THERAPEUTIC COMMUNITIES

It may seem strange to suggest that the natural environment could play a significant part in a therapeutic community treatment programme. To put it at its simplest, the idea of a therapeutic community is that community interaction is the factor which brings about change and here community means, of course, other people. It is by belonging to a group of peers that a person becomes more self-aware and can adapt his behaviour. It is by projecting his primitive feelings, anxieties and fantasies onto the community that the community can act as a container (Haigh, 1999) and become the therapist (Hinshelwood, 1979) or the doctor (Rapoport, 1960). The therapeutic community stands, par excellence, for the idea that it is other people, a human society which forms the basis for treatment, because psychotherapy is a dialogue between people.

Four TC Principles (Rapoport 1960)

Democratisation – (flattened hierarchy, sharing of decision making) allows self-management to emerge and altruism to flourish as a patient is allowed to contribute meaningfully to the treatment of others.

• Communalism -  (sharing of mutual tasks, close interdependency) promotes interaction with others, responsibility sharing, the abandonment of fixed social roles and attitudes, and the development of new relationships.
• Permissiveness – (difficult behaviour is tolerated) allows for catharsis, self-disclosure and the assumption of self-responsibility
• Reality confrontation – (presentation of behaviour as it is seen by others) can promote self-awareness and the development of identity and self-concept and learning through interpersonal actions.

Five Therapeutic Factors of TCs (Haigh 1999)

1. Attachment
2. Containment
3. Communication
4. Involvement
5. Agency

AN EXAMPLE TIMETABLE

Other features of the programme

• ‘Special’ meetings
• Out of hours support system
• Communal cooking, shopping, living: ‘Living learning experience’
• Joining programme
• Leaving programme
• Less intensive TC programmes

What is a Therapeutic Community?

A brief explanation from the Association of Therapeutic Communities

A Therapeutic Community (TC) is a place whose primary aim is to help people with their emotional and interpersonal problems. The way this help is structured is guided by a set of values and beliefs about the way people should treat each other and be treated, based on self-awareness, interdependence, deep mutual respect and assumption of personal responsibility. These shape the principles which underpin TC practice. TCs differ in the details of their approach, depending on the client group.

What are the values of TCs?

Central to all TCs is the belief that people can change, and that in order to realize their potential as individuals and active citizens, they require an environment that fosters personal growth. They need to form relationships with others in an atmosphere of trust and security, they need to be valued, accepted and supported by those around them and they need to take real responsibility for themselves, others and their environment. A strong sense of community membership and belonging are critical to the process; in order to benefit from participation in a TC the member must be positively motivated to change, and to accept the TC’s rules. These rules uphold the values and norms of the community, which are a reflection of those held by society.

What do TCs do?

A TC is an informal, casual environment. Members and staff are not immediately distinguishable from each other and there is a distinct communal atmosphere. The TC offers a safe environment with a clear structure of boundaries and expectations.

TCs have a daily structure that incorporates all practical arrangements for maintaining and developing the community, as well as a varied programme of formal and informal therapeutic activity, These may include group or individual therapy, creative therapies, social or cultural activities, and educational or work placements. All members of the TC are involved in the daily programme that contributes to both the individual’s needs as well as those of the community as a whole.

Everyone is expected to contribute to the life of the TC according to his or her ability. Members are expected to take responsibility for themselves (for example, in terms of personal cleanliness, tidiness and appropriateness of behaviour) and to participate in the running of the TC. This includes duties such as cleaning, gardening and administrative tasks, which are assigned by the whole community. Members and staff meet together regularly to discuss the management and activities of the community and to make decisions affecting them, for example members’ joining or leaving are particularly important. Members take on increasing responsibilities as their confidence and abilities develop during their time in the community.

Members tend to learn much through the routine interactions of daily life, and the experience of being therapeutic for each other. The goal is to improve members’ interpersonal functioning; first within the therapeutic community, and ultimately in the wider community. Feedback from peers enables members to reflect on the way their conduct affects others, and members may practice new behaviours and ways of relating and begin to gain increased self-esteem and knowledge of themselves.

Who can TCs help?

TC principles can be applied to the therapeutic care of a wide range of people in different settings. TCs can be residential or day facilities. They can be located across all sectors in Health and Social Care, including the Prison Service. They help some of society’s most vulnerable and socially excluded adults, children and young people.  Problems include mental disorder, learning difficulties, substance misuse, severe emotional and behavioural difficulties and offending behaviour.

References

Haigh, R. (1999) The Quintessence of a Therapeutic Environment. Five Universal Qualities, Therapeutic Communities. Past, Present and Future p. 246-257, (ed.) P Campling and R. Haigh, London and Philadelphia: Jessica Kingsley.

Hinshelwood, R.D. (1979) The Community as Analyst, Therapeutic Communities: reflections and progress (ed.) R.D. Hinshelwood and N. Manning, p.103-112, Routledge and Kegan Paul: London, Boston and Henley.

Rapoport, R.N. (1960) Community as Doctor London: Tavistock Publications.

Bibliography

Chiesa, M., Iacoponi, E., & Morris, M. 1996, "Changes in health service utilization by patients with severe personality disorders before and after inpatient psychosocial treatment.", British Journal of Psychotherapy, vol. 12, no. 4, pp. 501-512.

Davies, S., Campling, P., & Ryan, K. 1999, "Therapeutic community provision at regional and district levels", Psychiatric Bulletin, vol. 23, no. 2, pp. 79-83.

Davies, S. & Campling, P. 2003, "Therapeutic community treatment of personality disorder:

Service use and mortality over 3 years' follow-up", British Journal of Psychiatry, vol. 182, no.

Suppl44, p. s24-s27.

Lees et al (1999) Therapeutic Community Effectiveness: A Systematic International Review Of Therapeutic Community Treatment For People With Personality Disorders And Mentally Disordered Offenders. NHS Centre for reviews and dissemination

Websites

Association of Therapeutic Communities website: http://www.therapeuticcommunities.org/

A History of Therapeutic Communities: http://www.sanctuaryweb.com/Documents/Downloads/Whiteley.pdf