Revolution and flocking

What do Mao and geese have in common? Star Wards! I’ve been asking friends why they think that Star Wards has grown so fast and has unleashed such amazing energy and creativity. Richard Garside,

http://www.kcl.ac.uk/depsta/ppro/experts/expert/727

Bright’s chair but better known as a leading commentator on criminal justice (also known by what my mate Sarah refers to as as having “a brain the size of the planet”) said it’s Maoist. “Like the Let a Hundred Flowers Bloom campaign but without the execution of intellectuals.” I’d always thought that Percy Thrower had invented the concept of Let A Thousand (sic) Flowers Bloom. But no, it was the man responsible for millions of bicycles, snazzy suits and state murders. Intriguingly, we have inadvertently emulated some of the features of Mao’s approach to local change, at least in the initial stages of the Flowers’ campaign. He believed in setting out general principles centrally and then letting local people determine how best to implement these. (We’ll of course avoid the sharp reversal of the openness of Mao’s campaign, which resulted in the savage persecution of intellectuals who had been encouraged to criticise the official regime.)

A gentler comparison without a nasty ending was provided by my much-loved pal Phil Dourado. www.phildourado.com. Phil has just pre-launched what is likely to become an Internet sensation for leaders – the Leadership Hub. the world’s first online collaborative leadership development community.
www.theleadershiphub.com. Equally awe-inspiring is Phil’s role as a carer for his wife, Sandy, who has Huntington’s Disease. Sandy has written an amazing book about her experience of living with this devastating illness, and if you only read one book this year, or decade, read this one. Each chapter is written by a different member of the family, and if you only read one book chapter this year/decade, make it Danny’s. At 15 he has produced one of the wittiest, most insightful, courageous, compassionate and articulate pieces of writing I’ve ever seen.
http://www.phildourado.com/hdbook/

Phil and I have just come back from one of our regular city breaks, this time in Oslo. We were wandering happily in the opposite direction to our target destination of the Nobel Peace Museum. (Did you know that the Norwegian word for Peace is Fred? No, nor did we.) Either of us could lead an ambitious new social movement, but neither of us could find their way to the corner shop. We were chatting about Star Wards and Phil pointed out that it has the characteristics of a ’self-organising system’. He illustrated this with a description of water falling down a hill and eventually forming a river. But apparently flocks of geese or cranes also apply the same principles of ‘emergent behaviour’. “An emergent behaviour or emergent property can appear when a number of simple entities (agents) operate in an environment, forming more complex behaviours as a collective.”
http://en.wikipedia.org/wiki/Emergence
In other words, the sum is much greater than the parts. The wonderful Wikipedia (itself a fab example of emergent behaviour, with individual contributors creating the ultimate people’s encyclopaedia) points out that “In some cases, the system has to reach a combined threshold of diversity, organisation, and connectivity before emergent behaviour appears.” A nifty description of what Star Wards aspires to.

Safety on acute wards

I’ve rather unwittingly got involved in issues around safety on wards. It’s pretty obvious that when patients have something constructive to do during the day and good relationships with staff and each other, the number of violent incidents is going to be minimised. This is confirmed by research – including the results of a survey of wards participating in Star Wards. 50% reported a reduction of violent incidents as a result of their involvement in the project.

It’s strange, and risky, writing a blog because it feels private but is the opposite. But I’ll stick out my emotional neck (?) and say that I find all this stuff very upsetting. I’m not at all bothered at the prospect of being clobbered by another patient. It’s the staff reaction to violence that freaks me out. In particular, ‘rapid tranquilisation’ – i.e. being forceably injected. But this feels almost mellow compared to practices in continental Europe. It turns out that they use the alarmingly named ‘mechanical restraints’. All sounds very Heath Robinson but is actually very low-tech. And ghastly. Being strapped to the bed, sometimes for hours. Left alone, in some hospitals in rooms whose sole purpose is to have patients strapped to beds. Aaarrgghh!

I went to Italy for a conference and planning gig of a European project. Italy is celebrated for passing a law in 1978 closing all of its psychiatric hospitals. These have been replaced with community services and not very many acute admission wards in general hospitals. I visited one of these and was told that thre are no activities for patients and no nursing plans. Patients are only there a short time (about 7 – 10 days) but it still contrasts strongly with what happens in the UK.

So I’ve returned full of gratitude and relief for the prevailing ethos and practices of our acute wards.

Mental Health Today blog

There are some stimulating discussion prompts on the website of this indispensable magazine:
http://www.pavpub.com/mhtblog/

Crazy words

There’s a lot of preciousness about using ‘ordinary’ language about mental illness.

Journalists are regularly lobbied about words like ‘psycho’, ‘nutter’ etc

There’s a great article by Jo Brand, looking at the origin of some of these words and also at what some users/survivors think about them:
http://www.guardian.co.uk/g2/story/0,,2074299,00.html

I think that, like all language (spoken and perhaps especially non-verbal) it all depends on context, including who is using it. Not too many people flinch when I refer to myself as a lunatic. I think friends are rather relieved – that I’m relaxed enough to call myself this, and that they don’t need to be incredibly careful about how they talk about my illness. My psychiatrist/therapist sometimes responds to things I say with “Well, that’s just mad” and I enjoy the normality of the comment and it also makes a stronger impression than a technical interpretation might do. These are obviously contexts of trust and empathy.

While I wouldn’t warm to this sort of term being used with hostility, nor would I welcome any other terms! So if someone is trying to discredit me or something I say by referring to me being a ‘nutcase’, it wouldn’t really be any different to them saying “You would think that because you’ve got borderline personality disorder with accompanying dissociative states.”

Mainly, I like normal terms for madness because it makes me feel less stigmatised. (Not that I do feel stigmatised anyway…) People refer to themselves or others who aren’t mentally ill as ‘deranged’, ‘loopy’ etc. So they’re not just terms, or conditions, for those of us who have a diagnosed mental illness.

Unlike the service users in the article, I’m not anti-diagnosis. I’m anti excessive or inaccurate diagnosis, but as with all medical conditions, appropriate diagnosis can be essential in enabling us to understand what we’ve got, how we might have got it and, crucially, what we can do about it.

There are times, however, where the hostile use of common terms for madness is inexcusable. The best known example was The Sun’s front page ‘Bonkers Bruno’ headline when Frank Bruno was hospitalised. This prompted massive, hostile response from Bruno admirers and The Sun changed it in subsequent editions that day, apologised and carried out various other acts of penitence. The incident highlights some of the main features of unacceptable use of ordinary terms for madness, in addition to crude and hostile intent/impact:

1. being very public
2. attacking someone who at least in this context is vulnerable
3. the person has no immediate, equivalent way of responding/retaliating
4. the context of the comment, in this case an article, does nothing to undermine or challenge or prove the parody of the term

But in everyday, benign situations, I find it reassuring and humorous to be called barmy. Especially if the person using this term knows that I actually am.

Relational proximity

Not a great phrase, but it does describe what it’s about – how to build and sustain close relationships. It’s a model produced by the Relationships Foundation www.relationshipsfoundation.org and helpfully and unusually identifies core characteristics of good relationships. These are:

* directness – the value in having direct and immediate contact, eg wandering across the room to talk to a colleague rather than emailing them

* continuity – the longer the (good) relationship, the more likely it is to be solid

* multiplexity – not how often we go with someone else to a cinema with loads of screens, but how well we know people in their different roles -eg as a colleague, parent, golfer…

* parity – the extent to which there is equality of power in a relationship

* commonality – interestingly, not just a shared outlook or mutual interests, but also a positive appreciation of the differences between people

This is a valuable model for considering relationships on an acute wards – relationships between staff (including across different disciplines), between patients and, perhaps most problematically at the moment, between patients and staff.

Alternatives to CBT

When Patricia Hewitt gave a speech at the recent Mind conference she must have been bracing herself for lots of angry questions about the Mental Health Bill. But, amazingly, this issue wasn’t raised til right at the end of the Q&A session. Instead, there were question after question about the government’s apparent obsession with cognitive behavioural therapy. Delegates were scathing about this being further emphasised, or narrowed, by the innovation Hewitt had proudly announced – CBT online. Delegates pointed out that however useful CBT is, it can only address some mental health issues and other therapies are much more effective for other experiences.

http://www.communitycare.co.uk/Articles/2007/04/06/104048/mental-health-by-simeon-brodycampaigners-prompt-hewitt-to-consider-more-treatment-choice.html?key=COGNITIVE%20BEHAVIOURAL%20THERAPY

I’m fortunate to have a rather niche psychotherapy – mentalisation based therapy, which has been designed for people with borderline personality disorder. Before my mental illness got really out of hand and I was sectioned, I’d been having CBT from a brilliant therapist. But I got worse and worse. I was amazingly lucky that the hospital, St Ann’s in north London, has one of the country’s leading services for people with personality disorders, the Halliwick Centre. And even more fortunate that Anthony Bateman agreed to take me on as his patient. Prof Bateman and his colleague Peter Fonagy have written a compelling article about how the wrong sort of therapy for people with borderline personality disorder can not only be ineffective but actually damaging:

http://bjp.rcpsych.org/cgi/content/full/188/1/1

Let’s hope that Patricia Hewitt does go back to the Department and reconsider the proposition that a blanket application of CBT is good for all people with mental health problems.

Direct Payments

There’s a bunch of fascinating articles in this month’s Mental Health Today. In some ways, the feature on America’s experience of direct payments connects them all. And this illustrates the flexibility and targetedness of direct payments. The article is really worth reading in full:

http://www.pavpub.com/pavpub/mentalhealthtoday/showjournal.asp?Title=Mental+Health+Today

But a quick summary: service-users (or ‘participants’) are given a budget to spend on ’self-directed care’ to support their recovery and prevent relapse, hospitalisation etc. “Participants have so far proved to be good stewards of public money: individual budgets are regularly underspent.” People have used the money for traditional services (therapy etc) as well as for recreational and personal development opportunities. Joining Weight Watchers is a remarkable example of the many benefits of service-users choosing their own methods of recovery. “Weight Watchers provided me with a totally community integrated support system, nutritional education, kept me form isolating…increased my self-esteem, reduced the need for certain medication…” And she lost loads of weight.

The benefits of direct payments have been staggering, ranging from reduced use of hospital and crisis services to getting jobs or starting education.

The links with the other articles include the ability to secure culturally responsive services (there’s a depressing article about the non-use of a hospital for African and African-Caribbean patients) and the creative, communicative and therapeutic benefits of art activities.

Precisely because direct payments enable participants  to secure almost any type of service or resource (apart from drink and drugs – rock’n'roll seems to be OK as long as it’s with an ‘approved provider’), it gives an interesting extra dimension to everything in this month’s Mental Health Today.

Wotton Lawn Hospital

A visit to another amazing hospital. It can be done! And interestingly, not only by wards that take on an overarching model like Refocusing or the Tidal Model. There’s a short piece about Wotton Lawn Hospital in an earlier blog (sports therapists). But it was pretty mind-blowing visiting and finding out in more detail the extraordinary range and quality of services they provide.

Wotton Lawn Hospital is in Gloucester and I was very fortunate to be able to spend the afternoon seeing some of its work, thanks to the Matron Manager (or the Matron formerly known as Modern), Alan Metherall. The afternoon began in a representatively impressive way, with 7 healthcare assistants giving a presentation about the training they’d recently completed and being awarded their certificates. Any training for this much neglected professional group is to be welcomed, but especially one with the depth and values of the Gloucester training. As well as the valuable content (ranging from ethics, gender issues and recovery  models to the Mental Health Act and de-escalation), the training process is impressive. It includes structured, supportive training sessions, mentoring, observation of work practice, written assignments, discussion and projects.

A member of staff said that the training made him feel “more confident and more involved, and more aware of different situations.”

It’s true, and important to note and advocate, that the hospital has the benefit of some great facilities, including a large gym, physio room, therapy suite – oh, and the glorious Gloucestershire countryside on their doorstep. But other hospitals have equivalent or better services and don’t convert them nearly as effectively into excellent services for patients. Two of the things that impressed me most were improvisations. One of the dynamic HCAs who is an activity co-ordinator on the PICU described how there was a rather lethargic atmosphere on the ward one day. Spontaneously she found a paper plate and suddenly there was an animated game of indoor Frisbee!

And a ward with a kitchen which has no oven (excessively risk averse planning, presumably) hasn’t stopped the creative ward manager from regular cooking sessions for patients. They use a bread-making machine, make microwave and freezer cakes and harness the relaxed sociable potential of communal meals there.

The same ward has visitors from Pets As Therapy (www.petsastherapy.org), staff leads in areas as diverse as women’s issues and sports, and an impressive green philosophy. Even tea-bags go to the composter… and I sheepishly removed the plastic cup I’d chucked out, when they diplomatically mentioned that these get used to grow seeds. For the sensory  garden that patients and staff are designing and developing. While I was on the ward it was lovely to see a fragile-looking patient absorbed in potting up small plants. And it gets better and better. Patients go to the local garden centre to choose plants, books, brochures and folders about gardening have been resourcefully sought from local gardening clubs, there’s a sheet on the noticeboard where patients have written their ideas for the garden….

I have pages of notes about the superb practice from this ward alone, so do let me know if you’d like more details.

Still on the gardening theme, the Low Support Unit (whose energetic manager would prefer it to be called the Recovery Unit) is setting up not just a gardening group, but a social business based on the garden’s produce. They’ve transformed the over-run area that was previously used for ‘horticultural therapy’ and it’s an obviously great opportunity for the men to channel their strength and time. A former service-user who handily is a gardener helps out, which must be inspiring for the current patients as well as rewarding for the volunteer.

As with the acute ward briefly described above, there’s much too much great practice in this ward to include here. And while I can list some of the impressive features, it’s the staff attitude to and relationship with patients which is hardest to do justice to. Perhaps it boils down to the staff really liking and enjoying being with patients. (And of course not exactly a mellow, biddable group of patients. 12 people who have experienced the full range of incarceration, rejection and stigmatisation.)

And then there’s the therapies unit. A dance and movement session was going on in the gym when we visited, led by a specialist in this important combination of art and exercise. The artwork done achieves numerous objectives, ranging from an opportunity for a non-intrusive, relaxed OT assessment to producing truly high quality (luxury shop standard) products which are used on wards or can be taken to patients’ homes or given to their families. How much nicer to return home with a beautiful ceramic you’ve created yourself rather than just a CPA form?

Line dancing, exploring leisure sessions, peer supported substance misuse groups, making everything from dolls houses to greetings’ cards, going to the local tennis club and pool, museums and places of interest, total well-being sessions, ‘wake and shake’ start to the day with the sports therapist and/or physio…. Just an incredible range of high quality, enjoyable, esteem-building, sustainable activities.

Some of this is about resources, but mainly it’s about:

1. staff feeling that patients deserve and can make good use of a full range of activities, 7 days a week
2. recruiting, supporting and retaining great staff
3. having some seriously outstanding managers, including Alan

Antenna

Paralleling the impact on the nation’s conscience and consciousness of the Stephen Lawrence murder and inquiry, the death of Rocky Bennett is in many ways setting the agenda for tackling racism in mental health services. The disproprtionately coercive treatment experienced by black service users is now well-documented. One local service, in Haringey north London where I live, is working with young people from Afro-Caribbean backgrounds who have serious mental health problems. It is the best community based service I’ve come across, designed by and run with local people.

Among the many, many (sadly) exceptional features of the service are:

• a focus on individuals’ strengths and interests rather than medical ‘pathology’
• the translation of this into practices such as making most of the proactive contact between staff and users based on daily rather than psychiatric circumstances. Staff meet service users in cafes, talk about people’s whole lives and aspirations - and live locally
• the ‘constant dialogue’ includes clients being able to text and phone outside their weekly visits, and there’s a 24 hour phoneline, available to carers as well as clients
• Antenna carefully builds a positive profile in the community, by attending community events, speaking to schools, networking with churches and through media coverage
• the recovery model supports clients using mainstream, eg sports and employment, services and is designed to foster independence from the service
• there is a carer support worker, carers’ support group, outings and even holidays
• ex-clients are involved in supporting the service

The only information I’ve been able to find on the Internet feels very dry compared to the richness of detail at a recent presentation I attended. But it does give some of the background facts:

www.haringey.gov.uk/antenna_operational_policy.pdf

One striking aspect of this exemplary service is that there is nothing in the core structure that is explicitly directed at young people from Afro-Caribbean backgrounds. No black identity or music groups for example, which other services tend to build in. Reading the operational policy, it could equally be designed for any other BME group, or all or none. The cultural sensitivity is clearly integral to every element of the service, especially the selection and daily practices of staff.

David Bennett’s sister Joanna is a mental health professional and former lecturer in mental health. In evidence to the inquiry into his death, she warned against services focusing on “cultural matching” in favour of staff spending more time talking to patients and their families. Taking time to respect an individual, and ask what was troubling him and what he needed, was likely to be more effective than “talking about culture, ethnicity and cultural competence,” she said. Arguably, both are crucial if black service users are to experience treatment which isn’t just equitable but actively healing.

Patient power

Mind held a fascinating seminar last week on Putting the Soul Back into Psychiatry. Participants included the three heroes of the survivor movement – Peter Campbell, Louise Pembroke and David Crepaz-Keay. It was Chatham House rules but David said it was fine for me to quote him in the blog. It’s the wittiest thing I’ve heard about being this end of psychiatry and the need for “redistributing power”:

“There are thousands of good and bad psychiatrists and there are thousands of good and bad psychotics. But we don’t get any training for this. We need a Royal College of Psychotics. … If we withdrew our insanity for one week, the whole system would grind to a halt.”

It doesn’t look quite as funny written down, but anyone who knows David will be able to imagine him saying this and appreciate the politics and humour that charge the quote.