Therapeutic community

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Therapeutic community is a participative, group-based approach to long-term mental illness, personality disorders and drug addiction. The approach was usually residential, with the clients and therapists living together, but increasingly residential units have been superseded by day units. It is based on milieu therapy principles, and includes group psychotherapy as well as practical activities.

Contents

Therapeutic communities have gained some reputation for success in rehabilitation and patient satisfaction in Britain and abroad. In Britain, 'democratic analytic' therapeutic communities have tended to specialise in the treatment of moderate to severe personality disorders and complex emotional and interpersonal problems. The evolution of therapeutic communities in the United States has followed a different path with hierarchically arranged communities (or concept houses) specialising in the treatment of drug and alcohol dependence. [1]

History

Antecedents

There are several antecedents to the therapeutic community movement. One of the earliest is the change in treatment of institutionalised patients in the late 18th century, continuing throughout the 19th century. [2] A major contributor to this change is Philippe Pinel, a French physician who advocated for a more humane treatment of psychiatric patients. [2] In Britain William Tuke founded the Retreat where patients were treated according to humanitarian principles, called moral treatment. [2] Tuke based the treatment of mentally ill people partly on the Quaker ideology. The influence of Quaker principles continues through out the development of the therapeutic community. [3]

Moral treatment focused on a more humane treatment of patients and a stimulating environment that engages them in healthy behaviour. [4] An important distinction between the later therapeutic community is the strong hierarchy in moral treatment facilities. The superintendent had authority over and responsibility of the patients. The patients followed a strict schedule to promote obedience and self-control. [4]

After the First World War, multiple varieties of living-and-learning communities for young adults were established. Examples are the Little Commonwealth school run by Homer Lane and the Q camps initiated by Marjorie Franklin. [5] [2] The Q camps were based on Planned Environmental Therapy, which focused on normally functioning parts of a patient's personality and use them to deal with difficult social situations. [6] These projects all emphasized shared responsibility and decision-making and participation in the community. [2] What influenced the establishment of these projects were, among others, the developments in psychoanalytic theory in Great-Britain. [7]

United Kingdom

The work conducted by pioneering NZ plastic surgeon Arcihibald McIndoe at Queen Victoria Hospital and others at Northfield Military Hospital during World War II is considered by many psychiatrists to have been the first example of an intentional therapeutic community. [8] But this story is prone to adopt a origin myth approach. [2] The principles developed at Northfield were also developed and adapted at Civil Resettlement Units established at the end of the war to help returning prisoners of war to adapt back to civilian society and for civilians to adapt to having these men back amongst them. [8] [9]

The term was coined by Thomas Main in his 1946 paper, "The hospital as a therapeutic institution", [10] [11] and subsequently developed by others including Maxwell Jones, R. D. Laing at the Philadelphia Association, David Cooper at Villa 21, and Joshua Bierer.

Under the influence of Maxwell Jones, Main, Wilmer and others (Caudill 1958; Rapoport 1960), combined with the publications of critiques of the existing mental health system (Greenblatt et al. 1957, Stanton and Schwartz 1954) and the sociopolitical influences that permeated the psychiatric world towards the end of and following the Second World War, the concept of the therapeutic community and its attenuated form – the therapeutic milieu – caught on and dominated the field of inpatient psychiatry throughout the 1960s.

The first development of therapeutic community in a large institution took place at Claybury Hospital under the guidance of Denis Martin and John Pippard. Beginning in 1955 it involved over 2,000 patients and hundreds of staff. [12] The aim of therapeutic communities was a more democratic, user-led form of therapeutic environment, avoiding the authoritarian and demeaning practices of many psychiatric establishments of the time. The central philosophy is that clients are active participants in their own and each other's mental health treatment and that responsibility for the daily running of the community is shared among the clients and the staff. One phrase commonly used to summarise this treatment philosophy is 'the Community as Doctor'. 'TC's have sometimes eschewed or limited medication in favor of group-based therapies.

The Henderson Hospital first established in 1947 by Maxwell Jones and named after David Henderson evolved the specific concept of Democratic Therapeutic Community (DTC). Admission to and early discharge from the one year of residential treatment was by majority vote and residents of the DTC always held the majority in these votes. No psychotropic medication or one to one therapy sessions were available and so all the work of the DTC was pursued, on the one hand, in small or larger therapy groups or work groups and community meetings, which could be called (by the residents) day or night; and on the other hand, in the unstructured time in between these more formal spaces, in which belonging in and membership of a living community could become in itself a healing experience. The Henderson Hospital DTC became an international centre of excellence for the care of survivors of severe trauma who did not fall under conventional psychiatric classifications and towards the end of the twentieth century it was funded to replicate the treatment model in two other DTCs: Main House in Birmingham and Webb House in Crewe. [13] [14]

The availability of the treatment on the National Health Service in the United Kingdom came under threat because of changes in funding systems. Researchers at the University of Oxford and King's College London studied one of these national Democratic Therapeutic Community services over four years and found external policy 'steering' by officials eroded the community's democratic model of care, which in turn destabilised its well established approach to clinical risk management (this had been jointly developed by clients and staff). [15] Fischer (2012), who studied this community's development at first hand, described how an 'intractable conflict' between embedded and externally imposed management models led to escalating organizational 'turbulence', producing an interorganizational crisis which led to the unit's forced closure. [16] The three 'Henderson' DTCs had all closed their doors by 2008.

However, development of 'mini' therapeutic communities, meeting for three or fewer days each week and supported out of hours by various forms of 'service user led informal networks of care' (for example telephone, texting and physical support), now offers a more resource and cost effective alternative to traditional inpatient therapeutic communities. The most recent exponent, the North Cumbria model, uses a dedicated out of hours website moderated by service users according to therapeutic community principles. This extends the community beyond the face to face 'therapeutic days'. The website guarantees a safe group-based response not always possible with other systems. The use of 'starter' groups as a preparation for entry into therapeutic communities has lowered attrition rates and they now represent a cost-effective model still aimed at producing durable personal and intergenerational effects; this is at odds with the current trend towards the defensive needs of service providers, rather than service users, for less intensive treatments and management of pathways to control risk.[ citation needed ]

United States

In the late 1960s within the US correctional system, the Asklepion Foundation initiated therapeutic communities in the Marion Federal Penitentiary and other institutions that included clinical intervention based upon Transactional Analysis, the Synanon Game, internal twelve-step programs and other therapeutic modalities. Some of these programs lasted into the mid-1980s, such as the House of Thought in the Virginia Correctional system, and were able to demonstrate a reduction of 17% in recidivism in a matched-pair study of drug-abusing felons and sex offenders who participated in the program for one year or more.[ citation needed ]

Modified therapeutic communities are currently used for substance abuse treatment in correctional facilities of several U.S. states including Pennsylvania, [17] Washington, [18] Colorado, [19] Texas, [20] Delaware, [21] and New York. [22] In New York City, a program for men is located in the Arthur Kill Correctional Facility on Staten Island and the women's program is part of the Bayview Correctional Facility in Manhattan. [23]

Main ideas

The therapeutic community approach aims to help patients deal with social situations and to change perceptions they have about themselves. [24] Difficult situations are re-enacted and experienced and patients are encouraged to examine and try to learn from them with the help of group and individual therapy. [24] The communities function as a living-and-learning situations, where every interaction can serve as a learning moment.

There is no encompassing definition of what a therapeutic community should be. Some have therefore also argued that it follows a family resemblance. [25] A common conception of therapeutic community is a group of people living together in a non-hierarchical, democratic way that brings psychological awareness of individual as well as group processes. Furthermore, the community has clear boundaries of place, time and roles of the participants. [26] They are democratic because the patients are involved in decision-making to encourage a sense of responsibility. This is fostered by the non-hierarchical structure that tries to minimise dependency on the staff. [1]

A key principle is the creation of a culture of enquiry. [27] Everyone within the community is encouraged to reflect and ask question about themselves and others. [1] In this way the participants are supported by continuous feedback to create better self-awareness. [28]

The therapeutic community approach is informed by systems theory, organisation theory and psychoanalytic practice. [1]

Effectiveness

As an intervention model for drug-using offenders with co-occurring mental health disorders, therapeutic communities may help people reduce drug use and subsequent criminal activity. [29] Research evidence for the effectiveness of therapeutic community treatment is substantial [30] and a demonstration of the cost efficacy of a year of residential therapeutic community treatment was instrumental in funding being granted in the late 1990s for the replication of the Henderson Hospital DTC. [31]

Related Research Articles

Psychotherapy is the use of psychological methods, particularly when based on regular personal interaction, to help a person change behavior, increase happiness, and overcome problems. Psychotherapy aims to improve an individual's well-being and mental health, to resolve or mitigate troublesome behaviors, beliefs, compulsions, thoughts, or emotions, and to improve relationships and social skills. Numerous types of psychotherapy have been designed either for individual adults, families, or children and adolescents. Certain types of psychotherapy are considered evidence-based for treating some diagnosed mental disorders; other types have been criticized as pseudoscience.

Group psychotherapy or group therapy is a form of psychotherapy in which one or more therapists treat a small group of clients together as a group. The term can legitimately refer to any form of psychotherapy when delivered in a group format, including art therapy, cognitive behavioral therapy or interpersonal therapy, but it is usually applied to psychodynamic group therapy where the group context and group process is explicitly utilized as a mechanism of change by developing, exploring and examining interpersonal relationships within the group.

Social psychiatry is a branch of psychiatry that focuses on the interpersonal and cultural context of mental disorder and mental wellbeing. It involves a sometimes disparate set of theories and approaches, with work stretching from epidemiological survey research on the one hand, to an indistinct boundary with individual or group psychotherapy on the other. Social psychiatry combines a medical training and perspective with fields such as social anthropology, social psychology, cultural psychiatry, sociology and other disciplines relating to mental distress and disorder. Social psychiatry has been particularly associated with the development of therapeutic communities, and to highlighting the effect of socioeconomic factors on mental illness. Social psychiatry can be contrasted with biopsychiatry, with the latter focused on genetics, brain neurochemistry and medication. Social psychiatry was the dominant form of psychiatry for periods of the 20th century but is currently less visible than biopsychiatry.

This article is a compiled timeline of psychotherapy. A more general description of the development of the subject of psychology can be found in the History of psychology article. For related overviews see the Timeline of psychology and Timeline of psychiatry articles.

Psychiatric nursing or mental health nursing is the appointed position of a nurse that specialises in mental health, and cares for people of all ages experiencing mental illnesses or distress. These include: neurodevelopmental disorders, schizophrenia, schizoaffective disorder, mood disorders, addiction, anxiety disorders, personality disorders, eating disorders, suicidal thoughts, psychosis, paranoia, and self-harm.

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The Retreat, commonly known as the York Retreat, is a place in England for the treatment of people with mental health needs. Located in Lamel Hill in York, it operates as a not for profit charitable organisation.

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<span class="mw-page-title-main">Austen Riggs Center</span> Psychiatric hospital in Stockbridge, Massachusetts, US

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A residential treatment center (RTC), sometimes called a rehab, is a live-in health care facility providing therapy for substance use disorders, mental illness, or other behavioral problems. Residential treatment may be considered the "last-ditch" approach to treating abnormal psychology or psychopathology.

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Thomas Forrest Main (1911–1990) was a psychiatrist and psychoanalyst who coined the term 'therapeutic community'. He is particularly remembered for his often cited paper, The Ailment (1957).

The following outline is provided as an overview of and topical guide to the psychiatric survivors movement:

<span class="mw-page-title-main">David Henderson (psychiatrist)</span>

David Kennedy Henderson FRSE FRCPE was a Scottish physician and psychiatrist and served as president of the Royal College of Physicians of Edinburgh 1949 to 1951.

<span class="mw-page-title-main">Eileen Skellern</span>

Eileen Skellern FRCN (1923–1980) was an English psychiatric nurse who was involved in pioneering psychosocial and psychotherapeutic methods for treating patients. She helped open up new roles for nurses in mental health work, and demonstrated that they could be equal partners in a team, taking personal responsibility for patient care while collaborating with doctors and playing an important part in new developments in therapeutic treatment. While also taking a lead in education, administration and policy development, she did research and published in medical and nursing journals, and was a member of key committees in her field.

Ronald Arthur Sandison was a British psychiatrist and psychotherapist. Among his other work. he is particularly noted for his pioneering studies and use of lysergic acid diethylamide (LSD) as a psychotheraputic drug. As a consultant psychiatrist, his LSD work was mainly carried out during the 1950s and '60s at Powick Hospital, a large psychiatric facility near Malvern, Worcestershire, after which he spent several years in Southampton, where he was instrumental in the establishment of the university medical school. He returned to his native Shetland Isles in the 1970s and worked in psychotherapy there. He later specialised in psychosexual medicine on the UK mainland. Sandison died at the age of 94, and was buried in Ledbury near Malvern.

References

  1. 1 2 3 4 Campling, P. (2001). Therapeutic communities. Advances in Psychiatric Treatment,7(5), 365-372.
  2. 1 2 3 4 5 6 Whiteley, S. (2004). The evolution of the therapeutic community. Psychiatric Quarterly, 75(3), 233–248. https://doi.org/10.1023/B:PSAQ.0000031794.82674.e8
  3. ↑ Boyling, E. (2011). Being Able to Learn: Researching the History of a Therapeutic Community. Social History of Medicine 24(1), 151–158. https://doi.org/10.1093/shm/hkq096
  4. 1 2 Hollander, R. (1981). Moral treatment and the therapeutic community. Psychiatric Quarterly, 53(2), 132–138. https://doi.org/10.1007/BF01064897
  5. ↑ Chapman, C. (1914). The Little Commonwealth. Charity Organisation Review, 35(207), 119–124. http://www.jstor.org/stable/43789304
  6. ↑ Franklin, M. E. (1944, 1 December). The Use and Misuse of Planned Environmental Therapy. Paper read at the Psychopathology and Psychotherapy Discussion Circle.
  7. ↑ Mills, J. A., & Harrison, T. (2007). John Rickman, Wilfred Ruprecht Bion, and the origins of the therapeutic community. History of Psychology, 10(1), 22–43.
  8. 1 2 Harrison, Tom (2017-03-22). Bion, Rickman, Foulkes, and the Northfield Experiments: Advancing on a Different Front. Jessica Kingsley Publishers. ISBN   9781853028373.
  9. ↑ White, Alice (2016). "Chapter Five: Settling down in Civvy Street". From the Science of Selection to Psychologising Civvy Street: The Tavistock Group, 1939-1948 (Thesis). University of Kent.
  10. ↑ Main T. (1946). "The Hospital as a Therapeutic Institution". Bulletin of the Menninger Clinic. 10: 66–70. PMID   20985168.
  11. ↑ Reproduced in Main, Tom (1989). The Ailment and other psychoanalytic essays. London: Free Association Books. ISBN   978-1-85343-105-0.
  12. ↑ Martin, Denis V. (1968). Adventure in psychiatry: Social change in a mental hospital. Cassirer.
  13. ↑ Henderson Hospital 1947-2008
  14. ↑ Perspectives on Henderson Hospital. Warren, F. and Dolan, B. Sutton, UK: Henderson Hospital (2001). 188 pp.
  15. ↑ Fischer, Michael Daniel; Ferlie, Ewan (1 January 2013). "Resisting hybridisation between modes of clinical risk management: Contradiction, contest, and the production of intractable conflict". Accounting, Organizations and Society. 38 (1): 30–49. doi:10.1016/j.aos.2012.11.002. S2CID   44146410.
  16. ↑ Fischer, Michael Daniel (28 September 2012). "Organizational Turbulence, Trouble and Trauma: Theorizing the Collapse of a Mental Health Setting". Organization Studies. 33 (9): 1153–1173. doi:10.1177/0170840612448155. S2CID   52219788.
  17. ↑ Pennsylvania Department of Corrections www.cor.state.pa.us
  18. ↑ https://app.leg.wa.gov/ReportsToTheLegislature/Home/GetPDF?fileName=DOC%20Legislatire%20Report%20Yakima%20Theraputic%20Community%20ESHB%201109_b2b62836-0d6a-4e5f-a50d-e2270ce8df18.pdf [ bare URL PDF ]
  19. ↑ Stout Street Foundation www.stoutstreet.org
  20. ↑ Texas Department of Criminal Justice Archived 2008-08-04 at the Wayback Machine
  21. ↑ Therapeutic Community In a Correctional Setting Archived 2015-05-10 at the Wayback Machine
  22. ↑ Therapeutic Communities Association of New York State Archived 2008-08-29 at the Wayback Machine
  23. ↑ Stay'n Out: In-prison Treatment Programs for Men & Women Archived 2008-08-28 at the Wayback Machine
  24. 1 2 Kennard, D. (2004). The therapeutic community as an adaptable treatment modality across different settings. Psychiatric Quarterly, 75(3), 295–307. https://doi.org/10.1023/B:PSAQ.0000031798.95075.26
  25. ↑ Dunstan, F. & Birch, S. (2004). What Makes a Therapeutic Community? A Comparative Study of Ideal Values. In N. Manning, D. Menzies, & J. Lees A Culture of Enquiry : Research Evidence and the Therapeutic Community (pp. 175-187). Jessica Kingsley Publishers.
  26. ↑ Whitwell, J. (1998). What is a therapeutic community? Emotional and Behavioural Difficulties, 3(1), 12–19.
  27. ↑ Rex, H. S. P. (2017). The theory and practice of democratic therapeutic community treatment. Jessica Kingsley Publishers.
  28. ↑ Lees, J. (2004). A culture of enquiry: researching evidence and the therapeutic community (Ser. Therapeutic communities, 6). Jessica Kingsley.
  29. ↑ Perry, Amanda E.; Martyn-St James, Marrissa; Burns, Lucy; Hewitt, Catherine; Glanville, Julie M.; Aboaja, Anne; Thakkar, Pratish; Santosh Kumar, Keshava Murthy; Pearson, Caroline; Wright, Kath; Swami, Shilpi (2019-10-07). "Interventions for drug-using offenders with co-occurring mental health problems". The Cochrane Database of Systematic Reviews. 10 (10): CD010901. doi:10.1002/14651858.CD010901.pub3. ISSN   1469-493X. PMC   6778977 . PMID   31588993.
  30. ↑ Lees, J., Manning, N., Menzies, D. & Morant, N. (2004). A Culture of Enquiry: Research Evidence and the Therapeutic Community. London: Jessica Kingsley Publishers.
  31. ↑ Dolan, B., Warren, F., Menzies, D., Norton, K. 'Cost offset following specialist treatment of severe personality disorders' (1996) Psychiatric Bulletin 20, 413-417.

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