Wednesday, 10 December 2014

The Enabling Society

This is the title of a session I'm talking at next week, at the inaugural conference of the Psychosocial Studies Association. It's at UCLAN in Preston, and here's my two-pennyworth...


Thank you very much for inviting me to this – I really believe in what this association is trying to do, although I’ve been rather nervous in thinking about what I could write and have to say to real academics and intellectuals in a field that seems so far away from what I know anything about (which gets less as the years go by, I do feel). But then I saw Sasha do a talk at the Institute of Group Analysis a few weeks ago, based on her own research, and had one of those ‘aha’ moments: we’re actually thinking about the same things – that are very difficult to put words on – but are fundamentally about relationships. I felt that she was talking about ‘how we find our place amongst others’ – which is one of the emotional development principles behind a lot of TC work.

The relationships which we’re both talking about are with the world, with our own culture and tribe, with our acquaintances, with our family and intimates, and ultimately with ourselves. As I’m growing into a green and grumpy old psychiatrist, I’d also say relationship with the planet and nature. As I said at a Royal College of Psychiatrists event a couple of weeks ago, the aim of our current work to run therapeutic community programmes in an environment centre is to “connect people to each other and to nature, to help people to see that there is a life worth living, and on a planet that is worth living on.”  But more of that later – that is where we are going; we have to get there first.

So, once I had clicked that we are talking about the same fundamental things, just in different languages as it were - I felt that I could probably say something to this audience and in this discussion with my rather awe-inspiring colleagues on the platform. So I’m aiming to tell you a bit about the forgotten (and I feel neglected) story of therapeutic communities over the last thirty years or so. Somebody said, in a large group at an NHS campaign meeting a few weeks ago that ‘TCs are the last remaining vestige of truly democratic practice in the NHS’. I didn’t know him, but I wanted to rush across the room and kiss him – but that wouldn’t have been within the acceptable boundaries of large group practice, of course! However, I do feel that there is some extraordinary work being done in therapeutic communities, which is very much in the face of increasing regulation, which is very individualistically and rights-driven, and experienced as persecutory. The whole thrust of it denies any importance to interdependence, mutual responsibility, social cohesion, and group process – let alone what we call the dynamic unconscious and the whole irrational realm of how humans operate at their best. Which includes things like spontaneity, holding uncertainty, imagination, and what I call ‘therapeutic ordinariness’ and ‘creative chaos’.

I won’t labour this point, but it does feel like we all now live under a public management tyranny that is based on the ideas of cognitive-behavioural therapy, with an underlying principle of instrumental rationality. I was looking for the right words for this thing, and ‘instrumental rationality’     seemed to capture it best – the definition (Wikipedia, I’m afraid) is "A specific form of rationality focusing on the most efficient or cost-effective means to achieve a specific end, but not in itself reflecting on the value of that end, nor the means of arriving there".  So the way we work in TCs is to some extent an antidote to that way of thinking – although it is becoming increasingly difficult to protect the space within which the TC can happen. And maybe this means that we in the TC field – and perhaps wider therapy world - need to change our tack, rather than keep trying to ‘keep calm and carry on’. And I think that’s what I’m here to talk to you about – TCs, and the philosophy and values behind them, being a radical force for challenging the prevailing view that instrumental rationality is good for your mental health.

My own educational background is relevant, because – in the days when being a medical student was paid for by the state and we received a maintenance grant from the county council – I did an elective third year of two subjects which were at war with each other: experimental psychology and social psychology. In some ways, the experimental psychology was a doddle – we had already done half of it in anatomy and physiology the year before. But in other ways, the critical theory in the social psychology made me doubt that you could believe anything in the experimental psychology, for example IQ testing, because of the political framework it was in. At the very least, what actually mattered more to me (as a rather confused undergraduate) seemed to the reading we did of Laing and Winnicott, than of Skinner and Eysenck. And in a way, I have lived in that polarised professional world ever since – physical sciences versus social sciences, ‘real medicine’ versus psychiatry, CBT versus psychodynamics, diagnosis versus formulation, biomedical versus psychosocial, mental illness versus personality disorder, and perhaps TCs versus the rest!

So, back to TCs. In the 1950s the British social psychiatry movement was storming the world. In 1952 the World Health Organisation published the following advice:
'The most important single factor in the efficacy of the treatment given in a mental hospital appears to the Committee to be an intangible element which can only be described as its atmosphere, and in attempting to describe some of the influences which go to the creation of this atmosphere, it must be said at the outset that the more the psychiatric hospital imitates the general hospital as it at present exists, the less successful it will be in creating the atmosphere it needs. Too many psychiatric hospitals give the impression of being an uneasy compromise between a general hospital and a prison. Whereas, in fact, the role they have to play is different from either; it is that of a therapeutic community.'
And at the forefront of this movement was the Henderson Hospital, where Maxwell Jones was the medical superintendent. Maxwell Jones was a respiratory physiologist who ran a programme for battle-shocked veterans at Mill Hill Hospital in the Second World War, and started to realise that they were better at helping each other to get over what we would now call PTSD, than he was. He was giving them lectures about how their breathing makes them panicky, but – in the time between lectures as it were – they were sharing the emotional meaning of their symptoms with each other. So when he set up the Henderson after the war, that was the principle it was based on. An anthropologist called Robert Rapoport did a detailed ethnography on it, resulting in the book ‘Community as Doctor’ – which boiled it down to four themes: democratisation, permissiveness, reality confrontation and communalism.
·        Democratisation: every member of the community (all patients & staff) should share equally in the exercise of power in decision making about community affairs
·        Permissiveness: all members should tolerate from one another a wide degree of behaviour that might be distressing or seem deviant by ordinary standards
·        Reality confrontation: patients should be continuously presented with interpretations of their behaviour as it is seen by others, in order to counteract their tendency to distort, deny or withdraw from their difficulties in getting on with others.
·        Communalism:  there should be tight-knit, intimate sets of relationships, with sharing of amenities (dining room, etc), use of first names and free communication
Although these made Henderson famous throughout the world, Maxwell Jones didn’t like them – and nor do I. Not because they are wrong, or it wasn’t good research, but because they don’t capture that ‘essence’ that the WHO was talking about. Apart from perhaps communalism, they are very behavioural – and don’t at all capture the quality of experience and particularly the quality of relationships that members of a TC – both staff and service users – actually experience. A more modern version of ‘TC theory’ that is now quite widely used is much more inclusive of different types of TC (apart from just the Henderson model), and is based on five necessary experiences for emotional developmental, and how we recreate them in a TC: attachment and feeling a sense of belonging; containment and experiencing emotional safety; openness of communication in a culture of enquiry; inclusion and interdependence by finding our place amongst others, and empowerment or personal agency through finding an authentic sense of self. But that’s a different talk for another day.

We all know that everything changed in 1979, and I’m sure that most people here can articulate that much more eloquently than I can. But one of the consequences in our corner of the mental health world was that selfish individualism (for want of a better word) made TCs less and less acceptable. I think the same is probably true of group therapy in general. In their heyday, the 50s, 60s and 70s, every psychiatric hospital in the country had a residential TC, some whole hospitals were run on TC principles, and community day centres were run as TCs. Then everything changed as the wind came from a very different direction – and without giving a grizzly account of all the closures – there are now precisely no residential TCs in the NHS, the non-residential day units have been reduced from 5 to 3 to sometimes one day per week and most of them shut altogether; the latest one I have just set up in Slough is just two hours – the rest the ‘patients’ do themselves and elsewhere, and I’ll say more about that later. There was a brief respite during the Department of Health’s National PD Programme between 2002 and 2011, when several new non-residential TCs were set up in the NHS, but most of those are now being closed because they don’t fit into the IAPT programme – which is where PD now sits in the Department of Health policy terms.

Yet we pay seven million pounds for new fences at Broadmoor, and send ‘difficult’ patients to locked wards in the private sector which cost £250,000 per year, where they receive a trivial amount of trivial therapy, and have quite expensive and extremely individualistic mental health services which Sue Bailey, described as a ‘car crash’ as she recently retired from being president of the Royal College of Psychiatrists. Our policy priorities have certainly changed! But I must stop ranting like a grumpy old psychiatrist, and get back to TCs.

It is true that a few of the TC principles from the social psychiatry revolution live on, though in a very attenuated and pale form. Examples include service user involvement, community meetings on some of our ghastly inpatient wards, and maybe some hope and creativity in parts of the contemporary recovery movement. But these are grounded in the soil of marketised and commodified mental health care, and lack the radical roots of people really taking responsibility for themselves and each other and challenging the power base of the system. They are still fundamentally paternalistic.

But I want to turn to where we are right now in 2014. I think a tide is turning and there might be opportunities for a new form of TC value base to have a wider influence – hence the link to the ‘enabling society’ of our title here. We have been doing a lot of work at the Royal College of Psychiatrists since 2002, when UK TCs were probably at about their lowest ebb. With lottery money, formed a quality improvement project called ‘Community of Communities’ – and we’ve had just under a hundred members for the last twelve years. At a formal level, it works just like any other audit or even action research cycle – decide and set the practice standards together – review them – action planning – make changes – start all over again. But where it differs is the fact we insist on communities visiting each other, and being visited, each year – not for an inspection process, but for support and nurturance from like-minded people. And of course, it includes both services users on these visits, as well as staff of all seniorities.

From this, about five years ago we distilled a set of ‘core TC values’ as well as the more prosaic ‘service standards’. The service standards define what TCs need to do, and most other places don’t do, but the core values are not TC-specific at all: they are as close as we have yet got to the ‘essence’ that the WHO directive identified. And with that set of ten values we have established a different sort of quality process – what we call the ‘Enabling Environments Award’ – which is as applicable to a prison or office or school or church or business as it is to a therapy unit. It’s going down very well in the criminal justice sector – and we’ve just had a launch of it for the health sector, with endorsement by RCPsych for it as a potential solution for lack of compassion in the NHS, in the wake of the Mid-Staffordshire crisis.

Finally, a few wilder ideas on the fringes of enabling environments – which are to a wider RCPsych initiative called the ‘Positive Environments Framework’, to our tiny social enterprise called ‘Growing Better Lives’ and the Institute of Mental Health in Nottingham’s ‘Social Futures’ centre. These are just vague threads at the moment – and I have no idea if they will come together or not, but quite a lot of us are trying…

Greencare is the inclusion of nature in therapy programmes – and combined with TC-type groups which our social enterprise runs in a yurt at an environment centre between Slough and Uxbridge, they seem to be very acceptable and effective. We’re also thinking of using permaculture and transition town ideas to give it a more than just ‘group therapy plus horticulture’ by itself.

A psychiatrist colleague in Columbia, Alberto Ferguson, is in his seventies and has run TCs all his life. He has experienced a similar TC trajectory to what has happened in this country: first residential, then day units, then without dedicated premises. To me this shows that ‘the TC in the head’ matters more than the TC in the building – and in his small town near Bogota there is a widespread understanding of TC-type social cohesion. Ex-patients now run groups there to bring together families and individuals involved in the drug conflicts, to make reparation and have the different factions come to some understanding of each other.


So, to finish off, and take these ideas back to our 2-hour per week TC in Slough. The phrase a few of us are putting about – perhaps a bit mischievously, but only half tongue in cheek – is ‘Slough as a Therapeutic Transition Town’. Instead of the ‘TC’ being seen as the two hour group we run every Tuesday, that is just one hub for all the other therapeutic things people can plug into: from mindfulness and psychoeducation groups run by the NHS psychologists, to a very successful mental health choir, to greencare in our yurt, local sports for health groups, a therapeutic digital photography group with Arts Council funding. People’s experience is then of the whole range of activities - delivered by all sorts of different organisation – as being THE therapeutic community. Yes, I am talking about poor old Slough – if you believe that is possible, you’ll believe anything. But we’re going to try!

NHS morality and care based on compassionate values

It is difficult to disagree with the main thread of Cox and Gray's argument (1), that the NHS as a whole has lost its grip on being person- centred in any genuine way, amidst the industrialisation and authoritarian managerialism of the modern NHS. However, I would take issue that the College Centre for Quality Improvement (CCQI) is being idle about the matter.
For over twelve years, I have worked with CCQI staff to set up and develop three projects to promote exactly what Cox and Gray are asking for: robust systems of quality assurance and quality maintenance which focus on the emotional experience of the patients in their particular treatment environments. The Community of Communities quality network (2) for therapeutic communities started in 2002; the Enabling Environments award (3) (which is suitable for any setting) was established in 2009; and the National Enabling Environments in Prisons project began to improve relational-based practice in participating British prisons in 2009. All three projects continue to flourish, and more are planned.
The Enabling Environments award is based on a set of ten value statements which define 'relational excellence' in work environments. These value statements have been processed to form ten standards, each with several criteria for demonstrating that they have been met. Naturally, compassion and the quality of relationships are at the centre of the expectations. The standards are measured by submission of a portfolio - for which we have designed a flexible and hopefully enjoyable process, rather than a persecutory inspection. Rather than being part of the regulatory burden that many units nowadays feel, our experience to date is that participants take great pride in the process and receiving the resultant award. It is important to note that the existence of this award was prominently mentioned in OP92: "The Enabling Environments Award recognises that good relationships promote well-being, but that many organisations and groups fail to address this aspect of people's lives". It therefore already forms part of the College's response to the Francis Report.
Unfortunately, the response from NHS organisations (mental health and others) has not been encouraging - and the award is much better used and recognised in the prison service and all sorts of different third sector units. I believe this may be caused by a deeper malaise in the NHS, very much in line with what Cox and Gray are arguing in their paper. In short, the NHS is being run with a competitive business model to such an extreme and aggressive extent, that 'soft' values such as empathy, emotional intelligence and kindness are given no force.
Related to this, it is worth mentioning that the Institute of Group Analysis, alongside other organisations including RCPsych, are running a six-month listening exercise to gather information from staff across the range of NHS professions and specialties (4). When the information is collected and collated, it will be used to negotiate with politicians of all parties in advance of next year's general election. As Cox and Gray argue, this is a moral question - and a profoundly important one for all of us who want the NHS to survive in a form that we can once again be proud of.
Yours sincerely


Rex Haigh, Consultant Medical Psychotherapist


References:
1. Cox J and Gray A, The College reply to Francis misses the big question: a commentary on OP92, Psychiatric Bulletin, August 2014 38:152- 153
2. Haigh R., & Tucker S. (2004). Democratic development of standards: the community of communities--a quality network of therapeutic communities.Psychiatric Quarterly, 75(3), 263-277.
3. Johnson R., & Haigh, R. (2011). Social psychiatry and social policy for the 21st century: new concepts for new needs-the 'Enabling Environments' initiative. Mental Health and Social Inclusion, 15(1), 17- 23.

4. http://careers.bmj.com/careers/advice/view- article.html?doi=10.1136/bmj.g5185 (due to appear in BMJ print edition 23 August)

Saturday, 29 November 2014

British TCs for Italians

And so to Rome again...
To the second conference of the international network of democratic therapeutic communities, where Jan Lees and I have been asked to explain what British TCs are all about to an Italian audience.
It was another standing room only conference, at an adolescent TC about five miles out of the centre of Rome - but clearly, from the state of the decor and furnishings - a state sector TC.
But a good day seemed to be had by all.

Here's our prezi:  http://tinyurl.com/uktctalkrome

And the text, which we needed to have pre-written for the live interpreter:



Therapeutic Communities in the UK 1942-2014

Slide 2
Although TCs in the UK can trace theoretical and philosophical roots back several centuries, and across countries, the British Democratic Therapeutic Community Model is considered to have developed in its current form during the Second World War, with the work at Northfield of Bion, Rickman, Bridger and Main, and Maxwell Jones at Mill Hill.

Until recently, there were two models of TC operating in the UK – the British democratic therapeutic community model, and what was once known as the American model – also known as concept-based, and hierarchical TCs, but now widely referred to as addiction TCs. In the past, these models were regarded as very distinct, but more recently they have begun to become more similar – democratic TCs are increasingly treating people with substance misuse issues, and forensic histories, and addiction TCs are increasingly treating people with mental health as well as substance misuse issues. Rex and I named these cross-over TCs ‘Fusion TCs’, in a paper we wrote for the TC journal in 2008, and the similarities and differences are discussed at length there.

Slide 3
There are seven types of TC in the UK. There are mental health democratic TCs, which are part of the NHS; there are mental health democratic TCs, which operate in the not-for-profit sector; there are democratic TCs in the Prison Service; there are TCs for children and young people, etc., and residential schools, run along modified democratic TC principles; there are TCs for people with learning disabilities; there are addiction TCs; and there are other ‘lifestyle’ TCs, which include intentional communities, faith communities, greencare etc.

Slide 4
A we have already mentioned, British democratic TCs have their roots in a number of fields – in the ‘moral treatment’ ideas and practice of Pinel in France, and Tuke at The Retreat in York; in the ‘progressive education’ field, with the work of Homer Lane, David Wills and A. S. Neill; in the experiments in rehabilitating psychologically wounded soldiers in both World Wars, but particularly Bion, Rickman, Main, Bridge and Jones, and after the war, with the founding of Henderson Hospital by Max Jones, which became de facto ‘the British democratic TC model’; the setting up of HMP Grendon – the only prison to have therapeutic communities, and no other prison provisions; the Cassel Hospital, set up by Tom Main; and many others all over the UK.

Slide 5
The British democratic TC model was based on, amongst others, the following principles: it was to be an anti-medical model; hierarchies were to be flattened, and it was to be as egalitarian as possible – no uniforms, no name tags, no deference to rank or status; everything that happened in the TC was to be available for treatment, and to become part of the treatment – Jones’ ‘living-learning experience’ in the ‘here-and-now’; there was to be a constant ‘culture of enquiry’; there was to be shared decision-making, based on the democratic principle of one person, one vote; peers would be therapists for each other, and taking this therapist role was part of the treatment; in its purest form, there was to be no individual therapy, and all treatment would take place in large and small social and therapy groups. Rapoport, in his study of the Henderson Hospital – the Community as Doctor - in 1960, suggested there were four themes to the principles and practice of the British Democratic TC – permissiveness – initially at least , tolerating most behaviours from TC members in order to gain a picture of them and their difficulties; reality confrontation – to then face TC members with their behaviours and the effects on others, and help them consider other ways of relating to others; democratisation – allowing TC members to be actively involved in the day-to-day running of their TCs, and to take roles related to these tasks, which would increase in the level of responsibility over TC members’ time in treatment; and communalism – whereby all tasks – whether treatment, work or social, were shared amongst all TC members and staff, and were done together – including cooking and eating, and cleaning the loos.

Slide 6
TC fortunes have oscillated considerably over time. The 40s saw the beginnings of the British democratic TC; the 1950s saw the development of social psychiatry, which Max Jones argued was an extension into the community of TC ideas and practices; the 1960s saw the development of the anti-psychiatry movement, which fitted well with TC principles; and many TCs were set up in the 1960s and 1970s. However, by the 1980s, because of economic pressures, and an emphasis on individualism rather than community and society, TCs began to be closed. The 1990s saw the closure of nearly all NHS residential democratic TCs – there are now none left; however, the 2000 (noughties) saw some growth in prisons TCs, and other TCs through the National PD programme. Although modified TCs – especially day TCs - had been around for some time, in the 2010s their potential has been developed and expanded.

Slide 7
These changes, and particularly the closure of residential TCs, have led to the development of what we refer to here as ‘reduced dose’ TCs, particularly in the NHS. The 5-days a week – day TC - had been around since the 70s, operating from 9.30-3.30, Mondays to Fridays, and some British TCs adapted and changed from residential to day TCs, which helped them survive longer. However, even these struggled in times of economic stringency, and the desire for quick, cheap fixes, so many of these were reduced to 3 days a week, which allowed staff two days to do other activities, such as assessment and preparation groups, which were set up to try and improve retention. Since then, and largely as a result of the National PD programme in the UK, 2 day and 1 day mini-TCs, or 1 day and one out-patient group, have been developed. Latest variants include TCs which only last for 2 hours a week – called the micro-TC, with an argument that the TC is carried in the head, but also many other activities happen during the week, but without staff present.

Slide 8
Hub and Spoke TCs came about as a direct result of the National PD initiative, with its exhortation to be more creative with services, but particularly to try and increase access to services, particularly in more remote areas. The hub is a central TC – usually for 2-3 days a week – in a large town or city. The ‘spokes’ are one day a week TCs in several smaller towns. The same staff work in the TC hub and in the different spokes. This helps make therapy more accessible across a wider area.

Slide 9
The National PD Programme also prompted further creative adaptations to TCs – ‘itinerant’ and ‘virtual’ TCs. Cumbria developed a TC which met in a rural area for one weekly community day, and for the rest of the week, the community participated in an on-line moderated secure group. Edinburgh service users set up a purely virtual TC – it was an on-line community only, with agreed rules, like other TCs, together with occasional social activities.

Slide 10
Since 1978, the British Association of Therapeutic Communities has run ‘transient training TCs’, and for the last 20 years they have also helped run these in Italy. These TCs are 3-day, stand-alone, residential TCs for TC staff, to give them a living-learning experience of what it is like to come into a TC as a member. They are facilitated by experienced TC staff, and involve intensive group work – community meetings, small therapy groups, cooking groups, and creative and social activities. Like any TC, the whole group is responsible for what happens in the TC, including food, leisure time, choice of small groups, and what to do in case of crises.

Slide 11
We also believe that there are other treatment environments currently being developed in Britain which are not directly organised as TCs, but where the providers and staff have a ‘TC in their heads’. These include therapeutic environments; PIEs – psychologically informed environments for homeless hostels; PIPEs - psychologically informed prison environments - for prisons; and therapeutic child care; all of which are now being quality assured by the British Royal College of Psychiatrists. All of these are called Positive Environments, which is a new, beginning initiative, again within the Royal College of Psychiatrists.

Slide 12
With continuing adaptations and modifications of TC provision in Britain, I became clear that Rapoport’s themes were becoming out-dated, and that there was a need to develop a new theoretical basis that could cover these changes. It needed to be based on what were currently felt to be the necessary developmental experiences needed by TC members (based on various psychological theories), and particularly that we all need to experience primary emotional development for good mental health. What we recreate in a TC is secondary emotional development.

Slide 13
In 1999, Rex Haigh published a chapter in Therapeutic Communities. Past, Present and Future, called The Quintessence of a Therapeutic Environment – Five Universal Qualities. This work was partly an attempt to update Rapoport, but also to distill the common factors of any TC or therapeutic environment. These five universal qualities were defined as attachment, or encouraging a sense of belonging, and helping the patient reconstruct a secure attachment, so these can be used to bring about changes in relationships and patterns of behaviour; containment, or creating a culture of safety, of holding and of boundary-keeping, whereby difficult experiences and feelings can be tolerated and processed; communication, or a culture of openness – making contact with others, talking about experiences and feelings, and being able to symbolise them, and feeling understood, and building relationships; involvement, or a culture of participation and citizenship, and interdependence – the living-learning experience, where everything that happens can be used to therapeutic effect; and lastly agency, or a culture of empowerment, particularly in relationships, where the patient is their own expert, and a therapist for their peers, as well as being able to take positions of authority and responsibility, and make decisions about their treatment and how it is delivered.

Slide 14
Another new development in the TC field in Britain in the 2000s (noughties) was the development of the Community of Communities project, for quality assurance and improvement in TCs. This provides a national peer review process, which is more in keeping with TC principles and practice. Standards are democratically derived through representative groups of TC staff and service users, and are regularly reviewed and change by these groups; TC staff and members visit each others’ TCs and review them, and the reviews are reported back to an Annual Forum. This peer review process has now been rolled out through all the Royal College of Psychiatrist quality improvement networks, and covers many types of TCs as well as other therapeutic environments which are not pure TCs but any TC member would recognise elements of the environment.

Slide 15
The old asylums of the 19th and early 20th centuries in Britain used to provide farm working or horticultural therapy as part of their treatment programmes. These elements of treatment largely disappeared with the closing of the asylums, but recently have been undergoing something of a revival as greencare. Greencare is based around a relationship with nature and the earth, involves horticulture and farming, as well as animal therapy, and the use of therapeutic spaces. Greencare is increasingly being taken up by TCs, as well as many other treatment services, as an anti-dote to the industrialisation and capitalisation of mental health. For example, this year a horticultural unit in Cumbria has started a one day a week TC alongside their huge greencare project – 10 acres of fruit and vegetables. Rex and Jan are also directors of Growing Better Lives, a greencare TC project, based in a yurt near London.

We think all these developments demonstrate the creativity and adaptability of the TC as a mode of treatment in Britain.

Friday, 21 November 2014

The First Enabling Environments Annual Forum

Was a great day - but I haven't got any pictures or text or presentations or videos to put here yet.

Monday, 17 November 2014

Rethink for PD

I don't remember quite why I agreed to go to deliver a free three hour seminar to several people at Rethink HQ on why PD matters and how it is different from most of the rest of mental health, but the view from their seminar room alone was worth it. We even had to take our own sandwiches.
Unfortunately, because it was completely unscripted and unprepared, I can't remember anything that was said - although I have a vague recollection of getting quite excited, being rude about the government's mental health policy and using a couple of swear words. 
But by the end, everybody seemed happy and appreciative.
An odd afternoon, but I hope they end up doing something sensible about PD - they certainly seemed to get the point. But they are one of those big corporate NGO-type organisations - so you never can quite tell.