Running Groups Online: The Virtual Therapeutic Community

The past few weeks have introduced a lot of novelty into my life.  I’ve gone from someone who went to work every day to someone who is trying to work out how a way of working based on relationships can continue in a world where people can’t be physically together.  Some sacred cows of Mental Health work are being slaughtered.  Early last year I was in a meeting where people argued passionately that it was unthinkable for patients to occasionally meet their therapists in different rooms.  Now we are learning that it is contact that is essential, while the medium and environment come in a distant second.

Keir offers therapy, consultation and training around complex mental health issues via Beamconsultancy.co.uk

I love working in our day therapeutic community.  This is a group that runs for five and a half hours where the members share power with staff.  All our decisions are made by agreement, consensus and if required, by voting.  As the members always outnumber the staff this means that they hold the decision making ability in the group.  This level of empowerment/coproduction isn’t common in services and while it is cherished by its members, it can make organisations feel anxious.

Last week the group was cancelled as a response to the government advice to self isolate.  A lot of my weekend was spent trying to find a way to run a group without anyone actually being present.  One of the most useful things I found was this:

https://www.nhsx.nhs.uk/key-information-and-tools/information-governance-guidance

This gave out advice encouraging the use of video conferencing endorsed by the Information Commissioner’s Office, the National Data Guardian and NHS Digital. 

I went into work (the living room) on Monday hoping to work out a way to set up a meeting on Zoom.  To my knowledge, Central and Northwest London, Leeds and Northwest Boroughs are using this for video calls with patients.  

After speaking with managers in work I was encouraged to use Accurx.  I set this up and the test version (3 images of me on different devices and a guest appearance from @hoppypelican) seemed to work well.  When I tried it today it soon became apparent that on our version we could only have 4 people in a meeting at once. 

I spoke with IT who suggested Webex.  This is something I’d never used before but it wasn’t too bad.  You go to the website and sign up.  This eventually takes you to a place where you have the option to START A MEETING.  You’re then given the option to download the app or you can do it through your browser.  I downloaded the app.  You then end up in a meeting with a screen full of your own face.  Clicking on … lets you invite participants and there’s an option to COPY MEETING LINK.  I chose this and then emailed and text the link to everyone who was due in group.  Some people opted to join using the app on their phones, most people preferred to use their laptop. 

For the next 2 1/2 hours we help a group when we thought that it wouldn’t be possible.  We spoke of how different things would be. The uncertainty about privacy. The greater need for confidentiality. At one point we had 9 participants with everyone talking about how good it was to hold on to each other during these difficult times.  It wasn’t perfect, people had some issues with sound, some of us found it weird to be sharing the background of our living rooms and it took some of us longer than others to log in but we learned that it could happen.  On the positive side, eye contact seemed easier over the computer.  People who sometimes disappeared in group were more present than ever. 

Losing the physical contact with people will be very difficult to get used to.  We might all be learning some lessons about how we connect with people that we can’t be with.  What I’m often told is that it’s that connection that allows people to hang on. We need to keep people connected in these difficult times, particularly those who feel unworthy of care and compassion.

What I hope people can take from this example is that in the current emergency, groups do not have to stop.  Not only is it possible to do groups, people are doing them.  If I can help you to keep your groups going drop me a message Keir Harding OT on facebook, @keirwales on twitter or through the website.  

#StayAtHome (and run groups)

Leaving the NHS, the conference that never was and the impact of C19

Well this week is going to be nothing like it was supposed to be.  Instead of heading to the British and Irish Group for the Study of Personality Disorder annual conference, I’m going to be isolating at home with a vague sense of unease, guilt about not doing more, and a growing sense that this is the worst time possible to be leaving the NHS.

Keir provides therapy, consultation, training and supervision via beamconsultancy.co.uk

Going to the BIGSPD conference is a highlight of the working year for me.  I was totally self funding so I’d booked my days of work, got myself an air B&B and was looking forward to hearing about some of the really big developments happening at the moment.  I was most keen to hear how much we are spending on Out of Area treatment for people diagnosed with ‘personality disorder’, or people who self harm, or people who feel recurrently suicidal.  Someone had contacted every CCG to try and get this information which has so far eluded me.  On top of that, we were going to hear about the future of training around working with those who get this diagnosis.  I was really looking forward to an update on the CALMED trial – this is a controversial study to look at the efficacy of Clozapine for people diagnosed with BPD.  I’ve got mixed feelings about this.  I went to a low secure unit the other week and everyone there was on it.  We can argue this makes sense because it’s for the people with the most severe problems but I have serious concerns that this is one of the dangerous things that happens when people are out of sight and out of mind.  The biggest thing I’ll miss out on is having a debate with the staff of St Andrews around the ethics of private mental health placements.  I’ve been looking forward to this for months and while I’m sure it will happen, there’s a definite sense of anticlimax.  Lastly, I wanted to talk about organisation centred care with @hoppypelican.  Thi is our wry take on person centred care where we argue you can only deliver person centred care if you target the anxiety of the clinicians/organisations working with people.

What would have been novel this year is that the Mental elf would have been taking the conference beyond the room for the first time ever, helping us to reach people who have never thought about this area before.  I’m often surprised by the amount of people who are really interested in this area but have no idea that BIGSPD exists.  The more people who think alike, working together the better I reckon.  Alas this opportunity is going to pass…

So instead of doing all the above, I’ll be trying to see if therapeutic communities can happen online.  Instead of leaving the NHS a week on Monday, I’ll be seeing if theres a way to stay on and help out while the crisis passes.  Instead of a brave new dawn I’m looking at the kind of evening sky that would terrify shepherds and wondering whether I’m doing enough.

I’ve read a lot of dystopian/post apocalyptic fiction in my time and theres a big part of me that wants to go and panic buy.  To get a gun and head for the mountains.  To break into warehouses and put aside stores for the future.  The heroes of these stories tend to be pretty well prepared and there’s an itch in my brain that sees people wandering through town with 200 rolls of bog paper that tells me I’m missing out.  I’m noticing the urge to hoard and instead, I’m trying to practice some of what I spend a lot of my time preaching.  Calmness, trust in others, a belief that this too shall pass and mostly a deliberate turning of my mind to hope.  I really enjoyed and was inspired by Hope in the Darkness by Rebecca Solent recently.  I’m going to leave you with a few quotes from it, and my own hope that we find ways to be together while being apart, that we show how much we are connected by keeping away from each other and that we can hold each other without being present.  Take care of each other, (but stay at home).

“To hope is to give yourself to the future – and that commitment to the future is what makes the present inhabitable.”

“People have always been good at imagining the end of the world, which is much easier to picture than the strange sidelong paths of change in a world without end.”

“Hope just means another world might be possible, not promise, not guaranteed. Hope calls for action; action is impossible without hope.”

“Inside the word “emergency” is “emerge”; from an emergency new things come forth. The old certainties are crumbling fast, but danger and possibility are sisters.”

“To hope is to gamble. It’s to bet on your futures, on your desires, on the possibility that an open heart and uncertainty is better than gloom and safety. To hope is dangerous, and yet it is the opposite of fear, for to live is to risk.”

Keir provides therapy, consultation, training and supervision via beamconsultancy.co.uk

Its a decent book if you get the chance to read it, take care of yourselves.

The Most High Profile Articles on "Personality Disorder" of the past 2 years.

Hello Everyone, I came across this when preparing for the British and Irish Group for the Study of Personality Disorder’s annual conference. This is a database search of the most high profile journals with anything to do with ‘personality disorder’ tagged. You can read Mike Crawfords study saying Lamotrigine shouldn’t be prescribed and Jay Watt’s searing critique of the ICD-11 categorisation of personality disorder.

I haven’t done posts like this in the past so if it’s useful, let me know. Click on the button below to download the PDF. Enjoy.

An Overview of ‘Personality Disorder’

An Overview of “Personality Disorder”

This is a little collection I put together for the people I was training with the other week.  I’m sure there are loads of gaps so if you think something essential is missing do let me know.  Hope you find it useful.

Keir provides Training, Consultancy and Therapy around complex mental health problems via www.beamconsultancy.co.uk

What do services look like in England?  services in the UK.   Dale O et al (2017)

Essential Reading

The idea that people who were labelled as having a personality disorder were part of the core work of mental health services first gained traction in 2003 with the publication of the seminal No Longer A Diagnosis of Exclusion  (2003)

The Personality disorder Capabilities Framework describes the skills required for staff to work effectively in this area.  It is rarely used.  (2003)

The review of the 11 pilot sites of ‘personality disorder’ services (2007) Crawford et al describes useful features of effective services.

Stigma

There are some dodgy attitudes towards people who get the diagnosis out there.  This is a mix of papers that identify problematic attitudes and ways of challenging them.

The patients psychiatrists dislike (1988)

Attitudes towards patients with a diagnosis of ‘borderline personality disorder’: Social rejection and dangerousness (2003)

Jay Watts talking about how having a BPD diagnosis means you don’t get listened to Testimonial Injustice 2018

This is a critique of all diagnosis  thats tells us what we all know – people who get this label have lived through awful experiences. (2019)

This is a way of challenging some of the stigma Why Are People With Personality Disorder So Manipulative?

This brilliantly encapsulates how once we have a picture of what someone is like in our mind, everything they do can be twisted to fit that picture: How Not To Get A Diagnosis of Personality Disorder  by Recovery in the Bin 

The Not So Nice Guidelines for Borderline Personality Disorder. – This is a way of reading the NICE Guidelines for BPD but with a commentary about what services are really like.  By recovery in the bin again, specifically Lara Quinn and Erik

How to work with people who get/could get this diagnosis

This is the Ministry of Justice Guide to working with people with ‘Personality Disorder’.  Lots of stats, facts and figures (2015)

Meeting the Challenge, Making a Difference – This is the Guide to working with people diagnosed with personality disorder, written by people who identify with personality disorder. (2014)

This talks about Trauma Informed Care and why ‘what we usually do’ often isn’t helpful. 

This is the consensus statement on Personality disorder. A paper by a mix of professionals and people with lived experience outlining their vision for the future.

There’s a BBC report on it here

Specific Guidance

Most recently the Royal College of Psychiatrists Position Paper on Personality Disorder makes some very clear recommendations. The reference list from this is a good contemporary guide to useful papers.

NICE Guidelines Self Harm - soon to be updated

NICE Borderline Personality Disorder – The personal accounts of people who have been through services are really interesting.  Also gives an overview of different interventions.

NICE Antisocial Personality Disorder

What help is out there? 

Theres lots of therapies with an evidence based in this area.  These include….

Dialectical Behaviour Therapy (DBT) from the Mind website

Mentalisation Based Therapy (MBT)

Schema therapy

Therapeutic Communities – My favourite way of working with people

STEPPS – Systems Training for Emotional Predicability and Problem Solving

Structured Clinical Management (SCM). It is hard to find a good link on this.  The book it’s based on is this one

Cognitive Analytic Therapy (CAT)

Someone will tell you one is better than another.  The evidence is fairly similar.  It’s all about the quality of your relationship.

This gives an overview of MBT, DBT, TFT and GPM.  GPM is interesting (something similar over here known as “Structured Clinical Management”) as it is delivered by generic workers rather than specialists.  

What makes the work hard?

The Ailment by Tom Maine This isn’t the best copy but this is an excellent article that describes the impact complexity can have on staff.  This is the best article you can read if you work in this area!!!

With research suggesting up to 78% of people in prison could be diagnosed with personality disorder, here’s some relevant things to read –

The Working With Offenders booklet again.

The Bradley Report – This looks at mental health problems and learning disability within the criminal justice system

The Corston Report – Specifically about Women in criminal justice

Women and Girls at Risk – A heartbreaking read about the disadvantage women face throughout their lives.

Suicide

Safer Care for Patients With Personality Disorder is both a collection of statistics around people with the diagnosis who killed themselves, and a survey of peoples experience of living with the diagnosis.  Best/Worst statistic – Not one of the people who died by suicide was receiving NICE recommended care.

Medication

Olanzapine is as good as placebo

Lamotirgine isn’t helpful

Be afraid of clozapine

Local Pictures (From the UK but happy to add more)

Northern Ireland 

England Has the RCP position statement.  Scroll up

Scotland 

Wales – This link doesn’t work because Wales has nothing to say on this subject, to our great shame.

And just some other interesting stuff…

Personality disorder on the BBC

I read this blog a lot!  *shameless self publicity warning

https://themainoffenderblog.wordpress.com/ A very articulate account of what it’s like living with BPD by @hoppypelican

Online resources:

http://www.dbtselfhelp.com/ –  Lots of stuff  to work through – All DBT flavour

Sunday night chats on twitter #BPDChat – Also with a DBT flavour

For people who have just been given a diagnosis

This personal account is a good start.  Lots of resources in there. By the excellent Sue Sibbald @BPDFFS

Keir Harding provides Training, Consultancy and Therapy around complex mental health problems via www.beamconsultancy.co.uk

Below is a way of talking about complex emotional difficulties without talking labelling them Personality Disorder. 

An important area of mental health that is getting increasingly recognised is the way people express various forms of emotional distress. It can cause various behaviours:

People harm themselves, for example by cutting their arms
Drinking unsafe amounts of alcohol
Taking illegal drugs regularly, excessively or irresponsibly
Misusing prescribed medications (or those available over-the-counter at pharmacies)
By impulsive and reckless actions that could have have serious consequences, like driving too fast or having unsafe sex
Chaotic eating patterns – such as bingeing, vomiting, abusing laxatives or continuously eating too much. 

In addition, people with these problems often have repeated difficulties in relationships in ways like this:

Never keep friends very long
Cannot hold down a job
Isolated and lonely
Violence in intimate relationships
Over-sensitivity to criticism
Argumentative with people in authority
Feeling very abandoned when left alone or people leave
Unable to cope with making any decisions without help
Often switching between loving and hating family members.

Many people will experience these things at some time during their lives, perhaps in response to stress, but some are severely troubled by many of them for most of their lives. These could be called ‘long-standing emotional problems’, and they often go right back to childhood. In mental health services they are sometimes known by diagnoses like ‘complex needs’, ‘personality disorder’, ‘borderline’ or ‘severe and enduring non-psychotic disorder’. 

Although it is not always the case, people with these types of difficulties have usually had difficult childhoods, with adversities like repeated trauma, or physical, emotional or sexual abuse, or neglect and deprivation, or several severe losses and bereavements. On the other hand, some people who suffer very harsh childhoods seem to be somehow ‘protected’ from the long-term psychological damage it can do. Unfortunately, there is no easy way of finding out who will have more problems and who will have less – although research is always being done to help us understand these matters better.

People who suffer in these ways often do so silently, without getting any help and often feeling guilty or ashamed of how they ‘are’. They often do not even know that they have a problem that others have too – and can become very isolated and lonely with it. In fact, these problems are very common, and increasingly recognised. The reason people behave the way they do, and have the difficult relationships they do, is usually to deal with their feelings, and to try and cope with them. But their actions often do not help enough, and they can make matters worse. 

Very commonly, the behaviours can be confusing and upsetting, and this is as true for the people themselves as for those around them. This is because there is a lack of information and understanding about how these things arise, unwillingness to think and talk about them, and little knowledge about what can be done to support someone in this sort of emotional turmoil.

Although it is often the easiest route, there is recent research and NICE guidelines which suggest that medication is not usually the best way to deal with these problems. In the NHS, psychological treatment often helps, and this may take different forms. However, short-term ‘quick fix’ treatments and therapies are rarely very much help. Some psychiatric services are good at helping people with these problems, but because the number of people affected has only recently been recognised, many mental health staff do not yet have good training to deal with it.

In this situation, one of the things that can be very helpful is to help people to feel less alone and ‘odd’ – and for this, other people who have suffered similar feelings are usually better than professionals at understanding what it is like. 

(This was taken from the Emergence website)

And those are some things that might help you understand whatever personality disorder means and what might help.  Again, if something is missing let me know.

Keir

 Keir Harding provides Training, Consultancy and Therapy around complex mental health problems via www.beamconsultancy.co.uk