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Therapeutic community is a term applied to a participative, group-based approach to long-term mental illness that includes group psychotherapy as well as practical activities, and which may or may not be residential with the clients and therapists living together.
The term may have first been used in the 1940s by Harry Stack Sullivan, but the modern community was pioneered by Tom Main, Maxwell Jones, R. D. Laing and the Philadelphia Association, David Cooper and Villa 21 and Joshua Bierer, and gained some reputation for success in rehabilitation and patient satisfaction in Britain and abroad. The availability of the treatment on the National Health Service has recently been threatened because of changes in funding systems. In Britain, 'democratic analytic' therapeutic communities 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 followed a different path with hierarchically arranged communities (or concept houses) specialising in the treatment of drug and alcohol dependence.
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 1960’s. 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. 'TC's have often eschewed or limited medication in favour of psychoanalytically-derived group-based insight therapies.
The context of therapeutic communitiesEdit
Therapeutic communities do not operate within a vacuum and there is usually a powerful dynamic set up between the dominant culture both socially and in terms of the existing care system, and the therapeutic community itself
- Main article: Therapeutic communities - Their context
Therapeutic communities differ in their theoretical perspectives.
- Main article: Therapeutic communities - Theoretical perspectives
Models, innovations and developmentsEdit
- Main article: Therapeutic communities - Models
In the first decade of the 21st Century attempts were made, under the auspices of the UK Royal College of Psychiatrists, to clarify and codify some of the key features of a therapeutic community, in the UK sense of the term. This led first to the development of a Community of Communities, or CoC (http://www.rcpsych.ac.uk/quality/quality,accreditationaudit/communityofcommunities.aspx) ; and subsequently to the formulation and introduction of a standards-based quality improvement programme, bringing together Therapeutic Communities (TCs) in the UK and internationally, engaging them in service evaluation and quality improvement using methods and values that reflect their philosophy.
Nevertheless, this concern to identify the key features of a TC led, perhaps inevitably, to the exclusion or potential exclusion of a number of other communities or community-like approaches; for example, many communities for people with a learning disability were reluctant to accept the term "therapeutic", with its connotations of wishing to "cure", rather than to allow their members to live rich and fulfilling lives.
In order therefore to capture that which is positive in a wider range of settings, the CoC then agreed to development of a parallel working group, to consider how far the same or similar fundamental principles might be found, in a different guise, in other fields. This working group adopted the term "enabling environments" - consciously avoiding either "therapeutic" or "community" - and has gone on to develop and pilot a similar accreditation process for this wider range or organisations (http://www.rcpsych.ac.uk/quality/quality,accreditationaudit/enablingenvironments.aspx).
Two further spin offs from this work were then rapidly articulated. In homelessness resettlement work, the concept of a "psychologically informed environment" (or PIE) was used to articulate good practice in a field where the individuals as service users often had considerable psychological and emotional problems needing thoughtful handling, but "therapy" as such was not felt to be a helpful term. The UK Dept of Communities and Local Government - which is responsible for housing and homelessness policy - adopted this term in subsequent good practice guidance (issued jointly with the UK National Mental Health Development Unit) on meeting the psychological and emotional needs of homeless people (www.nmhdu.org.uk/complextrauma ) to describe innovative practice in outreach and resttlement work in hostels, women's refuges etc.
Meanwhile, in the criminal justice system, where earlier attempts to introduce Therapeutic Communities methods had rarely survived, the expanded concept of a "psychologically informed planned environment" was used describe comparable attempts to develop constructive ("enabling") environments, without the connotatins of a TC. "Planned" here refers to the fact that, in contrast to the evolution of methods in the TC ( or the PIE), a prison is a setting where all changes in the day-to-day regime had to be carefully managed and negotiated.
Community dynamics and processesEdit
- Main article: Therapeutic communities - Community dynamics
Staff dynamics and processesEdit
- Main article: Therapeutic communities - Staff dynamics
Staff training and developmentEdit
- Main article: Therapeutic communities - Staff training
Communities for different client groupsEdit
- Main article: Therapeutic communities - Different client groups
- Main article: Therapeutic communities - Research
References & BibliographyEdit
- Adolfo, F and Wilfredo, G. (2000) Constructing and implementing programmes: the role of the referring public mental health services. Therapeutic Communities Vol. 21, N0. 1 : p.p. 15 - 20.
- Antonnela, R. Berruti, B., and Guisto, G. (1998) Dangerous connections: How a therapeutic community meets the requirements of the Italian psychiatric care system. Therapeutic Communities Vol. 19, No. 3 : p.p. 227 - 238.
- Barnes-Gutteridge W (2001) Psychodynamic Psychotherapy and the Vicissitudes of Therapeutic Communities for troubled children. Therapeutic Communities Vol. 22, No. 4 : p.p. 301 - 318.
- Bowen, M., and Staebler G (2002) A Living Testament to the Power of Anarchy; an enquiry into relations between a therapeutic community and its social and political environment. Therapeutic Communities Vol 23, No 1 : p.p. 33 - 44.
- Burns T (2000) The legacy of therapeutic community practice in modern community mental health services. Therapeutic Communities Vol. 21, No. 3 : p.p. 165 - 174.
- Cameron, D. (1999) Pathological organisation, catastrophic change and psychological birth: the psychodynamic development of a therapeutic community in Northern Ireland. Therapeutic Communities Vol. 20, No. 3 : p.p. 217 - 230.
- Campling, P and Birtle, J (2001) The need for an NHS policy on developing the role of therapeutic communities in the treatment of ‘personality disorder’. Therapeutic Communities Vol 22, No 2 : p.p. 131 - 142.
- Charmet, G. (1997) Reflections on the experience of therapeutic communities in Italy. Therapeutic Communities Vol. 18, No. 2 : p.p. 123 - 131.
- Cox, J. (1998) Reflections on contemporary community Psychiatry: where is the therapy? Therapeutic Communities (1998) Vol. 19, No. 1 : p.p. 3 - 10.
- Goodburn, J. (1986) Paddington Day Hospital or the Psyche Misunderstood : Implications for Therapeutic Communities, Psychotherapy and Psycho-analysis. IJTC Vol. 7, No. 1 : p.p. 57 - 69.
- Hinshelwood, R. D. (1989) The Therapeutic Community in a Changing Cultural and Political Climate. IJTC Vol. 10, No. 1 : p.p. 63 - 69.
- Kennard, D. (1998) Therapeutic Communities are back - and there's something a little different about them. Therapeutic Communities Vol. 19, No. 4 : p.p. 323 - 329.
- Levinson, A. (1996) The struggle to keep a culture of enquiry alive at the Cassel Hospital. Therapeutic Communities Vol. 17, No. 1 : p.p. 47 - 57.
- Lindsay, J. S. B. (1986) The General Hospital and the Therapeutic Community in North Queensland. IJTC Vol 7 No 2 : p.p. 129 -138.
- McKeganey, N. P. (1986) Accomplishing Ideals : The Case of Hospital-Based Therapeutic Communities. IJTC Vol. 7, No. 2 : p.p. 85 -100.
- Montfoort, V. R., and Verwaaijen, A. (1994) The Accreditation Procedure for Psychotherapeutic Communities in Holland. Therapeutic Communities Vol. 15, No. 3 : p.p. 153 - 159.
- Rawlings, B. (1999) Therapeutic Communities in Prisons: a Research Review. Therapeutic Communities Vol. 3, No, 3 : p.p. 177 - 193.
- Therapeutic Community Open Forum Wiki site
- Radio TC International
- Association of Therapeutic Communities (UK) FAQ
- The Planned Environment Therapy Trust website
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