Therapeutic Communities for Psychosis

Philosophy, History and Clinical Practice

John Gale, Alba Realpe, Enrico Pedriali, John Gale, Alba Realpe, Enrico Pedriali

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781317723790
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Therapeutic Communities for Psychosis offers a uniquely global insight into the renewed interest in the use of therapeutic communities for the treatment of psychosis, as complementary to pharmacological treatment. Within this edited volume contributors from around the world look at the range of treatment programmes on offer in therapeutic communities for those suffering from psychosis.

Divided into three parts, the book covers:

• the historical and philosophical background of therapeutic communities and the treatment of psychosis in this context
• treatment settings and clinical models
• alternative therapies and extended applications.

This book will be essential reading for all mental health professionals, targeting readers from a number of disciplines including psychiatry, psychology, social work, psychotherapy and group analysis.

Part 1
Historical background and philosophical context

What has made it possible here to speak of reasonable madness, of the preservation of clarity, order, and will, is the feeling that, however far into the phenomenon we go, we remain in the realm of the understandable. Even when what one understands can’t even be articulated, named, or inserted by the subject into a context that makes it clear, it's already situated at the level of understanding.

Jacques Lacan 1993

Chapter 1
A view of the evolution of therapeutic communities for people suffering from psychosis

David Kennard

The use of supportive living environments for people experiencing psychosis goes back several centuries. This chapter describes four phases in the evolution of therapeutic community principles and their adaptation to meet the needs of people with severe mental illness.

Phase 1: the emergence (and submergence) of a humane approach to the mentally ill

The earliest example of a humane, social approach to mental illness is often given as Geel (also spelt Gheel) in Belgium beginning in the 14th century, where the mentally ill were brought to the shrine of St Dymphna, an early Christian martyr. Many recovered, and for those who did not a tradition was established of having a lunatic living in the home (Clark 1967). In Geel, it was said that lunatics could walk the streets, engage in commerce, deliver food, carry milk and were incorporated into the society and respected.

Although Geel demonstrated that a humane approach to mental illness was possible, in the 17th century the prevailing view of the human mind, associated with the mind–body dualism of Descartes, separated the concept of the rational human from irrational beings, classing the mentally ill with animals. This view allowed society to tolerate appalling treatment of the mentally ill until it began to be challenged by the Quakers who set up the York Retreat. The development at the beginning of the 19th century of what came to be called moral treatment introduced and disseminated a humane approach that has since become a key reference point for contemporary mental health services. I cannot better the following passage as an account of its development:

Any review of moral treatment as it was first practised at The Retreat needs to take into account the Quaker background of its founders. Early Quakerism, with its emphasis on the individual’s responsibility to cultivate a lifestyle which would encourage and nurture the ‘Inner Light’, brought its followers into many situations of personal and collective suffering. Quakers were vigorously persecuted for their beliefs and actions, often imprisoned, and regarded as deviant and troublesome. Quaker insistence on the spiritual equality of all human beings, regardless of race, education, gender, or age, offended many of the cultural mores of the period, and the sight of Quaker women preaching in public led to accusations of witchcraft. The relentless persecution suffered by the early Quakers led them to form a system of mutual solidarity. Those who had lost property or who had suffered injury or imprisonment could always count upon other Friends to provide money, shelter and other forms of practical and spiritual support. These two strands of thinking, that each individual is responsible for his or her own spiritual integrity and conduct before God, and that those who espouse these principles have a duty to serve, support, encourage and inspire each other towards a common spiritual goal, formed the basis for the practical expression of moral treatment as it was first practised at The Retreat.

Although the persecution of Quakers ceased by the late 18th century, the tradition of empathy with marginalized members of society was likely to have been a factor in the founding of The Retreat. In the 18th century ‘madhouses’ and asylums were brutal places. The justification for the treatment of the mad as if they were animals came largely from the Cartesian ideal that Reason and Logic formed the basis of all nature and that this was glorified and exemplified in the human being, God’s supreme creation. A human being devoid of reason and logic was therefore a contradiction in terms, and in fact, must then be regarded as more like a beast than a person.

Quakers did not share this mainstream idea of humanity. Although they believed strongly in the desirability of clear and logical thought, this was not as an end in itself or a definition of personhood, but rather a means to focus on a greater truth, that of the Inner Light, a positive, life-affirming experience, beyond words or logic. The Retreat’s founder William Tuke set about establishing an environment where people in mental distress could begin to take responsibility for their own emotions and conduct, in order that they might come into clearer focus with their own personal truth and their responsibility towards others.

(Borthwick et al. 2001: 428)

Borthwick et al. (2001) summarised moral treatment in terms of seven basic principles.

1. A concern for the human rights of people with severe and disabling mental health problems. There is a deep-seated belief that all men and women are created equal and are equally deserving of care. Each individual is unique and of value.
2. Personal respect for people with severe mental health problems. More than a recognition of rights, this implies tolerance of odd behaviour, recognition of the need for privacy and dignity, respect for the meaningfulness to the individual of their subjective experiences, respect for individual and cultural differences.
3. An emphasis on the healing power of everyday relationships. Kindness, acceptance, encouragement, affection, friendship, the opportunity to give as well as receive and an expectation of responsible behaviour, are all seen as powerful forces in helping an individual to recover his or her mental health.
4. The importance of useful occupation. Structured activity can have a calming influence, occupation can be a basis for relating to others and being part of a group and a sense of achievement and purpose are sources of self-respect.
5. Emphasis on the social and physical environment. The Retreat aimed to create a ‘quiet haven in which the shattered bark might find the means of reparation or of safety’ (Tuke 1813). Moral treatment stressed both the physical and social environment: the setting and the views should be pleasing, staff were to be employed for their personal qualities of tolerance, intelligence and integrity and numbers should be small enough to create a family like atmosphere.
6. A commonsense approach rather than reliance on technology or ideology. There was a mistrust of professions, with their tendency to seek power through claims of specialist knowledge and techniques. At the same time a commonsense approach accepted a need for supervision to prevent harm or exploitation and set limits to the tolerance of antisocial behaviour.
7. A spiritual perspective. For Quakers this was expressed in the belief that there is ‘that of God’ in everyone, an inner light in every individual, no matter how disturbed or withdrawn.

The Retreat, which opened in 1796, helped to spark a revolution in care of the mentally ill. In the early and mid-19th century there was great optimism and idealism in England, and also in the United States,¹ that a calm, well-ordered environment would restore mental health and well-being to the ‘shattered bark’. Sadly, the pressure of numbers combined with the growing belief that mental disorders resulted from biological rather than social factors, meant that the unintended legacy of moral treatment was the building of institutions of ever increasing size for 1000 or more patients. By the beginning of the 20th century they had became little more than warehouses. In the 1950s an American psychiatrist J.S. Bockoven described the scene in a typical mental hospital as, ‘the heavy atmosphere of hundreds of people doing nothing and showing interest in nothing, with endless lines of people sat on benches along the walls’. In a faint, poignant echo of moral treatment he adds that:

The visitor learns that the attendant is proud of the ward because it is quiet and no mishaps have occurred while he was on duty; because the floor is clean, because the patients are prompt and orderly in going to and from meals. The visitor finds that the scene which appals him with the emptiness and pointlessness of human life is regarded by the attendant as good behaviour on the part of the patients.

(Bockoven 1956: 168)

Phase 2: the impact of psychoanalytic ideas and democratisation on institutional psychiatry: the therapeutic community approach

While psychiatric patients languished in ward warehouses in the first half of the 20th century, elsewhere two ideas were having a major impact on therapeutic approaches to emotional and behavioural problems: psychoanalysis and democratisation. To put these two ideas at their simplest, Freud’s psychoanalysis offered the intriguing possibility that irrational behaviour and utterances had meaning if you could decipher the code. Respect for someone with a mental illness was no longer only a matter of concern for their dignity and well-being. It also meant listening to what they said as meaningful communication.

Democratisation as a method of treatment was first and famously tried in England by Homer Lane with delinquent children and adolescents at the time of World War 1. Lane modelled his Little Commonwealth on junior republics in the USA that used the American constitution as a model for therapeutic living, with community members as citizens. Lane also tried out psychoanalytic techniques with individuals at the Little Commonwealth, with more enthusiasm than expertise and this led to allegations of inappropriate behaviour with a female resident and to the closure of the place. Despite this unfortunate end, Lane inspired a number of pioneers who set up residential schools for maladjusted children in the early decades of 20th century using similar principles (Bridgeland 1971; Kasinski 2003). The 1920s and 30s was a fertile period for many experiments in social living (Pines 1999), influenced by a mixture of social idealism, psychoanalysis and new ideas in the social sciences.

It was during the years of World War 2 that psychoanalysts, psychiatrists and social psychologists first applied the recipe of psychoanalysis and democratisation to the problems presented by service men who were emotional casualties of the frontlines and had been transferred to the military hospitals at Northfield in Birmingham and Mill Hill in north London.

Although there is no explicit evidence that they were directly influenced by the pioneering work with children,² it may be argued that they were influenced by a Zeitgeist that included the discoveries of psychoanalysis and a willingness – and freedom – to experiment with new approaches to emotional and behavioural problems. Bion, Bridger, Main and Foulkes at Northfield brought their interest in unconscious motivation and group and organizational dynamics, while Maxwell Jones, a research psychiatrist, brought to Mill Hill an enthusiasm for sharing explanatory models of stress symptoms (called effort syndrome) and encouraging patients to become teachers to one another – an early example of user involvement. Between them they created a new model of mental healthcare. While it was Jones whose unit established its core principles (see later), it was Main who is widely credited with giving it its name: ‘a therapeutic community’ (Main 1946).

In the 1950s and 60s, following the creation of the National Health Service in 1948, the impact of psychoanalytic ideas and democratisation also began to be felt in the mental hospitals that housed those with severe and enduring mental illness. The NHS brought all the county asylums in England into one service and also brought a new wave of resourceful and determined young hospital superintendents who were aware of the work and ideas of Main, Foulkes and Jones. Following the end of the war Foulkes went to the Maudsley Hospital to teach group psychotherapy, Main became director of the Cassel Hospital and Jones took charge of the social rehabilitation unit at Belmont Hospital – later renamed Henderson Hospital. At mental hospitals like Fulbourn, Littlemore and Claybury the new ideas began to be put into practice, with admission or rehabilitation wards that had been run in traditional fashion being made over with regular community meetings and patients sharing responsibility for the day-to-day life of the ward. In the United States these ideas were also introduced into psychiatric wards by Wilmer, who visited Great Britain after the war and was keen to challenge Maxwell Jones’ view that psychotic patients could not be treated in a therapeutic community. In addition to attempts to set up ward-based therapeutic communities within a hospital, there was also what came to be called the ‘therapeutic community approach’ to the hospital as a whole (Clark 1965).

This, according to Clark, was ‘in some degree a revival of the old principles of moral treatment’ (Clark 1965: 948), and was supported by a report of the World Health Organisation in 1953 which said: ‘Too many psychiatric hospitals give the impression of being an uneasy compromise between a general hospital and a prison. In fact the role they have to play is different from either: it is that of a therapeutic community’ (WHO 1953: 17–18). The report spelled out the five constituent parts of this as:

• Preservation of the patient’s individuality.
• The assumption that patients are trustworthy.
• That good behaviour must be encouraged.
• Patients must be assumed to retain the capacity for a considerable degree of responsibility and initiative
• The need for activity and a proper working day for all patients.

Two parallel developments gave a considerable boost to the development both of ward-based therapeutic communities and of a therapeutic community approach to the whole hospital. One was the extensive use from 1955 of tranquillisers that ‘made possible contact with many patients who were previously unreachable’ (Clark 1965: 948). The other was a spate of sociological studies of mental hospitals in the United States. The most famous of these, Asylums, published by Goffman in 1961, introduced the phrase total institution to describe the way inmates were treated in collective identical batches (Goffman 1961). Other key studies included The Mental Hospital (Stanton and Schwartz 1954), which demonstrated how unexpressed conflict between ward staff could lead to disturbed behaviour among patients, The Psychiatric Hospital as a Small Society...

Table of contents

• Cover
• Title
• Copyright
• Contents
• Editors' biographies
• Editors and contributors
• Foreword
• Preface
• Acknowledgements
• PART 1 Historical background and philosophical context
• PART 2 Treatment settings and clinical models
• PART 3 Alternative therapies and extended applications
• Index