutic work is already taking place. Smart money is on UK approval for medical use within about 2 years - although details of how this will work are unknown.

Magic

Psilocybin for Depression, 'End of Life Anxiety' and addictions. Psilocybin is the most 'natural' of these three, being likely to have been used for several thousand years in religious and ceremonial settings. However, the formulation used for clinical trials must be synthesised de nove in the laboratory and adds vast costs to the administrative, clinical and practical hurdles of running rigorous research trials. Despite these difficulties, some very good randomised trials have been run - with impressive outcome results. However, they have had their credibility questioned by pedantic academic requirements concerning the choice of 'primary outcome measure'. Nonetheless, psilocybin holds out much promise for being an effective medicine of the future (and long-distant past, probably). Licensing for medical use is probably at least 3 years away in the UK.

Others currently in the frame include DMT or 5-MeO-DMT for very short and intense psychedelic experiences (much more convenient for administering in clinical settings) - for similar indications to psilocybin. Ibogaine is a more hazardous substance, with another long history of ceremonial use, with early research indications of likely effectiveness for addictions. Ayahuasca is a herbal concoction with probably as long a history of cultural use as any of the other natural psychedelics, particularly in South America: it is unlikely to gain clinical recognition in the west as it requires variably potent natural ingredients and shamanic expertise in brewing it. LSD is - at least in modern western circles - the granddaddy of them all, and is a powerful and very safe psychedelic. It was intensively and extensively researched in the 1950s and before 'the War on Drugs', but probably now carries too strong a taint or stigma from its widespread countercultural use in the 1960s. Of course, there are many others both natural (such as mescaline) and synthetic (a vast range of 'designer drugs' - particularly tryptamines and phenethylamines) - but they are much lower down the list of medicines likely to gain approval for clinical use.

 

BUT (1)...

Perhaps the true place of psychedelics is not in the treatment of what we call 'mental illness', but more in a well-being and preventative role perhaps in the context of a safe and benevolent community of users of mixed age and experience - to include the wisdom of elders and those with special experience. The danger of the field being taken over by medicalisation (including psychotherapy) is that far too much dominance will be given to the vary narrow view of effectiveness as researched by modern 'evidence-based medicine'; the numinous, ineffable, spiritual and mystical aspects (which are so often cited as transformative factors) could be lost in the world of highly-qualified and highly intelligent boffins.

 

BUT (2)...

Even more persuasive than the power of massed biomedical academics is that of venture capital. The language is of 'startups' and 'incubators', as well as 'return on investment' and 'leverage'. A long way indeed from human needs, relationships, emotions and distress - also from 5HT receptors and synapses, neuroplasticity, the default mode network and glutamate systems. The only driver behind this very powerful force of change is money, and a very great deal of it. I find that rather worrying

 

BUT (3)...

Many many people, myself included, are disillusioned and almost despairing about the state of the world, and how humankind appear to be destroying it. Hence the vigor of activist movements such as Occupy, Me Too, Black Lives Matter and Extinction Rebellion. Last week, I went to a 'Seeds' talk in Swindon with the title 'Science of Psychedelics', given by a speaker who clearly knew his stuff, and could communicate it vividly and passionately. But more influential than the facts he presented was his manner and milieu. The 200+ audience could have come straight from Swindon shopping centre once they had bought their Eventbrite tickets. When I arrived the setting looked much more like a rock concert than the sort of professional lecture I am used to - and had a long queue to the bar and a faint aroma of patchouli oil. The speaker - with very respectable academic credentials - looked for all the world like a bass guitarist without his bass guitar - strutting up and down the stage with the sort of cool and sex appeal that no clinicians that I know could do or would dare to attempt! 

Where's your bass guitar?

Just a few quick reactions: 

• it is great that science and new information are being publicly disseminated so effectively
• this is picking up on a much wider disagio diffuso - like the better known activist movements that want to change the world
• it takes too long to change public opinions and demands by professional medical research
• it feels sad that it is all becoming so commercialised and managed by PR experts.
• there isn't a single mastermind behind all these mechanisms for publicising psychedelics, and selling the potential importance of them, but many very committed, determined and intelligent individuals who are often working together.
• Are they missing something? (I have a feeling they are, but I don't know what it is!)

Taking a step back: looking with a third eye

Just three months ago...

Time to get back in the saddle after being grounded by covid for over two and a half years: where better than to than Zafferana Etnea in Sicily for the latest Italian LLE (Living-Learning Experience)?

Having forgotten most of what one has to do to travel on an aeroplane, never mind the extras since the pandemic, I was rather worried that I wouldn't be allowed on board because I had forgotten something. That is as well as feeling quite guilty about going back to having a hefty carbon footprint - the climate crisis seems quite a lot worse than it did when I was flying before 2020. Nevertheless, Heathrow was easier than I ever remember - then I got three seats to myself to Rome and onto Catania - and Fiumicino had clearly had a make-over, though the walk from the London plane to the Sicily one was as long as ever, but past some very flashy shops of (or to be precise, through the middle of them). Al Italia no longer exists with its friendly green and red stripes, and the ITA Air planes were glittery metallic blue. Passport control dead easy both ways - through the e-gates. My phone even worked contactless for a beer while I was waiting to be picked up - I was expecting more Brexit trouble than that!

The Mediterranean in front

Three of us were driven from the B&B the next morning, arriving almost but not quite late at the venue. Which was a modern three-storey building with about four bunk beds in every upstairs room and many Catholic icons, crucifixes and pictures - and an altar in the community meeting room (which we tucked out of sight behind some screens). However, the view was spectacular - Etna peeking through its very own clouds behind, and seeing all along the coast to the Italian mainland at the front. 

Etna behind

Working out what to do with the rooms was a bit of a problem, as the bunk beds were not moveable. So after discussing and agreeing several different solutions and changing our minds several times, with everybody disagreeing but not quite saying so, it took about half an hour to sort it out in the Italian way - just get on with it and move the furniture where we needed to. It meant that two of the three small groups were in different parts of the garden and the staff group happened in a top floor corridor. The garden groups were a new departure, which some of us found a bit worrying; and the staff room ended up being rather crowded when we were all in it.

The participants came from all over Italy - only one from Sicily, and groups of others from Rome, Tuscany, Sardinia, Venezia and Piedmont. The staff team was also bigger than usual - Veronica and myself from UK as supervisors (or so we thought when we arrived), David an LLE staff trainee from Florence; Amelia, Rosanna and Giuseppe as three local group therapists to conduct the small groups; Carmelo the administrator, and Simone the organiser. We started with a little friendly rivalry between us all about the number of LLEs we had attended. As I have been there since the very beginning, I have clocked up over fifty and Veronica about half that. Simone claims 14, and the small group conductors all single figures. David was quite early in the process, and this was his third, or possibly fourth. Cue much talk about parents, grandparents and transmission down the generations.

The fun really began when we talked through the amended timetable and started working out our roles. Simone was going to be the supervisor of the group therapists, and they would meet alone for most of the staff meetings. Veronica, David and I were 'the research group', and we would meet once each day by ourselves and once each day with the other staff. This soon made us feel a bit unwelcome in the staff room, though we soon got over it. Our task, loosely defined, was to observe and reflect on the overall group processes. It also meant that we didn't get involved in the discussions after all the groups, so only had a vague idea of what was going on for other people, except what we saw in the community meetings and in the social time together. 

Two other noticeable differences from most previous LLEs were the length of the community meetings, and the separation of 'free time' and 'community time' on the second afternoon. The community meetings were seriously longer than I have ever done before - two for 60 minutes, and four for 90 minutes. It is hard to know what difference this made to the process and to the experience for participants, except it made the 'downtime' between groups less - 15 minutes instead of 30, usually. We weren't in a position to observe how the separation of  'free' and 'community' time worked, as we were in our research group at the time - but it is a good thing for the staff team to think about in future.

Our first meeting of the research group was all over the place, to say the least: how Italians might see authority - never ending groups - generational transmission of pearls of wisdom - rivalry - Italian regions - South American countries - cultural adaptations for LLEs - therapists being provocative - boundaries (surprise, surprise!) - democracy which 'might be an illusion' - happy cohesive staff groups - how we might be helpful to the rest of the staff team -  and 'what's the research question anyway?' 

Subsequent meetings were often more personal, but also widely systemic. This included thinking about the Mafia and global organised crime - climate change - covid - language - aplologising - gratitude - warmth - trust - containment - unexplainable medical events - illness - death -and, running like a golden thread through everything we covered, relationships. Relationships between each other, between members of the community, between different groups, between staff and non-staff members, between staff members themselves, and between all of the above and the world outside. As often happens in good groups, I was left with a sense of the numinous: impossible to precisely describe or pin down in words, and only present in the space between us.

Practically, this research group was rather more satisfying and relaxed than supervising in the normal staff meetings: less rushed, more spontaneous and open to any subject any of the three of us wanted to raise. Although we allocated ourselves an hour for each of the research meetings, we usually over-ran, sometimes until the other small groups ended. We were our own small group, and quite proud of it! Our combined meetings with the staff group were quite like the usual after-groups from previous LLEs - but mainly focussed on the group processes in the community, and not individuals. There was no space, opportunity or indeed willingness to bring any details of our own discussions in the research group to the wider staff team. Similarly to how small group members often value their small group experience very highly, we treasured ours and felt the whole staff plus research group had a very different atmosphere (and task). We did do the 'one word feelings check' at the end of each of the staff meetings, led by Simone.

For me, I felt rather isolated and somewhat lonely as the only person there who did not speak Italian. Although it was absolutely clear that everyone was friendly and welcoming, I could never communicate freely. It was helped - a little bit - by the god Google, which does a very impressive job of translating live speech on one's phone; and rather more by a small number of community members who spoke good English and sat next to me in community meetings to convey at least the essence of what was going on. Many thanks to them. And even without the full comprehension of what was being said, I certainly heard, thought and felt that there was some therapeutic magic going on close to me - perhaps in the way we were with other, and how that changed over the three days.

Unfortunately, I made a mistake for the second evening's 'community time' - partly due to this feeling of isolation. After a few nice conversations with various people over dinner and afterwards, I felt it was time for retiring: my usual routine of reading then bed. So I went upstairs to the second floor bedroom zone (next to the 'staff group space' in the corridor), for the night. I learned the next day that I had just missed participating in the lively, funny, silly Italian song session that for which everybody else sat out on the veranda. The staff started to be seen as humans, and the 'us and them' quality of the relationships was well-dismantled. And I had been grumbling to the research team how there didn't seem to be much space for playfulness or fun in this community! How wrong I was, and how sorry to miss it. Maybe I should just put it down to my age.

For reasons of confidentiality, I am not going to mention any personal details of what happened in the community meetings, but I do want to convey something of the positive, but realistic, tone of the closing community meeting. One lovely analogy somebody made was to the clouds - how sun and warm blue sky can quickly change to dark clouds and torrential rain. How it can suddenly get cold, and then have us back in sunshine a in few minutes (or hours, or days). I always like weather analogies, because of their link to chaos and complexity theory - and how relevant that is in human emotional development. There was also discussion of the limits to what is possible in the LLE format, which was something of a recurring theme (and often comes up in LLEs - often in the form of 'it's amazing how far we have come in three days' or 'I wonder how to continue this afterwards'). In the final moments we had a go-round for check-out, and we did it as 'what ingredient would you be if the community was a cake we were making together?'. Another favourite for me, as I often think and talk of groups as a pudding to which we all add our own unique flavours or ingredients.

So it feels like the research group was worthwhile - and a good addition to the 'super-supervisory' arrangements for the international LLEs, though some tweaks are probably needed. The longer groups and shorter breaks certainly need to be thought about, and a few typos or timing errors on the agenda and timetable need to be corrected: but these are minor and separate matters. The research group could interestingly include academic or clinical or lived experience 'outsiders', as well as the grandparents, senior old fossils and therapists training to be LLE staff members (as we had in Etna). 

But as always, thank you so much to everybody involved for making such a rich, fascinating and emotional experience!