Wednesday, 6 August 2014

The toxic culture in the NHS

A few random thoughts in warming up for the forthcoming big NHS campaign:


·         One of the most important principles of any therapy is to establish an environment which feels emotionally safe (free from extraneous anxiety) for its participants – and this is not the case for many people in the NHS now.

·         In the NHS this is a task for managers nowadays, but they are not succeeding at it – probably because they do not feel safe themselves.

·         Professionals do not feel trusted to do anything apart from what they are asked – or told - to do.

·         Staff who feel exposed and in fear of criticism will not function at their best; some will crumple under the strain – and become unable to work. This leads to high levels of long-term sickness and early retirement on medical ground.

·         Working in the NHS has many inherent anxieties (including uncertainty, death and limited capabilities of medicine) – to add a massive tranche of ‘governance anxieties’ with threats about matters such as corporate risk and policy compliance is intolerable.

·         When professionals feel disempowered – by having little control over the way they work – primitive mental processes will lead to behaviour that will undermine the enforced changes.

·         A culture of ‘zero tolerance of human frailty’ (for example) is logically equivalent to one of infinite intolerance!

·         Positive efforts to promote healthier working environments (such as the Royal College of Psychiatrists’ ‘Enabling Environments’ project www.enablingenvironments.com) receive little attention when the focus is all on fear, blame and keeping out of trouble.

·         Authoritarian managerialism’, without compassion, empathy or psychological understanding of the emotional needs of the workforce, seems to be the root cause – and comes from the tone set at the top of the organisation, and by its political masters.

·         The cause of ‘authoritarian managerialism’ itself is probably modern management’s need to have certainty, which is impossible in health – but is seen as desirable in business. Hence rigidity, lack of creativity and spontaneity, and policies for everything.

·         Other models exist, such as ‘therapeutic communities’ in mental health – where ‘us and them’ power imbalances (which are more a consequence of commercialisation than medical arrogance nowadays) are minimised through detailed attention to psychological factors and open communication.

Dates: 20 September, 8 November, 24 January (London); Others in regions to be confirmed; Launch of declaration 28 March.


Watch the Careers section of the BMJ for more details.

Saturday, 26 July 2014

Life on the Magic Carpet

All week I had been sitting on a sensible conference room chair, on the hard glazed tiled floor, looking slightly enviously at the antics on the ‘magic carpet’, at the front. I think it’s about 3m x 6m, cobalt blue background with symmetrical geometric floral patterns in carmine, mustard, black and white, with a coarse weave. Although a bit gaudy, it looked like an almost sacred space on which much of the real business of intensive physical support took place. I noticed that, backstage, they had a collection of rugs, sheets and very soft pillows that were brought out from time-to-time.
At its fullest, I counted thirty seven people on the carpet, including a baby, a toddler, probably a dozen children, twenty-odd adults, and two dogs (the only concession to greencare!).
Detail from the Magic Carpet
But far more interesting than the brute facts was what was happening on it – it seemed to have a whole sub-culture of its own. It was the way in which transient physical contact was continually happening – and wordlessly defining and delivering immensely supportive non-sexual, but very intimate, short term physical relationships. So, to try and be as objective as I can about something so fluid, dynamic and wordless, I shall start with a ‘hierarchy of closeness’ which I soon observed. But of just what was it a hierarchy? Several answers to this crossed my mind over the week – including
·        familiarity with the method (perhaps like the in-crowd and the newbies);
·        how far people had gone in the ‘transition’ process (the more ‘transitioned’ being much more active on the carpet);
·        similar, but with those I saw as ‘staff’ being much easier with using their bodies there;
·        how much ‘space inside them’ people had to offer support – and on the other side of the coin, whoever was most needing of support (the physical support itself could take place in the conference chairs, with people sitting either side, in front and behind - but more commonly happened on the carpet. In fact, people were often led from their chairs onto the carpet by a couple of others when they were looking particularly upset or agitated);
·        how comfortable people were with touching others spontaneously and without explicit permission – including cultural factors (it is certainly not very British behaviour!), age, gender, physical characteristics etc;
·        how comfortable people were with their own bodies.
·        And probably plenty of other things beside.

Life on the carpet
So, what did this hierarchy look like? I'm sure academics and social scientists have done this with far more scientific rigour - but I just wanted to try and capture and understanding of it from being almost in the midst of it, though slightly on the sidelines. Also, I wanted to find a way to communicate it to others back home - in a way we can think about if to, and how to, use it in our own programmes. And I had plenty of time sitting in Bari airport waiting to board my delayed flight home!

Starting with the least connectedness, this is what I made of it:
(1) the least involved were individuals sitting there, not in contact with each other, cross-legged (1a) or legs in front (knees bent (1b) or flat in front (1c)) watching whoever was talking at the time. When a bit more at ease, or familiar with the ways of the carpet, people would become recumbent, though still without any contact with each other:
(2) lying back on an elbow, left-lateral or right-lateral (2a), or lying flat on their back (2b). That’s pretty much all you can do by yourself, so the next levels of the hierarchy introduce touching:
(3) simple touching, such as hand on shoulder, head, foot or back (3a) – just for a second or two; (3b) sustained for a few minutes or more.
(4) as (3), but with gentle continual caressing, stroking or rubbing.
(5) Stroking cheeks, caressing hair, or rubbing head (the latter being more common with children) – without eye contact (5a) or with short eye contact (5b) or long eye contact (5c)
(6) The next level up the carpet hierarchy which I observed, and thought was a significant step up the hierarchy, was continuous contact of big areas of the body. It seemed to have numerous variations: (6a) sitting back-to-back, facing opposite directions; (6b) sitting side-by-side both looking the same way; (6c) holding hands, fingers together; (6d) holding hands, fingers interlaced; (6e) including embracing, arms round shoulders or waists; (6e) sat behind or to either side, embracing or hugging; (6f); ditto, but also including having faces very close together or; (6g) touching. Then moving on to (6h) head resting in the other’s lap (6i) lying together with full contact between one person’s front and the other person’s back. Small children would often also go on to full contact front-to-front (6j), but I assume that didn’t happen at all between adults because of its sexual implications. However, complete entanglement at all sorts of angles and postures (only possible for children or young people with considerable physical supplenesss) did happen – and probably represents (6k).
The next level up the hierarchy, (7), would be to add movement – such as caressing or stroking – while people are already in that continuous physical contact.
Kissing – perhaps (8) – is hard to place in this hierarchy, because it fits in at almost all the levels above (2). Again, if one wanted to describe a kissing hierarchy, perhaps it could be described as (8a) air kisses; (8b) lateral cheeks; (8c) forehead, nose, chin, shoulders, neck, back; (8d) lips (but never prolonged or remotely sexual).
If this scale continued, one might well expect (9) to include erogenous zones and (10) to be sexual intercourse – but, interestingly, this never looked or felt remotely likely. To the ‘northern European eyes’ I mentioned on the first day, it’s hard to say exactly why not - but I think it’s an unspoken combination of trust and respect (‘I trust you that this is not at all about sex’), purposefulness (we are here to support each other towards better health), as well as a sense that ‘something more important is being done here’, and that sex would confuse or even spoil it. It was also seen in the almost complete gender-blindness with which people did physically support each other – which was only different when the particular circumstance required it (such as a man needing male support in a tyrannical mother discussion, or a woman needing to understand what support from a good father felt like).




After the long-distance people had said their goodbyes, the carpet was looking a bit empty – so, feeling that I had missed out on something that might be important, and rather than sitting in the conference chairs, I thought I would summon up the nerve to give it a try. It was fine - I lasted there until the final review finished at 0025 on Saturday morning. For the first hour or so, I was happy with (1) and (2) – slouching around on the carpet like you might do in front of the fire or TV at home. But then, as people came and went, there was quite a lot of symmetrical touch (3), brief caressing (4) and long big goodbye hugs.

Hugging is another important part of it all – though they obviously didn’t all happen on the carpet - anywhere in the hotel was fine. In the conference room, there was a frequently used ritual which was both playful and sincere. Whenever somebody was given a hug in front of everybody, for something they did or said, everybody started applauding, and then slowly shouting out ‘uno... due.. tre... quattro... cinque... sei... sette... otto... nove... diece’ (also sometimes done in English or German) - usually up to ten but all the way to twenty for particularly special ones. I got one of these when I clambered out of the swimming pool, fully clothed and dripping wet, at the end of the last night party...

When I was lounging on the carpet though, the ease of it all felt like it differed with who the contact was with, and I expect this is not how it should be. For me it was also riddled with typically neurotic English doubts like – ‘am I OK to be doing this?’; ‘will they think I’m being presumptuous?’; ‘am I doing this right?’ and numerous similar concerns. But – obviously with the worrying head rather than the open heart - the big question for me was what were the signs and signals that allowed, maintained or escalated it. It was easy to work it out for the times people were in visible distress – talking about emotional subjects, difficulty speaking, tearfulness, as well as the more overtly angry, aggressive and violent outbursts: people just quietly and compassionately moved over to people and offered them the physical support thy needed. Indeed I experienced this several times myself when I was speaking or clearly moved – if I was faltering, or talking about strong feelings, one or more people would almost magically appear next to me. And my experience of it was entirely caring and loving – with reciprocal gratitude and appreciation - although a little embarrassing for my English propriety and reserve!

Back on the carpet, when I was lying down looking at the ceiling, there was one member of the group with whom I felt that I had established a particularly easy relationship, who came to sit nearby. So I (mostly consciously, wrongly thinking through the things I mentioned above) decided to seek that comfort and connectedness of physical contact – and moved my head into his lap (6g, above). After a few minutes of mutual caressing and contact, the active situation of the group moved on – people moved around, and I returned to sitting cross-legged. So although that was probably my furthest excursion into this world of impromptu physical support, it did feel powerfully meaningful; you could easily describe it using TC words like ‘belongingness’ or analytic ones such as ‘containment’.

But, all in all, I couldn't fathom the ‘rules’ for it – and in a very immediate and emotional way it transcended any strictly objective analysis like that. When I first arrived, I found the amount and intensity of it all shocking and energising in equal measure – and can quite understand why people run away and subsequently denigrate it (based on fear of closeness, of course).  But, seeing how genuine and caring this intense physical contact always was – and how utterly authentic and lovely everybody there seemed to be – I really think it needs to be taken seriously as a serious therapeutic intervention, in the right setting and circumstances. Hence my trying to make sense of it in this way in this blog – but please DO post replies if you have any particular thoughts.

Finally, to return to abstract theory, I believe it is absolutely connected to pre-verbal life – both ontogenetically (as we develop ourselves, from babies needing nurturance) and phylogenetically (as we have developed as a species – with the evolution of sophisticated cortical function, which many aspects of modern life have wrongly championed over limbic ones). We forget, suppress or ignore our emotions – and deeper numinous and spiritual experiences - at our peril.

Most psychotherapies recognise this, but some do not. But I have said enough about this before!

Just a thought about greencare here. One thing I often say is that people with severe borderline conditions very often trust animals much more than they do humans - obviously because they have been so badly let down or abused by humans in their past. They get great comfort from looking after animals, and are very physically free with them - as indeed are most people. This can be a very useful precursor to trusting humans enough to talk and start exploring their experience therapeutically - I well remember a mute and deeply depressed and hostile young woman in a TC who came alive, with almost an inner radiance, when she was with animals - but returned to her impenetrable and mute sullenness in the community meetings. But over time, step by step, for example talking to her when she was with the animals, she was able to engage in the therapy. But this process - of doing the comforting physical contact with humans - seems to be very effective in short-circuiting the need to relate to animals, and very quickly developing an uncanny level of trust between people.

So, lastly, a few words of thanks for those who made this remarkable experience possible. It all started with with Enzo Bellomo, the Italian cardiologist I met in London a couple of years ago, when I was speaking at a James Naylor Foundation event. After a while, he came to see what we are up to in our greencare project and TC in Slough, and introduced me to Mariano Loiacono at a small seminar I arranged at the Royal College of Psychiatrists. When I was then invited to the intensive week, it was like a seven days of white space in my diary – where I didn’t know what I would be doing, but knew that I wouldn’t be doing anything else. For that white space – which turned out to be such a nurturant oasis in my overbooked symbolic-rational schedule – I must give all my heartfelt thanks to Dr Mariano Loiacono and his amazing team at the Fondazione Nuovo Specie Olnus.




Friday, 25 July 2014

Closing the wound in the belly

I only have one pair of shorts with me, and thankfully they had dried out by this morning.

The order of the day is the reviews, also called 'Balancing' - and it means hearing from everybody about their experience at the intensive week. I had been warned that it was such an important part of the whole process that it took priority over meals, bedtime, and everything else. Previous last days, we learned, had not finished until 0400 on the Saturday. At least my plane home isn't until 1635!

As is the way of things here, the first thing to do was celebrate - and that was about thanks and celebrations to everybody who had helped with the organising and conducting the groups. Numerous people were carried round the room on the shoulders of fit young men and women, to dramatic music and racous applause - ending with very heartfelt adulation of the maestro himself. Then it was the turn of the other English guests and myself to be thanked for our participation. Mine included the showing of a rather embarrassing video of last night's swimming pool incident! But the warm and genuine gratitude clearly went both ways; I expressed how I felt that I had received a gift that I would take home to England, and try to grow it there.

After a very powerful video of an orchestra playing a fugue of  'Ode to Joy' in an Italian Piazza, we had a few minutes of organisational business. Mariano explained how his retirement and ultimate death are approaching, and the work needs to be sustained beyond that. He made it very clear that the method is not him - but is the people involved in its numerous local and regional activities as well as the central organisation; it will change and develop according to them and their vision.

Various people, most of whom are here, are helping in various roles with the 'Fondazione Nuova Specie Olnus', which was formed three years ago to coordinate and promote development of the method (www.nuovaspecie.com). Economic times are hard, with
The Snail and Quadrangle logo
Mariano supporting much of the work with his own money, and all the people I have identified as 'staff' work for nothing. They did have some government support in the past – but this has disappeared in the recession. They make a small amount of money from the sale of books - and they will lose their base and space at the hospital in Foggia next year. So they are fundraising, hoping to buy and develop a farmhouse and land nearby, in which they can hold the intensive weeks. An architect has drawn up plans for outdoor group space and a building for dining and other activities - so this is one of their main hopes for the future.

In fact the reviews started with an architect, who eloquently described the way in which the surroundings affect us, and with the cycle of the seasons> Although  which I was rather enjoying. But he got a firm rebuke from the chair – as needing to talk in feelings, from the heart, rather than intellectualisations from the head. Then a succession of others took to the chairs at the front - with the usual casual agglomerations of supporters. Sometimes the encounters were aggressive, and even physically violent - with the participants being kept physically safe with vigorous restraint from those around them; in others Mariano had to work hard to generate the passion and energy - like when he spent a long time trying to get a young boy to yell 'vaffancoulo' at him.
'Tell me to FUCK OFF'
The pattern of what was happening was difficult to understand at the time – as some of the encounters seemed needlessly severe – but it was only by discussing it directly with Mariano the next day that I cottoned on. His personal manner – which comes across to sensitive English eyes as somewhat brutish and callous – is deliberately used in the context of long-term relationships with these families, with a shrewd and perceptive judgement of what they need and what they can take (widely acknowledged by the participants) – all of which is dressed up and concocted in brash Italian humour (which often left the interpreters quite lost for words – and me completely in the dark). 

It is also to do with the structure of the week – and the whole Friday event is to ‘close the wounds in the belly’ that may have been opened up during the week with care and humour. Importantly, everybody there gets the opportunity to be in the hot seat – as part of the process of assessing how everybody is, and ensuring they are not leaving without expressing their feelings. It is an important part of the rhythm of the week – with the crescendo rising to the Wednesday morning ritual, with deliberate expression of angry and negative feelings on Thursday and this to round everything off on Friday.

So this is what the whole week looked like:

Morning
Afternoon
Evening
Sunday
0900 - 1700
Trip to Gargano National Park and the seaside
1800 - 2030
Introduction session
Monday
0930 - 1330
Dynamics
1530 – 1930
Dynamics
2030 - 0030
Birthday party
Tuesday
0930 - 1330
Dynamics
1530 – 1930
Dynamics
Music and singing round the hotel piano
Wednesday
0930 - 1330
Ritual
1530 – 1930
Theory
Music and singing round the hotel piano
Thursday
0930 - 1330
The Ring
1530 – 1930
The Ring
2100 - 0030
Last night party
Friday
0930 - 1330
Reviews
1530 – 0025
Reviews
Saturday
1000 – 1300
Debrief with Mariano and team
1635 BRI-LGW


Thursday, 24 July 2014

The Ring

I don't know what the other hotel guests make of us lot - drifting around the lobby, coffee and and swimming pool - arm-in-arm, in huddles of cuddles, or randomly accosting each other for kisses - and rarely passing each other in the corridors without deliberately touching each other. All with a remarkably easy familiarity. We must look like beings from another world! If it happened in London, I am sure they would either throw us out - or call the police and have all our emails hacked...

Mariano Loiacono
Speaking the unsaid
Today's groups are flagged up as specially for family conflicts - and to specifically voice things that have previously gone unsaid. This is 'The Ring' - and the analaogy with boxing or wrestling seemed to be rather relished by those who had been here before. After mopping up some unfinished business from yesterday, the stage was set. Mariano himself conducted it all, sitting on a high chair at the front of the carpet. He calls families (at least two, but sometimes four or five members) to come and sit on the carpet at his feet, and several others whom he thinks would be good to support them. The family members sit facing each other, in the blue corner and the red corner, as it were; the rest of the ring is made up by the supporters, sitting or lying on the carpet in an intimate huddle, all around the family.


Most families spend half an hour or so in the ring, although one took over two hours - and made us all late for dinner. The sequence is usually the same

  1. One of the family is invited to say the things they have been unable to, to one or more of the other family members. With full physical support from those around.
  2. Mariano commentates and reflects, I think in the style of 'structural family therapy' - often making extremely provocative suggestions (for example 'you three should get together and all kill yourselves')
  3. The other family members respond - ideally with feelings rather than thoughts - again, with as much support as they need.
  4. Mariano again intervenes
  5. Any supporters wanting to speak are invited to contribute - again, more from the heart than the head (interestingly, they are usually better at this than the family at the centre).
  6. Mariano summarises, and usually suggests simple structural interventions to try (for example, keep apart for a time, leave home, talk more about feelings together)

All interspersed with rather less music, dancing and light relief than on previous days.

The Celebration Cake
Not much spare time today - we didn't get to dinner till 2030, and the last night party was due to start at 2130, in the garden. The party - for an alcohol-free zone - was as wild as they come: ridiculously energetic dancing, impromptu rap bands, toasts with an enormous celebration cake (for the first ever international intensive week) and a dance tableau expertly choreographed by Anarita from London with the twelve best female dancers in the group. It finished, mush to the hotel management's disapproval, with a vote being held for who next was going to be chucked into the swimming pool. I thought I has escaped when the manager came out to ban us - but sadly, he allowed one last victim to be chosen. And guess who that was to be!

However, as a fully clothed wet dripping mess, I was able to exact a certain amount of revenge by extreme hugs with whoever I catch!








Wednesday, 23 July 2014

An extraordinary Italian Shamanic ritual

Interestingly, especially for Italian events, nearly everybody was on time for a 0930 start, directly after breakfast this morning. We all went up to the third floor meeting room (see the photo from the day before yesterday) to find our entrance blocked - we weren't allowed into the large group space in our usual desultory and disrespectful way.

Instead, we had to take off our shoes and leave them in the ante-room, form an orderly queue and keep quiet. Can you imagine it! One hundred and thirty people, mostly Italians, being asked to queue and stop talking...

Once the room was ready, a reception committee was formed on the other side of the door - and we were allowed in, one at a time. One of the more experienced group conductors hugged each of us, and then passed us on, by the hand, to the 'reception committee' - which was a gaggle of children just inside the door. One of the children held our hand and led us to our allotted place, with the gaggle of them accompanying each of us. Then the gaggle returned to base to bring the next person in.

Our allotted places were at the end of a large forming circle of people, all holding hands, who were gently swaying to soft Native North American chant music. The chairs has all been put to the sides, and there was a small table in the middle of the room with a bowl of water surrounded by foliage. The whole circle filled up in about half an hour, I think about 130 people; nobody said a word during this time. Some special arrangements were made to accommodate people who did not understand or could not tolerate it - one person near me, for example, needed to be held in a secure hug throughout the process by one of the group conductors. Once the group was complete, we were asked to sit or lie wherever we liked, and were given a short powerpoint presentation explaining the development of the ritual over the 38 years of the method's development. 

It started with an Ethiopian Catholic priest, who ran it as a semi-religious event with a strong Christian and Catholic structure, metaphor and iconography. Later in the group's history (I suspect when the Ethiopian priest died), there was a Zen Buddhist influence with the ritual (which marks the mid-way point of the intensive week event) being based on Buddhist practice and ritual. More recently, it has changed to have a Native North American Shamanic structure, content and process. We were informed that there were no satisfactorily respectful terms for 'Native North American' in existence, which did not suggest its brutal colonisation. So the 'Dancing People' was used, with an explanation based on the shape of the American continents: North America being the male dancer, South America being the pregnant female dancer, and Middle America being where they were holding hands.

As the four elements were evoked in the description of the ritual to come, the auspiciousness of the morning's windy weather was acknowledged and we were all invited to dip our hands into the ceremonial bowl of fresh water and wipe our faces with it. I presume the earth was represented by the hard floor on which we sat, with the fire being the extreme emotions that were to come.
"Dancing on the edge of chaos"

Once everybody had dipped their hands in the water, the main part of the ritual began. We were asked to close our eyes and gently move around he room, to soft 'Dancing People' music. Bumping into people was part of it, and we were to acknowledge them with a short caress or touch, then move on. This must have lasted ten or fifteen minutes before we were asked to remain in contact with whom we bumped into (or move on to choose another person if not happy with our first contact) and start with a deep, long, intensive hug. This is all still with our eyes closed. We were then taken through a routine to slowly explore and caress the whole body of the other person. It started with the head and shoulders, and arms and back. We were then led to the chest and asked to ignore the sexual significance of it, and continue the same process of appreciating and cherishing the other person's physical body through touch and caress - often quite hard, as well as softly. Then we were encouraged to move to the bottom, legs and feet, and finally to the whole person - before being asked to move on again, our eyes shut all the time. I do not know who she was, and never will.

Once everybody was moving again we went through several stages of an intense crescendo – all still with our eyes shut (though that wasn’t absolutely possible in the later stages!). First we were to walk in small circles, and then to choose a direction and move that way whoever got in our way with determination that that was ‘our chosen direction’. Then to change direction, and keep repeating it.

During this time the gentle music faded out and the drumming started. It gradually became faster, louder and more frenzied as our movements become more forceful and determined. The final instruction was to dance as if nobody was watching (and indeed, if all were following their instructions, nobody was watching!) - and be absolutely free to do whatever movements you wanted. 

When I thought that the drumming couldn’t get any more extreme, it did. And then again, and again. We were also now being implored to vocalise - first our names, which soon became increasingly primitive, loud and elemental. I lost my sense of time, and was only limited by my middle aged cardio-respiratory system and general unfitness. But after I don’t know how long, it did stop – and everybody collapsed onto the floor in sweaty heaps – mostly connected to others by minor or major physical contact, with quiet Dancing People’s chants and pipe music playing. After another indeterminate time, the music faded away and we were slowly coaxed back to Wednesday morning in a third floor conference room, somewhere in Italy.

The ritual was the prelude to the ‘transitions’ – where people who were chosen and judged ready by the group conductors – were then invited to undergo the 'transition' process. Closely aided and supported by the group conductors and numerous others, they were led into an extreme emotional state, and then, after the extreme regression, swaddled and slowly supported back to a normal level of consciousness. Two happened in the time we had – both extremely moving and painful to witness – but it would feel disrespectful for me to describe them in any more detail here. Suffice to say that they were very different.

Then another marvellous Italian pranzo (lunch).