I have just been asked to write a foreword for a book by Father Hank Nunn, a Canadian Jesuit now aged 82, who set up Athma Shakti Vidyalaya - a therapeutic community in Bangalore.

This is a first draft, which describes something of my experience of ASV when I visited it in 2003. I hope it will help to promote the book, and the work of this remarkable therapeutic community.

The view from ASV, the road towards Bangalore city centre

 In about 1980 I remember being sent to a strange place. I was a medical student, and we were often sent to strange places -  from theatres where the surgeons wore space suits and do operations by remote control to rural GP surgeries with afternoon tea and linen table cloths; from rooms where babies are born to rooms where corpses are dismembered. This one was even more different, though.

I had been warned by previous students that this acute psychiatric admission ward, the Phoenix Unit in Oxford, was not somewhere to wear the normal jacket and tie. So I kitted myself out in a big red sweater and jeans, and I arrived there on a bicycle a couple of minutes after the suggested 8.30, and I was casually pointed in the direction of a large dilapidated room where I soon had to forget any ideas I had of hospital hygiene. I squeezed into the room to be confronted with a large circle of chairs - perhaps 40 people - where it wasn't possible to tell the consultant from the cleaner.  I had to find my own chair and pull it up next to a large restless man who just looked at me and laughed. "What's your diagnosis then, eh? You must be manic like me with a jumper like that." He trumpeted this at what felt like 120 decibels, and I just wanted the ground to swallow me up.  There was an excruciating silence (probably all of twenty seconds) before everybody introduced themselves.

After my initial culture shock of joining a therapeutic community, I went on to thoroughly enjoy it. I found something completely different about the way people were with each other - I learnt my psychiatry the same as other students who were on traditional wards, but I also got an inkling of something that is very hard to define or put in words. It was something about being allowed to be yourself, about playfulness, and creativity.  

That short experience set me on a quest and an adventure that I am still following, thirty-two years later. What is it that makes somewhere ‘feel’ safe? How do you set up places where staff enjoy working, and give their best? How do you run mental health services for love rather than for money?

I have tried to capture this essence in different ways since 1980 – not least by training as a psychiatrist, and soon realising that the elusive secret was not to be found in that territory. I was getting warmer when, training as a group analyst in 1994, I tried using my course dissertation to put the theory I had been taught into a developmental sequence called ‘the Quintessence of a Therapeutic Environment’. And perhaps even warmer when, as chair of the Association of Therapeutic Communities in 2002, I helped to instigate the ‘Community of Communities’ as a quality network to identify and set standards for therapeutic communities.

The entrance to ASV - created by the community, of course

One of the absolute highlights of that exciting time was a visit I made in November 2003, to a therapeutic community in Bangalore, that was hoping to join the project network. I knew that they used a reparenting (‘cathexis’) model of transactional analysis, for I had met people from their sister project in Birmingham. I knew cathexis had been controversial some years previously, in the United States and international transactional analysis organisation, as well as locally for the Birmingham therapeutic community. But my only intention was to go with an open mind, and see what I could find of this elusive ‘essence’ in a setting so different from all my previous experience of mental health services. As always, I was more interested in the ‘general therapeutic conditions’ than I was in the intricacies of a particular model of treatment.

Three memories stand out for me: I will call them ‘warmth of welcome’, ‘unlabelled living’ and ‘fight for survival and growth’.

The neighbours - mid monsoon season

The warmth of welcome was deeply moving, and I could tell from the moment I crossed the threshold that the intangible quality, which was so elusive and difficult to define, was present in abundance. I remember telling somebody when I got home that you could tell a therapeutic environment by ‘its smell’ – which didn’t exactly mean the physical aroma so much as the unconscious, primitive, limbic sensations that emanate from the social field your are joining. Within minutes, I remember playing backgammon with a community member and not having any worries about exactly where I was sleeping, what was on my timetable for the visit, or who was who. Several thousand miles from home, in a place where everybody was new to me, I felt I had arrived home.

The ‘unlabelled living’ was fascinating to me as a mainstream, though psychotherapeutically-minded, psychiatrist. The hard lines I had learned between psychosis and neurosis, between schizophrenia and personality disorder, and between traumatic and biological causes - dissolved into thin air. People were being treated as themselves, for themselves, each according to their own needs. Echoes of Laing, I wistfully remembered. But here, being done with compassionate meticulousness in a economic climate where the alternative was a social exclusion harsher than anything we know back home. To me, the therapeutic intention – and the palpable manifestation of it – was orders of magnitude more significant than any specific therapeutic techniques or methods.

The ‘fight for survival and growth’ was sadly familiar. Those of us who choose to work in these complex and indefinable ways always need to establish an ‘island of containment’ within which the work can continue. In the process of economic globalisation and market managerialism, the natural tendency will inevitably be towards instrumental rationality – with easily defined treatment processes and specified outcomes, which is of course antithetical to therapeutic community practice. I remember animated discussions with a parent, and being excited by plans to set up a similar unit elsewhere in India: ‘how could all this excellent work fail to be properly recognised?’, I thought. I was, and always will be, rather naïve about these things.

Father Hank Nunn, November 2003

But all these experiences now make me realise the enormous task of the leader of a therapeutic community, and the ever-increasing impossibility of the task of mere survival, never mind the possibility of growing and thriving. In ASV, one man has held this vision alive, through many years of surviving, thriving and carrying a flame through a hurricane, and this book is his account of that Herculean task. It tells Father Hank’s own story, laced with illuminations about the links with his Jesuit faith, his philosophy of compassion and the detailed methods he uses. It is a true and authentic account of what it means to love thy neighbour, profoundly understand another’s distress, and be human in the wilderness.

It smells like a dead horse

It was a horrible job - almost like an autopsy of a very large creature that had become a close companion. Foolishly dressed in sandals and shorts, the first job for Fiona, Tim, Sophie and myself was to make war with the dense thicket of nettles surrounding our twenty-one foot mongolian gur. After we had taken a coal shovel to them, with a vengeance that could only come from numerous painful stings, we started the dissection.
First the canvas came off - quite a neat and tidy job. Then the innards. Too gross to give a blow-by-blow account, I shall just copy the report of the autopsy finding that I emailed to the colleagues involved...

Hello all

As you probably see from my other emails, I am very worried about the state of the yurt and how much of our energy it is taking up. We need it to be a fully-functional therapy room by the end of August if we are going to meet our targets for starting up the groups we have said we would for the EcoMinds project.

I am so worried that this just won’t be possible that I have written to Jamie asking if there would be space to use some of the classrooms at Iver, instead.

The felt layer - with mouse and other damage, and a very nasty smell

The cotton lining - once as white as snow...

Here’s what we found when we took it apart yesterday, and various thoughts about it:

• The canvas layer (three sections plus cap) are dirty but structurally OK - now folded up and covered with cap at the site.
• The five sections of felt are mostly dry now - but some are ex-mouse-infested, and all are mouldy, decayed and rotten in places. Also they are holed where the mice were, heavily stained and full of spores in some spots, and altogether extremely smelly. All five pieces are currently in the conservatory at TDU in Wexham Park Hospital - but Niddy has said it cannot stay there if the smell penetrates into other parts of the unit.
• The cotton liner is unevenly brown-stained all over from the felt beneath and green-stained in steaks with the mould from the wooden ribs. It also has extensive areas of pin-pricks of black mould/mildew. It is also in the hospital conservatory.
• The wooden frame is still standing and seems structurally sound - though several of the ribs in the area opposite the door are disfigured and sagging, presumably from the continual weight of wet felt above them.
• Both the trellis walls and the ribs are covered in different colours of mildew and mould, with many spores visible on the ‘furry’ surface.
• The wooden crown appears to be clean and in excellent condition!
• The door has lost its varnish in several pateches, and the metal door furniture is rusty. It does not fit in its frame, so cannot be fully shut (though this is a longstanding problem).
• The wood-burning stove is currently in pieces and very rusty. The backplate needs moving from the top to the back to accommodate the flue, but the bolts holding it are seized up with rust which has not been released with WD-40, oil, grease, brute force etc.
• The new flue is dented and slightly squashed from transit, but we know this is not remediable, and should be fittable.
• Our other equipment (like fire extinguisher, first aid kit, toolbox etc) are all OK.

Questions to decide

·         Do we want the wooden floor that we agreed? Whatever floor we have, it will need a damp-proof membrane installing under it - which will almost certainly require the wooden structure to be fully dismantled.

• ·         Things we could do ourselves are:

o   install damp-proof membrane under the floor;

o   disinfect/peroxide bleach the woodwork and maybe paint with fungicial sealant;

o   scrub the outer canvas;

o   purchase new lining

o   purchase new felt layer

o   paint and restore the fire to good order

o   clean up the door

o   buy the furniture we need and decorate it to make it a good therapy space

o   Take the whole thing down as necessary and re-erect it (but this needs at least 4 people for 1-2 whole days)

• ·         Things we probably need help with are:

o   install the fire and connect the flue;

o   clean/bleach/disinfect the cotton lining;

o   get the door working properly so it shuts properly and is lockable

• ·         Things we definitely cannot do ourselves are:

o   mend the felt (although there is a possibility that it will be OK when fully dried out - though I would not be confident it doesn’t contain some infestation or other that will recur or cause future problems)

o   find the time and manpower to do all these things!

• ·         At the moment, my favoured solution would be to get somebody to do it all for us - perhaps an English yurt-maker - and pay them whatever it costs - and include renovating and installing the fire and flue. This should all be possible to do before this coming winter.
• ·         Another option would be to buy new felt and lining from the original manufacturers in Spain, and restore and rebuild the whole thing ourselves. If this is what we decide - I think it will probably not be possible to get it up before the winter, so we will have to be without it until Spring 2013.
• ·         The minimal but fastest option is to make do with what we have got - damp-proof the floor, scrub the woodwork, put the felt back on when it’s fully dried, either clean or replace the cotton liner, and put it all back up ASAP. However, this does mean that we need to find a lot of people and time to do it all - and I doubt that we could get a new cotton liner at all quickly (which needs to go on the wooden frame first, in good weather)
• 
  
• Can we discuss and decide how to proceed before the end of this week please, folks?

David, Susan, Peter and I will have to approve any spending - but I think the stress it is putting on us all, and the whole project at the moment, is currently so much that we might need to just agree to pay for it all to be done for us.

Rex

PD is a major MH problem

This flier is the product of several meetings and discussions over the last few weeks:

Dear Cornwall

Gentle rolling Devon

Just past Exeter...

The Red Cliffs of Dawlish

And into another land...

Typical Cornish architecture

Truro 1984-87: city of pubs and rain

Carrick Roads from Penmere

Memories of 1987: typical Cornish architecture

Not may people realise how big this is...

This week I received an interesting email, in my role as moderating clinical messages on the National PD website (www.personalitydisorder.org.uk)  from somebody whose son has finally found a specialist service for what is probably diagnosable as Emotionally Unstable Personality Disorder. This is after agonies of  being passed from one service to another, nobody being able to help, and no honesty about the likely diagnosis.

It is so encouraging to hear from somebody who can see the size of the problem here – I so often feel that I’m ranting on about something that nobody is interested in. And the response from ‘the system’ is so corporate, anodyne or cautious to render it meaningless: “so much is being done to improve community care”, “the government’s first priority is public protection” and “all the European metrics show how well we are doing” are all things I have heard recently, and the last was from the government’s director of mental health in a very uncomfortable personal conversation I had with him. 


With the growing despair that the world of mental health is going the wrong way, several of us who are ‘medical psychotherapists’ met John Alderdice in the Lords last week (he is a retired medical psychotherapist himself).  His advice was to get local and make a fuss (as there is no central control anymore beyond awfully empty and arid things like ‘No Health without Mental Health’)  – but to focus on good MH stories where it is being done well. Personally – since reading Paul Mason’s ‘Why It’s Kicking Off Everywhere’ – I have been trying to send a daily tweet and a weekly blog about it all (hence you reading this!). I know it takes a while to get these things going, so I will persevere for a few months yet - or until I am 'silenced'!

I started medical life as a GP – but, being most interested in the ‘soft psychiatry’ that they were very good at teaching us as part of the GP training in Cornwall in the 1980s, decided to return to Oxford to train as a psychiatrist – but was sorely disappointed with what I found. Although I remember thinking how much more opportunity there was to do psychosocial practice better in primary care, and being sorely tempted to go back to being a GP, I remember my trainer’s wife – a feisty Bodmin magistrate – saying, as her parting shot to me, ‘at least go and do something about PD, Rex!’.


Since then, I think I have had a fair stab at that – although usually in the teeth of opposition to my determinedly ‘biopsychosocial’ approach. But I did get a reasonably lucky break for my consultant job, when in 1994 I was appointed to develop a ‘therapeutic community’ as part of a regional psychotherapy service in Berkshire – then another when I was invited onto the DH working party to help write the government’s PD policy guide ‘No Longer a Diagnosis of Exclusion’. It was only when I had to diagnose our service users for Royal College of Psychiatrist student examinations in about 1998 that I realised that all our 'patients' had Borderline Personality Disorder!  In the DH working party, I ended up causing quite a stir by gathering a gang of about twenty very unhappy – and generally rejected – service users from across England and setting up focus groups with them and fairly senior civil servants. Suddenly, somebody realised that there might be a problem here.

That was in 2002, and over the last decade many flowers of excellent service have been blooming – but there are still many areas of desert. That is as true geographically (88% of England has no ‘tier 3’ PD services) as it is professionally (unfortunately, the inherent conservatism of my own profession either sees the psychosocial approaches as ‘not real medicine’ or are frightened of the challenge to their authority that it might imply. 


Furthermore, what little hope that there was for further development of community services for PD has been largely dashed by the recent ending of the national programme – and effectively insisting that IAPT is “the only show in town” (see last week's blog entry). 


One glimmer of hope that we are holding onto is that the time is indeed very opportune to ‘do it locally’. If we could organise a good campaign to educate and inform the CCGs before they come into operation next April – which means me and like-minded colleagues (in our ‘spare’ time), and three days a week of Fiona (a passionate and energetic graduate of a proper PD treatment programme). 


Our fear is that the message will be lost in the clamour for ‘really important’ NHS services – and that people who are ‘attention seeking’, ‘manipulative’ and  ‘their own worst enemy’ don’t deserve public money.


Our hope is that three things will  get recognised (1) good treatment is now available – and GPs and psychiatrists no longer need to tear their hair out with these ‘difficult patients’ (3) the burden of suffering – patients, families and friends – is immense and (3) good treatmet availability will save far more money than it costs.