Dr Rex Haigh. Catania, 22 June 2013
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1 Therapeutic Communities in the UK: PAST, PRESENT & FUTURE Dr Rex Haigh Consultant Psychiatrist, Berkshire NHS Mental Health Trust Project Founder and Lead, Community of Communities, Royal College of Psychiatrists Clinical Advisor (to UK Government), National Personality Disorder Development Programme Senior Fellow, Institute of Mental Health, Nottingham University Board of Trustees, Institute of Group Analysis, London Founding Director, The Consortium of Therapeutic Communities Director, Living & Learning CIC Director, Growing Better Lives CIC President-elect, Community Housing and Therapy London Catania, 22 June 2013
2 PAST Outline The need for Community of Communities, 2002 Accreditation, 2005 Government links personality disorder PRESENT Recognition of problems by government Enabling Environments EEs Training LLEs FUTURE Greencare International training International development LAMIs
3 PAST Who are we? What are we doing? What are other people doing? Are we doing it right? Will we survive?
4 History of troubles for TCs Problems around Isolation nobody knew what others were doing Lack of recognition TCs not taken seriously No support from official funders (eg MRC, ESRC) Arguments over the A-word But: Research grants from National Lottery Popular trainings Met requirements for service user involvement and other policy drivers Stubborn, determined and passionate clinicians and ex-service users
5 Induction Day Community of Communities launched 26 October 2001 Friends Meeting House, London 77 delegates From 38 communities
6 Aims a distinctively TC framework for quality improvement a systematic forum for exchange democratic definition of TC-ness, owned by the members satisfactory research definition - as an alternative to a treatment manual a body to influence statutory regulation
7 The first Community Meeting of the Community of Communities, October 2002
8 Stuart Whiteley, Director of Henderson Hospital and founder of ATC
9 David Kennard: psychologist, author, editor
10 Annual Cycle Annual Report The AR analyses the collective performance of the member communities Agree Standards Service standards are reviewed and revised by members Annual Forum Presentation of aggregated data and opportunity for members to get together Self-Review Each community reviews their own service against their standards Action Planning The community discusses ways to improve their service Peer-review The community hosts and delivers peer-reviews visits Local Review summaries Results are fed into a local report
11 MAIN MESSAGE The new quality and review process MIRRORED the therapeutic community process Group process Inclusive network of relationships Regular and agreed structure, clear boundaries Democratic principles Service users at the heart of it; TCs at the heart of it
12 The A word - ACCREDITATION Fear of persecution by inspectors Not developmental and inclusive, but judgemental and insensitive BUT we did it differently Building on existing network of relationships First worked in prisons Then NHS Now not-for-profit services, and all other TCs
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17 The A word - ACCREDITATION Fear of persecution by inspectors Not developmental and inclusive, but judgemental and insensitive BUT we did it differently Building on existing network of relationships First worked in prisons Then NHS Now not-for-profit services, and all other TCs
18 Government Set up 11 PD programmes Many were TCs, others used TC principles Recognised the CofC accreditation in commissioning
19 The UK Personality Disorder Programme 11 new pilot projects new day-tcs in total (3, 4 or 5 days per week) >10 new mini-tcs (2 days per week or less) Also other approaches: 2 managed networks 2 DBT-based Also psychodynamic, CAT, CBT one early intervention with adolescents Includes modifications such as internetbased groups
20 Government Set up 11 PD programmes Many were TCs, others used TC principles Recognised the CofC accreditation in commissioning New structures to replace Henderson Hospital with a number of specialist services for severe personality disorder mostly borderline, not forensic
21 The International Systematic Review: detail of meta-analysis odds ratio
22 PRESENT A headache for the Government, 2013 Mid-Staffordshire hospital FRANCIS report Too many deaths My interpretation: Professionals have been so overwhelmed by administration and bureaucracy that they no longer show COMPASSION or HUMAN UNDERSTANDING of patients emotional needs
23 One solution ENABLING ENVIRONMENTS Started 2009 Using the VALUE BASE from CofC standards 10 VALUES Quality Mark Valid in any social or work setting (church, office, home for elderly people, psychiatric ward, etc) Different process to CofC Portfolio multi media and fun to do! Very successful in prisons at the moment
24 COMMUNICATION SAFETY BELONGING INVOLVEMENT BOUNDARIES DEVELOPMENT EMPOWERMENT OPENNESS STRUCTURE LEADERSHIP
25 One solution ENABLING ENVIRONMENTS Started 2009 Using the VALUE BASE from CofC standards 10 VALUES Quality Mark Valid in any social or work setting (church, office, home for elderly people, psychiatric ward, etc) Different process to CofC Portfolio multi media and fun to do! Very successful in prisons at the moment
26 Training: Living and Learning A training programme based on DEMOCRATISATION AND FLATTENED HIERARCHY COMMUNALISM AND BELONGINGNESS REALITY CONFRONTATION AND PERSONAL RESPONSIBILITY EMPOWERMENT Three day experiential workshop A transient therapeutic community for staff Recognised by Institute of Mental Health Validated by the Open University Institute of Group Analysis Short Course status applied for Detailed ethnographic analysis undertaken and published in 2006 Quantitative evaluation brief results follow Full study planned 2014
27 The Living-Learning Experience
28 Blue trend line shows a slight improvement over time (cc=0.24, p<0.05). No clear relation found to number of students on the course, or previous group experience.
29 What did they all gain? Team / organisational Knowledge / theory Personal skills Personal impact, use of self Other ways Little / not at all % of replies mention this theme gained after 3 months at course end expectations
30 Conclusions from 2012 evaluation Most people felt they had been helped by the course and that it would improve their performance at work. People often said how they felt that relationships were equal, and that they had genuine feelings of empathy and closeness to others, and it made them feel more human The course gives an experience which feels like that of a client in a Therapeutic Community.
31 Coming to Sicily LIVING-LEARNING EXPERIENCE Thursday 10 Saturday 12 October 2013 Caltagirone
32 FUTURE Outcome measures LAMI countries Greencare
33 Outcome measures Inspired by Norwegian Network All members of TCs do the same questionnaires (symptoms, social functioning, quality of life etc) Analysed together so each TC can see how much their members improve Also environmental measure. Update & simplify WAS/COPES
34 Greencare Use of nature as part of therapy
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38 LAMI countries London conference in September Global Mental Health The gap between self-care and professional care NOT to export high-tech psychiatry for few people But to export training for TCs so they can grow TCs in their own culture
39 Finally We can learn from you as much as you can learn from us Let us share good ideas Come to London and see our communities and our Community of Communities And the other way too Thank you
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