Offender Rehabilitation and Therapeutic Communities

Enabling Change the TC way

Alisa Stevens

• Publisher: Routledge
• Year: 2012
• Print ISBN:
  9780415670180
• eBook ISBN:
  9781136233913
• Topic: Sciences sociales
• Subtopic: Criminologie

Offender rehabilitation has become increasingly and almost exclusively associated with structured cognitive-behavioural programmes. For fifty years, however, a small number of English prisons have promoted an alternative method of rehabilitation: the democratic therapeutic community (TC). These prisons offer long-term prisoners convicted of serious offences the opportunity to undertake group psychotherapy within an overtly supportive and esteem-enhancing living environment.

Drawing upon original research conducted with 'residents' (prisoners) and staff at three TC prisons, Offender Rehabilitation and Therapeutic Communities provides a uniquely evocative and engaging portrayal of the TC regime. Individual chapters focus on residents' adaptation to 'the TC way' of rehabilitation and imprisonment; the development of caring relationships between community members; residents' contributions towards the safe and efficient running of their community; and the greater assimilation of sexual offenders within TCs for men, made possible in part by a lessening in 'hypermasculinity'.

By analyzing residents' own accounts of 'desistance in process' in the TC, this book argues that TCs help offenders to change by enabling positive developments to their personal identity and self-narratives: to the ways in which they see themselves and their life. The radically 'different' penal environment allows its residents to become someone 'different'.

1	Therapeutic communities and prisons

Grendon is about changing mindsets: changing your attitudes, beliefs, and values, so that you can be the best person you can be.

(Johnny, Grendon)

A democratic therapeutic community (TC) is surprisingly difficult to define. At its most general, the term refers to a psychosocial method and programme of treatment which is intended to help troubled people, residing in or regularly attending a carefully designed and maintained social community, understand and, as far as possible, lessen or overcome their psychological, social, and emotional problems. This is achieved in two ways: first, through residents’ active participation in group (or occasionally, individual) psychotherapy, in order to unearth, examine, and work through the often unconscious motives, unresolved conflicts, and learned maladaptive self-protective behaviours that can result from traumatic or abusive formative experiences (Malan 1979; Cordess and Williams 1996; Campling 2001); and second, through residents’ contribution to the daily nurturance of an interdependent, cohesive, pro-social environment, including involvement in specific activities of therapeutic benefit to the individual and of practical or domestic benefit to other community members.

A well-functioning community serves as ‘the primary therapeutic instrument’ (Roberts 1997a:4). It provides daily ‘living-learning experiences’ (Jones 1968:106) and opportunities for self-discovery and ‘two way communication of content and feeling, listening, interaction, and problem solving, leading to learning’ (Jones 1980:35) which, over time, enable residents to recognize, reflect upon, and understand their problems and work towards change. The general ‘feel’ of the TC should be of a dynamic ‘culture of enquiry … into personal and interpersonal and intersystem problems’ (Main 1946, cited in Dolan 1998:410), where every incident and every interaction is potentially subject to therapeutic scrutiny. Each member of the community should be able to participate equally in administrative decision making and contribute meaningfully to other residents’ therapy. The former allows residents to acquire a profound sense of investment in, ownership of, and responsibility for their community’s decisions, their implications and implementation, and the safe and effective functioning of the community. The latter ensures that the community’s ‘total resources … are self-consciously pooled in furthering treatment’ (Jones 1968:85) and promotes a sense of egalitarianism between residents and staff. Amenities and domestic arrangements are shared, and informality and the ‘freeing’ of communication encouraged. Residents’ ‘deviancy’ and ‘mistakes’ are accepted rather than condemned, but this tolerance is tempered by the imparting of constructive ‘therapeutic feedback’, in which community members relate the impact such behaviour has upon them and instigate discussion upon the ‘issues’ they consider this raises for the resident (Rapoport 1960; Haigh 1999).

Another way to understand what a TC is, is to understand what it opposes. In psychiatry, from whence the TC originates, it denotes an approach to care that avoided the medical model, with its reliance on diagnostic categories and pharmacological remedies, and rejected the autonomy-sapping and power-abusing characteristics of ‘total institution’ mental hospitals. Here, paternalistic medics preoccupied themselves with the maintenance of control, hierarchy, and routine and slavish adherence to a myriad of, often bizarre, bureaucratic rules (Stanton and Schwartz 1954; Belknap 1956; Caudill 1958; Goffman 1961); whilst no more was expected (or desired) from patients than they played an apathetic ‘sick role’ (Parsons 1951). In prisons, the environment with which this book is concerned, the TC represents a counter-culture way of imprisonment and offender rehabilitation. For prisoners, this means the TC seeks to resist the ‘criminalistic ideology’ (Clemmer 1958:300) of the inmate code and reverse the counterproductive effects that prevent imprisonment from being ‘a constructively painful experience’ (Johnson 1996:xi). For prisons, the TC way demands that the institution relinquishes some decision making to prisoners, empowers them to take more responsibility for themselves, and loosens, within limits, its automatic over-reliance upon, and at times in secure prisons, obsessive fetishism about, security, as the meta-narrative of the prison’s purpose. As a method of offender rehabilitation, the TC extends beyond current penological preoccupations with minimizing or managing risk of harm and re-offending, to offer help to the prisoner as a whole person, with complex, multi-dimensional needs and frequently, low self-esteem and minimal aspirations for and expectations of a productive and peaceable life after prison. In both psychiatric and penal settings, the TC’s ultimate aim is to ensure that the community member can enjoy a ‘stable life in a real role in the real world’ (Main 1996:80) that awaits beyond the TC. As a result, the living experience within the community needs to be as ‘normal’ as possible, and to offer daily opportunities to acquire and practise ‘normal’ ways of being, behaving, and relating to and interacting with others.

Part of the reason for the definitional vagueness that still afflicts therapeutic communities comes from the adoption of TC principles in various similar-but-different institutions internationally. Specifically in relation to penal or forensic establishments, these include variations on social therapeutic regimes in Europe, and addictions TCs in the United States and elsewhere.

Notably, Denmark’s renowned Treatment Institute at Herstedvester prison in Copenhagen was the first European institution to forge a TC ‘approach’ (Clark 1965)¹ with its establishment in 1935 – almost three decades before Grendon – to provide intensive psychiatrist-led, individualized psychodynamic therapy. Indeed, Grendon’s first governor, Dr William Gray, travelled to Herstedvester in 1967 to consult with its medical director, Dr Georg Stürup, then considered to be ‘the high priest of prison psychiatry, and his institute the mecca’ (Royal College of Psychiatrists 1986:125). Herstedvester provides a national resource for male and (since 1987) female, often personality disordered,² sometimes psychotic,³ serious offenders, and has gained an enviable reputation for working successfully with recidivist, sadistic sexual offenders by combining psychotherapy with chemical castration (Stürup 1968; Hansen and Lykke-Olesen 1997; Mollerup et al. 2005). Germany, meanwhile, has developed an extensive network of social therapeutic prisons, either as independent institutions wholly devoted to social therapy or as part of a ‘regular’ prison (Dünkel and Johnson 1980; Lösel and Egg 1997; Ortmann 2000). Switzerland boasts an 11-bed ‘centre for sociotherapy’, La Pâquerette, at Champ-Dollon prison,⁴ near Geneva (de Montmollin et al. 1986; Bernheim and de Montmollin 1990; Federal Department of Justice and Police 2011); and the Netherlands offers a secure forensic psychiatric hospital, the Van der Hoeven Kliniek, in Utrecht (Feldbrugge 1990; de Ruiter and Trestman 2007; de Boer-van Schaik and Derks 2010). Like their English democratic TC counterparts, these institutions work with serious violent and sexually violent, (severely) personality disordered offenders, whilst the Van der Hoeven Kliniek additionally works with people with major mental illness.

By contrast, addictions (also known as hierarchical, concept, or drug-free) prison-based TCs are specifically for offenders with problematic drug use. Many offenders in democratic (sometimes known as psychoanalytic, milieu, or Maxwell Jones) TCs will also have had substance abuse problems, but the addictions model targets offenders where their main ‘issue’ is drugs, rather than personality disorder. Scholars disagree about whether addictions TCs are, in ideology and practice, predominantly similar to (Sugarman 1984; Vandevelde et al. 2004; Shefer 2010a) or significantly different from (Glaser 1983; Lipton 1998, 2010) their democratic cousin, but certainly they share an encouragement of residents’ active involvement in, and responsibility for, the day-to-day running of the TC; a respect for the social learning and behavioural reinforcement that occurs naturally in the course of communal living; and a distrust of the medical model of addiction (Jones 1980; Wexler 1997). Conversely, residents are expected to conform to an overtly hierarchical regime, with disciplined adherence to the community’s rules, engagement in a structured day, the incremental earning of (and potentially loss of) privileges, and progression through clearly defined stages of treatment.

The addictions model’s history, international expansion, and underpinning principles are beyond the scope of this book (but for which, see de Leon 1997, 2000; Lipton 1998; Kooyman 2001; Broekaert et al. 2006). In brief, though, this model originates with the creation of Synanon⁵ in Santa Monica, California, in 1958, and Daytop Village and Phoenix House in New York, in 1964 and 1967 respectively. These promoted a form of community-based treatment based on the self-help 12-step cognitive-behavioural programme established by Alcoholics Anonymous, and adhered to a set of explicit values or concepts consistent with ‘right living’ and the psychological causes of (alcohol and drug) addiction and its treatment. Daytop Village and Phoenix House subsequently developed into very successful, non-profit making global organizations, offering a variety of treatment programmes for people with substance abuse problems across community, residential, and custodial settings. From the late 1980s in America, federal training, support, and funding for hierarchical TCs in prisons ensured that these programmes became well established (Wexler 1997). Following a plethora of consistently positive outcome evaluations (inter alia, Wexler et al. 1990; Schwartz et al. 1996; Pearson and Lipton 1999; Wexler et al. 1999; Lees et al. 2004; Mitchell et al. 2007; cf. Zhang et al. 2011), especially when multi-stage (with aftercare) TC treatment is provided (inter alia, Knight et al. 1997; Inciardi et al. 1997; Hiller et al. 1999; Martin et al. 1999; Inciardi et al. 2004; Prendergast et al. 2004), the hierarchical TC can now claim to be ‘the treatment of choice in American prisons’ (Wexler 1997:161) for offenders with drug problems. The success of these programmes in America in turn encouraged the Prison Service in England and Wales (and elsewhere) to introduce hierarchical TC treatment in 1996, as part of its reinvigorated drug treatment and rehabilitation strategy (Mason et al. 2001). Programme specification, development, and delivery was contracted to external providers. As with democratic TC units, discussed shortly, establishing, nurturing, and expanding addictions TCs has proven difficult. Five units (three of which were for women) survived only briefly (Shefer 2010a), but the renamed Phoenix Futures currently delivers addictions TC treatment in four units within men’s English prisons (Phoenix Futures 2012).

The term therapeutic community therefore has to be used with some care and caution, since it can mean different things to different people, given its diversity of practice and breadth of clientele. The sole focus of this book, however, is the democratic model of TC treatment for prisoners, and reference to TCs in the chapters to come implies only this democratic model in prisons, though the research findings will doubtlessly resonate with practitioners and residents of other TC ‘types’. In this chapter,⁶ after outlining the origins, expansion, then contraction in use of democratic TCs in psychiatry, I proceed to explain why and how, via a meandering and uncertain pathway, TCs came to be adopted by a limited number of English prisons, with varying degrees of long-term success. The chapter concludes by summarizing existing research on the forensic TC’s evidence base, and thus the potential it holds to help the serious imprisoned offender become ‘the best person you can be’.

A short history of therapeutic communities

The origins of therapeutic communities can be traced to the earliest attempts of providers of psychiatric care to offer ‘moral treatment’⁷ (Kennard 2004; Whiteley 2004), but most clearly developed from the creation during World War II of specialist units to treat traumatized military personnel presenting with acute dissociative, neurotic, and hysterical disorders. The regime in these units was, separately but within a short space of time, devised by a handful of, often Tavistock Clinic-trained,⁸ British psychiatrists and psychoanalysts, who were inspired by psychoanalytic, psychological, and social scientific theorizing about small group processes, interpersonal relations, and social environments (inter alia, Freud 1922; Adler 1924; Mead 1934; Lewin 1935), and were informed by their determination not to replicate the punitive and disabling mistreatment which Great War shell-shocked⁹ soldiers had encountered. It seemed to them that the authoritarian, oppressive, and dependency-inducing culture of the secure psychiatric hospital only exacerbated self-damaging behaviours, so that their patients were, in effect, prevented from getting well because their ‘treatment’ was taking place within an anti-therapeutic environment. Conversely, they thought, a more humane, tolerant, and empowering milieu, which provided for a flexible, egalitarian organizational structure and collaborative, group-based interaction, might relieve more effectively their patients’ symptoms of distress (Manning 1976; Kennard 1998).

The initial, modest attempt at innovation occurred in the unlikely setting of a temporarily converted public school at Mill Hill, north London, to which psychiatric patients from Maudsley Hospital were evacuated in 1940. Maxwell Jones, a psychiatrist researching effort syndrome,¹⁰ decided to share the findings with his patients through regular didactic lectures. He soon realized, however, that his patients understood more, and their morale and self-esteem consequently improved, if he involved them in interactive group discussions. These small groups fostered social learning, encouraged greater sociological contextualizing of the challenges that treatment posed, and began to affect the social structure of the ward by promoting a flattened hierarchy between staff and patients, which allowed for some decision making by consensus and more open communication (Jones 1952, 1968; Whiteley 2004).

Wilfred Bion, meanwhile, was appointed director of the Training Wing of Birmingham’s Northfield military psychiatric hospital and charged with rehabilitating men who, although psychologically disturbed, were considered capable of returning to military service. Together with his colleague John Rickman, Bion decided to confront his patients’ disruptive behaviour by redefining disciplinary problems, in suitably combative terms, as the ‘common enemy’, and by attending proactively to the therapeutic climate of the treatment setting. For six weeks in 1943, they introduced discussion groups and communal activities, designed to replace the fractured social bonds of war with the mutual support of a peer community and, hence, ‘to treat socially the social elements of the patients’ neuroses’ (Roberts 1997b: 14). The insubordination and subversion of military discipline this (what has been retrospectively called) ‘first Northfield experiment’ represented, however, proved intolerable to their superiors and Bion and Rickman were transferred. Undeterred, over the next three years Siegmund Foulkes and Harold Bridger, amongst others, implemented gradually a ‘second Northfield experiment’ – but crucially, this time with the approval of a new, more supportive, commanding officer – which again advocated the use of group analysis, regular meetings, creative pursuits, and social activities involving the whole community (Kennard and Roberts 1983; Harrison 1999; Whiteley 2004).

In 1945, Northfield acquired a new hospital director, Tom Main, who sought to incorporate techniques from both psychiatry and psychoanalysis to construct a psychodynamic and interpretative exploration of his patients’ objective difficulties through their subjectively felt interpersonal frustrations and conflicts. In an article published in May 1946, Main argued that the neurotic individual with disturbed social relationships needed ‘a framework of social reality which can provide him with opportunities for attaining fuller social insight and for expressing and modifying his emotional drives according to the demands of real life’ (Main 1996:77). He rallied his colleagues to replace the ‘social refuge’ of the hospital with an internal community, and the role of the expert ‘superintendent’ psychiatrist of patients with a humble ‘technician’ among patients, whose daily task was to study and facilitate the therapeutic potential of and communication within the community and the effective social integration and personal development of its patients (ibid.:79). Several commentators have since timed the appearance of Main’s ‘stirring and inspirational’ paper as the ‘date of birth’ of the democratic therapeutic community (Kennard 1996:71).

Somewhat by accident then, a dispersed cluster of innovators discovered that small group discussion could constitute a therapeutic tool and encourage members to become more involved in the daily management of their environment and more invested in self-managing their problems. Many TC pioneers went on to develop illustrious careers. Foulkes (1948, 1975) and Bion (1961, 1970), for example, became world-renowned authorities upon group psychoanalytic psychotherapy. Main further developed the TC model during his tenure as medical director of Cassel Hospital, in Richmond, Surrey, establishing both his reputation as an ‘outstanding’ psychodynamic psychiatrist and the Cassel as an internationally known centre for psychodynamic psychotherapy (British Medical Journal 1990:1718). The concept and contemporary practices of the TC are most associated, though, with Maxwell Jones, whose efforts to treat complex personality and psychopathic disorders at the Social Rehabilitation Unit at Henderson Hospital,¹¹ in Sutton, Surrey, prolific stream of writings (inter alia, Jones 1952, 1953, 1968, 1976, 1982), and international evangelizing of social psychiatry¹² secured for him the reputation of the ‘father’ of the TC movement (Manning 1976). While Main and his Northfield colleagues can therefore claim the creation of the TC philosophy, it was Jones at Mill Hill who devised the method (Whiteley 2004), and most conspicuously disseminated its development.

During the 1960s and 1970s, the number of British TCs, both in the National Health Service (NHS) and independent non-statutory sectors, continued to grow, and acceptance of its ideals to flourish within psychiatry. More liberal, ‘open-door’ psychiatric hospitals became the norm, as mental health professionals recognized the importance of the emotional and social atmosphere of the treatment setting, and society became more understanding and accepting of mental illness. The loosely organized anti-psychiatry movement¹³ – comprising, amongst others, the existentialist and radical psychiatrists Ronald Laing (1960, 1961, 1966); Thomas Szasz (1961); and David Cooper (1967, 1980) – also mobilized critical thinking about the social role and bio-medical basis of psychiatry, and facilitated the opening of a number of TCs, most famously the experimental community at Kingsley Hall (see Barnes and Berke 1971; Burston 1996) and Villa 21 (Cooper 1967).

Yet, some of these (ultimately, short-lived) regimes attracted considerab...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Series editor’s foreword
• Preface
• Acknowledgements
• List of abbreviations
• Introduction: offender rehabilitation and therapeutic communities
• 1 Therapeutic communities and prisons
• 2 Conducting research in prisons: tightrope walks and emotion work
• 3 New beginnings: commencing change the TC way
• 4 Care, trust, and support
• 5 Responsibility, accountability, and safety
• 6 Vulnerability, unmasking, and ‘de-othering’
• 7 Pursuing change the TC way and beyond
• Notes
• References
• Index