Wednesday, 2 April 2014

The end of the road for radical approaches to PD

Two wasted decades?

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

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

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

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

Slumping in Slough

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

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

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

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

Thames Valley Trouble

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

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

But what we got is:

  • Separate NHS foundation trusts fiefdoms, with very little managerial collaboration possible between trusts. 
  • Little appreciation of the particular needs of PD.
  • Very limited genuine service user partnership.
  • Commissioning with no understanding of the social and economic/political context of PD.
  • Managerialism and governance writ large.
  • Severe risk-aversion with a joyless culture of authoritarianism, hierarchy and compliance control.
  • Remoteness from senior management and strategy decisions. 
  • An increasingly biomedical framework for psychiatry.
But, to give due credit, we also got extraordinarily effective and innovative programmes from which many many people have been able to experience transformative therapeutic progress. With extraordinarily committed staff who have all been prepared to 'go against the tide' and suffer he parallel process of alienation from the mainstream.

National Personality Disorder Development Programme Dissolution

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

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

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

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

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

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

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

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

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

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

Sunday, 23 March 2014

Therapeutic Communities in Sicily

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

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

The psychiatric authorities in Sicily also want to forge links with the British ‘Living-Learning Experience’ (LLE) therapeutic community training ( which has been essential TC training in the UK for nearly twenty years now. This has involved close liaison with the British ‘Living and Learning’ team, which already includes two Italians and another Italian-speaking therapist (from Uruguay).
The "regional psychiatric authorities"
Numerous LLEs have been held in Sicily since 1999, twice at Erice, in Caltanisetta, Partenico, and with two based on a converted fishing boat in Trapani  (for training new British personality disorder teams, one from Oxford and one from Nottingham). A formal one-day event, organised by the regional psychiatric authorities, was held in Piazza Armerina, for about a hundred delegates, in 2008. After much work developing their clinical model of therapeutic ‘community in the community’ practice, this was followed by the first LLE for Sicily’s new therapeutic communities at Caltagirone in 2013, and a second one last weekend at Altavilla Milicia, near Palermo.

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

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

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

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

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

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

Sunday, 16 March 2014

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

The Round Chapel, Hackney

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

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

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

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

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

I think that is sufficiently radical to stop there, and reflect on it…
Is this a gig?

Friday, 21 February 2014

Bigged up at BIGSPD

Jolly chuffed about this one - but worried for weeks beforehand about the acceptance speech...
The BIGSPD 2014 Senior Practitioner Award, the glass dagger, presented at Lincoln
But is seemd to go down quite well, in the end.
Here's the text - please do use the blog to feed back, if you like.

I’m going to follow in Nick Benefield’s tradition from BIGSPD last year – by preparing a written-out talk which I’m going to read to you. It’s just about twenty minutes long – so you can choose now to go or stay!
But Nick and I also thought that the field needs a few rants to keep it awake and sparky – so this is a rant. And it’s much easier to get more rants per minute if it’s written out in advance.  Although I might come across rather gloomy and pessimistic in it, that’s not all I feel – a bit like Nick and I have been saying for years, “PD” and proper service user involvement is a fifty year project, and we’re only really about ten years into that.

First, thank you BIGSPD so very much, for the honour of this award: it’s a real delight to have a captive audience to shout at for twenty minutes – I think of myself as a grumpy old psychiatrist nowadays, who was working in this strange field of ours before anybody outside academic circles knew that it was a field. And I’m not really a researcher at all – I’ve definitely got the wrong sort of personality disorder for that - so I think of myself as a clinician through and through. Perhaps I’m a particularly grumpy one because I have been so disillusioned and disappointed with medicine, then psychiatry, then psychotherapy, and now therapeutic communities and personality disorders.

So I’ll start with a quick bit of biography, which takes me back to my first ever encounters with psychiatry. The first things I learned about psychiatry were from elective social science modules I did in my final undergraduate year at Cambridge – where the Social and Political Sciences Faculty was a hotbed of radical and critical thinking – and I was particularly taken with the modules on child development, on psychoanalysis and – surprise, surprise! - on antipsychiatry.

Of course Ronnie Laing was still alive then, and he was guest of honour at the annual Cambridge MedSoc dinner that year (although sadly incoherent with the abundance of fine wine on High Table). But it was with these ideas fizzing around in the back of my mind, that two years later, I was about to start as a clinical student at Littlemore Hospital in Oxford, on Bertie Mandelbrote’s firm, the Phoenix Unit. I had been warned by previous students that this was not somewhere to wear the normal tweed jacket and sober tie (which the standard medical students uniform for psychiatry at the time).

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 met a bloke wearing hardly any clothes sitting on the doorstep smoking a roll-up. Without any words, he casually pointed me in the direction of a large dilapidated room - where I soon had to forget any ideas I had of hospital hygiene, with most people smoking and a thick fog I could barely see across. I expect they would go bananas nowadays if the infection control matron or the health promotion people saw it.

I squeezed into the room between two people’s backs, 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 on the other side of the room 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 about 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, for that’s what I had landed in, 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 – just being human together yet also be able to be fully professional. And I have been looking for it ever since – and (in most settings) been rather disappointed – hence moving from general practice to psychiatry to psychotherapy to group analysis to therapeutic communities to personality disorder. And I’m even disillusioned with them now! My own answer – which I hope will make sense in the next ten minutes – is currently greencare, and maybe even something about nidotherapy.

So – first – why am I disillusioned with therapeutic communities - when they have been my life’s work, and are the places where I’ve come closest to finding this ethical, authentic way of working that first struck me, back in 1980? Maybe the best word for it is that they have become institutionalised – and are losing the power and freedom to be open, to enquire, to question and challenge. The trouble is that this process of institutionalisation is about as inevitable as gravity, when they have to exist in a larger setting and system, especially one that is as authoritarian and rigid as the NHS. We tried to do something to ameliorate it with the ‘Community of Communities’ quality network at the Royal College of Psychiatrists – which I presented here at BIGSPD’s 2nd ever conference in Jersey – as ‘democratically derived standards - an alternative to manualisation’. And although that project is still going strong, but it is becoming increasingly apparent that it is not enough by itself, and it is also becoming somewhat regulation-bound.

Institutionalisation I think has a sibling - which we’ve already heard about from Glenys at the               opening of this conference: industrialisation.  I think it’s the same as what entrepreneurs call ‘scaling-up’. And the thing that inevitably goes with it is disempowerment, and maybe this arises because of the removal from the workers of the means of production, in managed health care, we clinicians have less and less say in who we see and what we do. So we suffer disempowerment – which is of course the opposite of what we try to do for our service users, who we hopefully try to empower.  And, as individual clinical professionals, we have very clearly lost the battle against regulation, manualisation, and maybe industrialisation that will follow it: we are not to be trusted unless we follow explicit protocols, even about how to wash our hands and answer the phone. Even George Orwell couldn’t have made it up! I am now in a state of learned helplessness about it all - to the extent that Steve has twisted my arm in to writing a manual with him to describe how we do non-residential TCs in our Thames Valley services.

Which leads to my other disillusionment with TCs – that they have been misunderstood by people in the research world – when they are thought of as a specific treatment. I believe – and Steve and I differ on this to some extent – that the TC is actually a container for treatment, rather than a treatment in its own right. But the container has a considerable, and I expect measurable, impact on many other things about the treatment – such as engagement, attendance and attrition rates, user-satisfaction, staff-satisfaction and ‘culture’ (of which, more later).

The container also allows people to feel safe - emotionally safe – and this is something that they might not experience if they were just in ‘bare therapy’. It also gives them support from each other in the gaps between groups, and can really provide a deep sense of meaning to hold their different therapeutic experiences together - and this is helpfully from a reflective place that is slightly apart from the therapy itself.
So that ‘culture’ is the catch-all of what it is all about – and I think it’s very close to what researchers in individual therapy call ‘non-specific therapeutic factors’, and what I am forever banging on about as the quality of relationships. It is also what helps to minimise the feelings of ‘us and them’ – which is about attachment and therefore something absolutely fundamental to our experience of the world.

However, ‘making a good culture’ is not as easy as sending people on customer relationship courses, or communication skills training – as it goes a lot deeper, and demands a level of commitment, openness to scrutiny, and personal insight that not everybody is able or willing to give.

And unfortunately, I am a bit of an extremist about these things and I happen to believe that every service or working culture should be an ‘enabling environment’, and that people who don’t want to work in an open and authentic way should go somewhere else. We’re working on this in the more recent project we have set up at RCPsych, with the ‘enabling environments’ quality mark to show that a particular environment meets ten basic relational standards – for how people relate to each other.

Delegates here from the criminal justice sector are likely to  know much more about it than those in mental health – as the new programmes to develop ‘relational security’ in prisons and approved premises are going from strength to strength, with the development of PIPES (psychologically informed planned environments). The development of similar facilities called PIES (psychologically informed environments – but not planned in the same way they are in prisons) is also going well for the homelessness and housing sectors. But no such luck or government commitment in the health sector. They seem to be blind to the power of groups and therapeutic organisational cultures.

So back to TCs, where this culture is the most important factor in: within it, all sorts of therapies can be and usually are incorporated – and more distress and disturbance can be managed, with people being better held in a user-friendly way, than they would be with the bare therapy by itself. But I DO also believe that TCs are effective treatments in their own right – in other words ‘the whole package’ of container plus specific therapy - with the therapeutic meat in the sandwich, as well as with the bread which is the therapeutic environment. That’s what Steve and I are writing up as a manual of the method, as well as the complex treatment that Steve and Mike Crawford are researching in their RCT. First results expected soon, we hear!

But even if that trial is successful in showing effectiveness, I have worries about the consequences of ‘scaling up’ – and how it might well get industrialised and institutionalised into something that is not recognisable as a human-scale and personal treatment, by losing its autonomy and ability to reflect upon, and change, its own processes. I just fear the ‘ooh we can’t do that here, it’s not in the manual’ tendency taking over; in other words the staff and service users’ empowerment to reflect and think about what’s going on, and how it might be done differently, is fundamentally undermined by an authoritarian and non-democratic process of ‘compliance’, or similar. This is what has happened to most of the TCs that were around when I qualified – they became too rigid, or precious, or sanitised, or interfered with – and died. But maybe they needed to.
So that’s enough about TCs and why I am losing faith in them – now to PD. My biggest whinge here is how the world has been taken over by internationally branded, packaged and marketed treatment programmes: the Alphabetti Spaghetti therapies, as I call them. Each with a three or four letter acronym (except STEPPS, which has managed to get away with a very long and strange one), and a product champion from a high powered university, a manual high in the Amazon charts, a few RCTs with at least one respectable meta-analysis, and training courses that sell out like Glastonbury. And every one of them that I’ve come across, I think is great – the ones I know are all based on really sound therapeutic theory, well organised clinical practice, and lots of therapeutic common sense that hardly anybody would disagree with. BUT…
What’s the ‘but’? Well, I have just knocked up five (I like prime numbers!):

Well, first, it seems to reduce the whole serious business of improving therapeutic provision to a horse race, or beauty contest, of who can best market their wares; it does not encourage joining-up and cooperation – but fragmentation and competition, between people who should be working together in fighting bigger threats (like big Pharma and DSM 5! – oops, sorry, I’d better not get onto drugs or diagnosis or nobody will get lunch, or be home in time for tea!).

Secondly, it plays into the hands of commissioners who want everything very simple so they can buy one bundle of xyz therapy at such a price for 500 people a year and one package of abc therapy on special offer, for a thousand people a year. Market forces, managers with MBAs, a bit of sharp project management, and problem solved. But no - we should be telling commissioners, and policy makers, that PD is more complicated and complex than that, and that we (as therapists and clinicians) could come up with all sorts of transformational ways we can make mental health services better – but they can’t do so without thinking about it much more, and getting us involved in that process of thinking about it. But it’s not happening much, as far as I can see.

Thirdly, what I was saying about TCs just now – what happens in therapy is about the quality of relationship than about the specific technique. The Dodo bird verdict, as I remember Glenys talking about it, at Ravenscar, many years ago – “all the therapies have won, and all shall have prizes”. In the PD world, I always think it is something about trust and hope – as opposed to the usual risk and recovery agenda that is so predominant at the moment. But rather than just accepting the Dodo Bird Verdict and continuing with the inter-therapy horse races and beauty contests, shouldn’t we be trying to distil and better understand just what that ‘quality of relationship’ is all about? To be fair, maybe that’s what work like the competencies framework, and Glenys’s rat sandwich, are about.

Next, where is the voice of service users and carers in all this? I don’t mean as token members of various committees, but as equal partners in all stages of development of the field. We have a great opportunity here – there are very many keen and articulate service users who have a much better idea of it feels like to be in a lousy service and a good service than any of us professionals here do - and unless we really take that into account, I believe we will end up with ‘doctors-know-best’ type services that are more likely to annoy the hell out of service users, than do much good. Again, it’s about quality of relationship – something I think we did quite well in the late lamented national PD programme. But thankfully, we still have good representation here at BIGSPD – but I hope the impetus to sustain that last through times of severe NHS austerity. Service users are so much part of the solution rather than the problem.

Finally (you’ll be glad to know), the big one – whose game are we playing?
·        by reducing people’s severe, overwhelming and sometimes fatal distress to a much disputed and stigmatising label;  
·        by reducing the treatment choices to consumer products in the global market place all with their alphabetti spaghetti acronyms;
·        by reducing clinicians’ roles to that of obedient daleks;
·        by reducing understanding and meaning of people’s experience to RiO entries on a risk register?

I would contend that this is the management philosophy of the American insurance industry, and although we are much less influenced by their partners-in-crime the pharmaceutical industry, the neo-liberal economics and its need for growth by the consumerisation-of-everything times we live in. The only way to commercialise relationships is called prostitution – and I don’t think we want to get into that. But because of this inexorable and global process, which I dearly hope is ultimately unsustainable itself, we are at risk of losing the human touch, being micromanaged into impotence, being persecuted by the compliance police - and all going to hell in a handcart. Thanks goodness for our service users – who I think are our only good defence against the tide!

All a bit depressing, really.

But I’ll finish off with my own solution – which is greencare. Vanessa and San did a lovely poster of some qualitative work on our own greencare project, in dear old Slough, it that was up yesterday. Greencare is usually defined as therapy including contact with nature, and it has been described as ‘the antidote to institutionalisation’ and as ‘mindfulness in action’, as well as the themes on the poster. But to me, by working with nature in a very explicitly psychotherapeutic way, we can ensure that we do not fall into the five snags above that I have just feared for PD. It is small, human-scale, not industrialisable, necessarily unpredictable (like the recent weather), and usually spontaneous and creative. But unfortunately, it does also mean that we don’t get any sustainable funding. But we’re working on that.

It almost brings me full circle back to Peter and his Nidotherapy. One reason Nidotherapy appeals to me is that it doesn’t have an acronym – but also that it is a concept rather than a method. I remember saying to Peter at a BIGSPD conference many years ago that I reckoned it was based on group analytic theory – because it didn’t look at the patient in isolation, but was equally interested in the environment around the patient (and that’s also like the figure and ground picture of the Gestalt). He didn’t particularly like that – but now I’m coming back to it. It’s not a commercialisable new brand of therapy – but a change of frame of thinking: from individual to context. That change of frame is what I think greencare is too – not worrying so much about the exact blow-by-blow ‘who did what’ and ‘who said what’ of therapy, but by attending to something that is more about relationships. Relationship between people, and relationship between people and their environment – what goes wrong in those relationships and what things might make them better, or at least a bit better.

Which, sort of, brings me back to where I started – in that crazy circle at Littlemore Hospital in 1980, like something straight out of Cuckoo’s Nest. But I think that set me off on a track that eventually led here – and who knows where next. But thank you very much, BIGSPD, for giving me the Senior Practitioner Award – it has been an honour to be able to rant at you for twenty minutes. And sorry to keep you from your lunch! But thank you again.

Friday, 8 November 2013

Talking in Taiwan (2) School of Nursing, Yang Ming University, Taipei

Risk of the Day
‘The most power one ever’ hit land in the Philippines at 0500 this morning, reported on CNN just after breakfast. Some steady wind speeds of 200kph and over 1000mm of rain in places. And we’re not that far north of the Philippines here, and it was getting a bit blustery yesterday.
Classification:     NAG (natural and act of God)
Control:                Not much (1/4) – but be aware of the weather forecast before you expose yourself
Likelihood:          1 (almost always mid-summer)
Impact:                 3
Score:                   4

Second leg of the High Speed Train – the fifty minutes had disappeared before I got the chance to even half-finish writing my talk for the School of Nursing, due at 1330. And – in Taiwanese hospitality fashion that I’m now getting too used to – Lue’s ophthalmologist sister had invited us to lunch. Ten minutes back at the hotel afterwards to hastily scramble together the rest of the talk, as a Prezi.

Arrived at the talk just in time, to an audience of about 50 – mostly young student nurses. A bit of a technical glitch (almost exactly the same as last Saturday) when they couldn’t get my laptop to connect to the ceiling projector, so had a bit of jokey banter with the audience which seem to relax everybody – or at least it did me, and probably not the frantic technicians who were on their third projector by this time. I couldn’t really do without it as most of the talk was a photo slide show about different aspects of greencare. But it sparked into life and I was off – for about an hour. After the talk we had a good half hour for questions, and what good questions they were too: from ‘how do I start it on my ward?’ to ‘what is the inspiration that people need to get engaged in it?’ to ‘if it is aesthetic, how can you show that?’.

Off to the northern end of the metro to see sunset over Fishermans Wharf from Lovers Bridge in Tansui, and the planes streaking across the purple sky reminding me where I would be in just over 12 hours. Ever willing to pack in a few more activities, we then went to see Lue’s brother in the ophthalmology practice which he shares with his sister – but he was overcrowded with patients, so it was just a quick ‘hello’. Interesting to see how a medical clinic looks though (busy!).

Anxiety then started to rise as my nostrils twitched and Lue led me to sit down in a fast-food joint, opposite but about 10cm away from an attractive young Taiwanese woman who was tucking into a large bowl of rice noodles. It was almost embarrassing to have to watch her expertise with the chopsticks from 10cm away, but I think I picked up a couple of useful tips about how to hold them together, and how to shovel considerable volumes in without dropping it all over the place.

The anxiety was turning to panic as we waited and watched – then it arrived: the challenge was on. Having failed to master the art of enjoying stinky tofu the first time round, I was to be allowed a chance to redeem myself. Lue made it sound even more attractive by explaining that it was in a spicy dish with large intestines. I also found a large vermillion jelloid mass in my bowl, which I thought might be liver – but I was informed was clotted pig’s blood. So – unable to bear the shame and humiliation of a second failure – I dug the sponge-like slabs of stinky tofu from the bottom of the bowl, thought of England and demolished them. By the third or fourth I was almost wondering if I was getting to like them, but I don’t think I’ll be doing an experiment to find out for sure any time soon! Sadly, I was too full by then to manage the intestines and pigs blood – and simply basked in the triumph of my gastronomic achievement.

From there back by metro to the ‘must see’ Shilin night market – dazzlingly bright, noisy and smelly (guess what of!). The food hall downstairs was utterly bonkers – how could so many people be packed into a vast brightly-lit underground hangar with raw food bits of everything imaginable and more besides, mountains of freshly cooked food stacked up in every direction you could look, stalls, cafes, cooks, and swarms of people seemingly all mixed in together ? But so it was; we had a modest bowl of soup and single dumpling.

I have already mentioned a few branches of Lue’s extensive family, and as we were walking off the metro, we met two more of them, who were duly introduced to me. And – just to top the lot for warm and generous gestures to a stranger like me – they insisted I took packet of special spiced pork to have as my supper when I got back to the hotel. Food they had bought for themselves and their families, they gave away to a poor starving wretch like me!

And so, with hospitality overload and gratitude fatigue, and not quite having captured in this blog what Taiwan is really like, to bed. What an extraordinary week, and what amazingly generous and kind people.

New Thing of the Day

The frenzy of the food floor at the night market – and the question to which I need to give serious thought: why are Taiwanese people so thin?