Rex Haigh

The quintessence of a therapeutic environment

Purpose – The purpose of this paper is to describe the necessary primary emotional development experiences for healthy personality formation. Design/methodology/approach – The paper is a critical synthesis of psychoanalytic theory. Findings – Five experiences are judged necessary for health ‘‘primary emotional development’’: attachment, containment, communication, inclusion and agency. These can be deliberately recreated in therapeutic environments to form a structure for ‘‘secondary emotional development’’. Practical implications – The ways in which these qualities of a psychosocial environment can be produced are described. Social implications – Failure to recognise the importance of these qualities of an environment can cause unhealthy, or frankly toxic, psychosocial environments in various settings. Originality/value – This is the author’s original work, and has relevance for all psychosocial

Social psychiatry and social policy for the twenty‐first century – new concepts for new needs: relational health

– This final article in the series of three identifies and illustrates the links between the “enabling environment” approach and contemporary social policy themes such as relational health, public health, social inclusion; and the “Big Society”., – The paper begins with an example of the standards‐based approach in practice. It then indicates other areas where this approach is currently being explored. Finally it summarises recent contemporary policy frameworks for which the EE approach, it is suggested, supplies both a shared vocabulary and a practical, evidence‐able agenda., – There is growing recognition of the need for a “sea change” away from a simple clinical interventions framework for community mental health and addressing health inequalities. There are clear linkages in this new approach with past and emerging policy frameworks in public health and corporate social responsibility, including the need for more “bottom up” solutions with local ownership., – This series of three papers is the first introduction to psychologically informed environments and the enabling environment approach to be made available to the general and specialist public.

Service User Involvement in the National PD Development Programme

Abstract This paper is a compilation of four contributions which endeavour to bring together the numerous strands of service user involvement that have been integral to the work, thinking and culture of the National Personality Disorder Development Programme.

Transient therapeutic communities: the “living-learning experience” trainings

Purpose – The purpose of this paper is to describe transient therapeutic communities (TCs) and their value for training. Design/methodology/approach – This is a descriptive account which includes the findings of two field study evaluations, and direct participant feedback. It is an exploration of the application of TC and group analytic theory to transient TCs. Findings – The transient TC format is an excellent training format for creating a powerful and effective environment for learning and personal development in the very short time frame of three days. Practical implications – These courses are a very efficient and effective way of promoting reflective practice, enabling environments, and emotionally safe working practices. The trainings are useful for a wide range of people from mental health professions, those working in human resources, and those in senior positions in industrial, commercial and public sector fields. Social implications – This paper will raise awareness that target-driven training ...

What is happening in the world of therapeutic communities

This overview of the contributions to the special edition illustrates something of how the collection of papers reflects the marginal nature of therapeutic communities, and makes parallels as to how they are forever struggling to survive, yet generate a passion of ideas and intellectual resilience that no project-managed health service can extinguish. It briefly describes the theoretical and geographical terrain covered, and signals how the cross-disciplinary incorporation of congruent ideas can be added to the traditional bedrock of therapeutic community practice. It ends by stating the context of the new, and seemingly successful, organization which assembled these contributions into its inaugural conference – and suggests that the journey could, and ultimate should, go further.

Milieu approaches and other adaptations of therapeutic community method: past and future

Purpose The purpose of this paper is to provide an overview of the application of therapeutic community (TC) method in non-TC environments. Design/methodology/approach Milieu treatment is defined and differentiated from TC “proper”. Literature is reviewed covering attempts to use TC methods in inpatient wards, across hospitals, and more recently in the criminal justice system and more widely through the enabling environments initiative. Findings It is unclear whether TC milieu treatments proved helpful in acute ward environments in their heyday in the 1950s, 1960s and 1970s, in particular those involving people suffering from acute psychosis, and the changing landscape of psychiatric provision may make further investigation difficult. The reasons for this, and for the difficulties reaching a firm conclusion, are outlined. In contrast, TC milieu interventions appear to be demonstrating usefulness more recently in less mixed populations without the implementation of full TC “proper”. Research limitations/implications Much of the research is old and the methodology poor, which limits the conclusions that can be drawn. Practical implications Recent innovations pick up in a more accessible way principles of therapeutic communities that can inform and improve care in a variety of contexts. They are sufficiently well defined to lend themselves to research, which should now be a priority. Originality/value After a gap in developments in the field, recent innovations are reintroducing elements of TC functioning to new contexts including criminal justice settings, inpatient wards, homeless shelters and city communities.

The quintessence of a therapeutic environment: the foundations for the Windsor conference 2014

Purpose – The purpose of this paper is to introduce the “Quintessence” framework and its roots in TC phenomenology; to explain how each of the contributors to the conference is related to it; to pose questions about how the “TC movement” may use the underlying ideas in the future. Design/methodology/approach – Adaptation of theoretical ideas to a conference structure. Findings – As the necessary developmental experience for everybody, the quintessence principles are recreated in well-functioning therapeutic communities, and in the 2014 Windsor Conference. Research limitations/implications – As a theory that is becoming well used in the TC field, it needs more qualitative, quantitative, critical or philosophical underpinning. Practical implications – Widely accepted as useful in TCs. Social implications – Has wider applicability. Originality/value – Derived from condensation of numerous relevant psychological, sociological and systemic theories.

Therapeutic communities and group analysis

Purpose The purpose of this paper is to highlight theoretical and clinical similarities between therapeutic communities (TCs) and group analysis (GA). Design/methodology/approach Literature review shows comparison of TC and group-analytic concepts with illustrative case material. Findings Findings reveal many similarities between TCs and GA, but also significant divergences, particularly in practice. Practical implications This paper provides theoretical basis for TC practice, and highlights the need for greater theorising of TC practice. Social implications This paper highlights the importance of group-based treatment approaches in mental health. Originality/value This is the first paper to review the relevant literature and compare theory and practice in TCs and GA, highlighting their common roots in the Northfields Experiments in the Second World War.

Training for enabling environments

Purpose The purpose of this paper is to demonstrate the training value of a residential “enabling environments” (LLEE) workshop in relation to the Royal College of Psychiatrists’ (RCPsych) ten specified standards, as rated by workshop participants. Design/methodology/approach A 34 question yes/no/na questionnaire was drawn up, derived from the ten value-based standards and criteria which need to be met for the enabling environment (EE) award by the RCPsych’s Centre for Quality Improvement (Table AI). It was administered after six residential workshops, in Italy and UK, to 99 participants. Results were analysed for each of the six workshops, and for each of the ten standards, to show the degree to which participants recognised whether the standards were met. Findings High rates of positive responses were recorded with little variation across the six workshops sampled. Some standards and criteria showed higher levels of positive responses, and some showed slightly higher scores for “not applicable”. Practical implications Experiential Living-Learning Experience (LLE) workshops provide a valid training experience for those developing or working in EEs. Social implications Value-based standards can only be fully understood by direct experience of them, as verbal or written explanations fail to convey the psychological impact of the experience. Originality/value The questionnaire and its translation is the original work of AL. RH is the founder of LLE training workshops and the EE award.

Personality disorder service provision: a review of the recent literature

Purpose The purpose of this paper is to describe the evolution of the field of personality disorder since the publication of “Personality disorder: no longer a diagnosis of exclusion” in 2003. Design/methodology/approach A review of both the academic literature contained within relevant databases alongside manual searches of policy literature and guidance from the key stakeholders was undertaken. Findings The academic and policy literature concentrates on treating borderline and antisocial personality disorders. It seems unlikely that evidence will resolutely support any one treatment modality over another. Criticism has arisen that comparison between modalities misses inter and intra patient heterogeneity and the measurement of intervention has become conflated with overall service design and the need for robust care pathways. Apparent inconsistency in service availability remains, despite a wealth of evidence demonstrating the availability of cost-effective interventions and the significant inequality of social and health outcomes for this population. Research limitations/implications The inclusion of heterogeneous sources required pragmatic compromises in methodological rigour. Originality/value This paper charts the recent developments in the field with a wealth of wide-ranging evidence and robust guidance from institutions such as NICE. The policy literature has supported the findings of this evidence but current clinical practice and what patients and carers can expect from services remains at odds. This paper lays bare the disparity between what we know and what is being delivered. The authors argue for the need for greater research into current practice to inform the setting of minimum standards for the treatment of personality disorder.