The Theory and Practice of Democratic Therapeutic Community Treatment

Rex Haigh, Steve Pearce

• Publisher: Jessica Kingsley Publishers
• Year: 2017
• Print ISBN: 9781785922053
• eBook ISBN: 9781784504830
• Topic: Psychology
• Subtopic: Social Psychology
• Index: Psychology

Democratic therapeutic communities have been set up all over the world, but until now there has not been a manual that sets out the underlying theories, and describes successful practice. Based on their own substantial experience and expertise, the authors of this new textbook explain how to set up and run modern therapeutic communities as effective evidence-based interventions for personality disorder and other common mental health conditions.

Including detailed templates and practical information alongside a wider historical context, this encyclopaedic handbook will enable clinicians to develop and implement a democratic therapeutic community model with confidence. Highlighting the importance of belonging to a wider community, this book also shows how to ensure the needs of patients are considered and met, and that patients themselves can see in detail what this approach entails. This is an invaluable resource for clinicians and service commissioners working in the field of recovery from personality disorder, as well as those working in mental health and healthcare. This book also provides a useful model for professionals working in prisons and the justice system, long-term drug and alcohol rehabilitation and education, and students of group analytic, psychotherapy, and counselling courses.

PART 1

History

CHAPTER 1

A History of Therapeutic
Communities

Geel and the mentally afflicted pilgrims

Although therapeutic communities were only identified as a specific entity in the 1940s, their theoretical, practical and philosophical origins go back much earlier. ‘Mentally afflicted pilgrims’ travelled to worship at the shrine of St Dymphna at Geel in Flanders in the mid-thirteenth century, were taken in by the local residents and cared for communally, and some commentators have identified this as the first recognisable format reflecting the principles and practices of therapeutic communities (Parry-Jones 1981). Oliver Sacks eloquently describes the history in his Foreword to Eugene Roosens and Lieve Van de Walle’s anthropological illustration of Geel’s current state:

In the seventh century, the daughter of an Irish king fled to Geel to avoid the incestuous embrace of her father, and he, in a murderous rage, had her beheaded. Well before the thirteenth century, she was worshipped as the patron saint of the mad, and her shrine soon attracted mentally ill people from all over Europe. Seven hundred years ago, the families of this little Flemish town opened their homes and their hearts to the mentally ill – and they have been doing so ever since. (Roosens and Van de Walle 2007, p.9)

This was a rural agricultural setting, and the main work activity was labouring on the land. Those suffering from some form of mental ill-health (probably mostly what we would now call learning disability) were taken in by the villagers, who are reputed to have taken some pride in demonstrating how well they cared for their charges: they were weighed annually, and the weight gain over the preceding year was taken as a measure of good care. A range of structures and procedures were in place for looking after these individuals in the context of individual families and wider village life (Roosens 1977). The therapeutic tradition still continues at the original town of Geel (60 km north-east of Brussels in modern-day Belgium), although it has been modified so that agricultural work is not now a prominent part of the therapeutic programme (Roosens 1977, p.34).

Moral treatment

The next documented and identifiable strand of therapeutic community ideas emerged in ‘moral treatment’ in the eighteenth century. William Tuke founded The Retreat hospital in York in 1796, based on the development of his ideas on moral treatment. Tuke’s particular approach was to treat the insane as closely as possible to how one would treat ‘normal’ people (Tuke 1813). Moral treatment is also particularly identified with Pinel, who referred to ‘treatment through the emotions’, and practised at the Salpêtrière in Paris in the early nineteenth century (Rothman 1971). These ideas crossed the Atlantic, and in 1817 a hospital was founded in Pennsylvania modelled on The Retreat by the Pennsylvanian Quakers (Scull 1979). Robert Whitaker, a prominent critic of modern mental health practice, describes moral treatment as a welcome but relatively short-lived phase in the history of mental treatment, superseded first by physical treatments, psychoanalysis and eugenic practices as they emerged early in the twentieth century, and then by chlorpromazine and the extensive use of psychotropic medications in the mid-twentieth century (Whitaker 2011). Therapeutic communities, and the fundamentally humanistic approach they espouse, have always been a form of moral treatment: a call for a return to those values was made by the World Health Organization in 1953 (see ‘Social psychiatry’, below) and, arguably, as much needed in contemporary times.

Therapeutic education and social pedagogy

A similar tradition, which evolved independently, is the field of therapeutic education for children. Bridgeland, in 1971, described residential therapeutic education as ‘a first attempt at combining psychotherapeutic ideas with participatory democracy’ (Bridgeland 1971). Homer Lane set up the ‘Boys Republic’ between 1907 and 1912 in Chicago for deprived urban children. He imported the idea into the UK in 1913 and set up the ‘Little Commonwealth’ in Dorset, also for disturbed youngsters (Bazeley 1928). In 1924, A.S. Neill set up Summerhill School, which continues to this day as an institution specialising in progressive education (Croall 2013; Neill 1948). These ideas were taken up by others, notably George Lyward at Finchden Manor (Burn 1956), and David Wills (Wills 1967) and Marjorie Franklin (Franklin 1966) with the Hawkspur and Q camps’ experiments in the 1930s. David Kennard, a leading British therapeutic community commentator, describes Wills’ experiments as being closest to the therapeutic community (TC) approach, and all of these ventures are known by the term ‘planned environment therapy’ (Kennard 1998). The Mulberry Bush School, in Oxfordshire, UK, developed a psychoanalytic model of childcare after the Second World War, where the therapy is an integral part of the child’s day. This continues as a national provision for traumatised and antisocial young children. Melvyn Rose adapted the planned environment therapy ideas in the 1970s for the ‘approved school’ model for very disturbed children at Peper Harow (Rose 1990). He ran this strictly as a therapeutic community, and the emerging ideas were also taken up by other approved schools, borstals and probation hostels. A descendent organisation from the Peper Harow Foundation, Childhood First, continues to run residential therapeutic communities for children, although it does not use the term ‘therapeutic community’. Charterhouse Group was formed to represent therapeutic communities with education for children and adolescents in the UK, supporting a dozen residential therapeutic schools in the late twentieth century. The commissioning arrangements after this became more favourable for independent providers to establish small therapeutic homes for particularly troubled children, and many of them adopted a therapeutic community approach, sometimes using the term ‘therapeutic child care’ with its associated quality standards, but also without using the ‘therapeutic community’ name.

As well as therapeutic communities for disturbed children in the education field, there are a number of communities for people, of all ages, with learning disabilities. The best known of these are the Camphill Communities founded by König, which are based on the ideas of Steiner and his ‘anthroposophy’ (Bloor, McKeganey and Fonkert 1988), to which Montessori schools also owe an acknowledgement of their own theoretical base (Ness 1983). A similar, Catholic-based movement called L’Arche was founded by Jean Vanier in 1964 (Vanier 1982). These groups are closer in intention to the thirteenth-century caring communities in Geel than to hospital- or community-based intensive treatment programmes. They could be described as ‘therapeutic living communities’ (implying that they are communities in which the participants live therapeutically) rather than therapeutic communities (with the implication that therapy is a specific intervention).

Wartime UK experiments, 1939–45

The origin of democratic therapeutic communities in health care is normally traced back to three experiments during the Second World War: two at Northfield Military Hospital in Birmingham (Harrison 2000) and one at Mill Hill Hospital in North London (Jones 1946, 1953, 1979). At Northfield, Bion’s experiment with Rickman (Bion and Rickman 1943; Bion 1961) was stopped after six weeks when his work was more challenging than the military authorities would permit, as Tom Main later described:

neither the commanding officer nor his staff was able to tolerate the early weeks of chaos, and both were condemning and rancorous about Bion’s refusal to own total responsibility for the disorder of others. (Main 1977, p.S10)

Bion was replaced by Main, Foulkes and Bridger (Bridger 1946). This ‘Second Northfield Experiment’ continued with a less provocative and more integrated therapeutic community programme until the end of the war (Bridger 1985). Tom Main went on to be director of the Cassel Hospital at Richmond (in the village of Ham) in London, which for many years has been a renowned intensive inpatient psychotherapy unit. He coined the term ‘therapeutic community’, at the time referring to those in mental hospitals, and offered the definition:

an attempt to use a hospital not as an organization run by doctors for their greater technical efficiency, but as a community with the immediate aim of full participation of all its members in its daily life and the eventual aim of the re-socialization of the neurotic individual for life in ordinary society…a spontaneous and emotionally structured organization rather than one which is medically dictated. (Main 1946, p.66)

S.H. Foulkes went on to found group analytic psychotherapy (Foulkes 1948, 1983), culminating in the foundation of the Institute of Group Analysis in 1972. Harold Bridger died in 2005 after a lifetime’s work in organisational consultancy with the Tavistock Institute of Human Relations.

In 1941 at Mill Hill Hospital, Maxwell Jones (then an award-winning respiratory physiologist) saw that soldiers suffering from what was called ‘effort syndrome’ were more helpful to each other than the staff, sharing the emotional meaning of their experiences in discussion groups (Jones and Lewis 1941). After developing a successful short-term programme based on this principle during the war for a hundred or so men at a time, Jones later went on to set up the ‘Industrial Neurosis Unit’ in South London to get ‘vagabonds and scroungers’ back to work. This became the Social Rehabilitation Unit at Belmont Hospital, and later the Henderson Hospital, which became the flagship ‘British model’ democratic therapeutic community proper from the 1950s until its closure in 2008 (Whiteley 1980). Jones particularly developed the notions of ‘living learning’ and working with the ‘here-and-now’ in therapeutic community work.

These three experiments in two locations are the start of the British model of democratic therapeutic communities and raised fundamental and ground-breaking challenges to the nature of authority in treatment settings. Many of these ideas seem less challenging 60 years later, and some have become part of government policy, for example, patients becoming ‘experts by experience’ about their own condition.

Social psychiatry

Although it was Tom Main who coined the term ‘therapeutic community’, it was Maxwell Jones whose name became most closely identified with the democratic therapeutic community movement through the rapid growth and popularisation of ‘social psychiatry’ in the 1950s. Between then and the 1970s, all the leading British psychiatric hospitals had wards operating as therapeutic communities: Ward 1 at the Maudsley Hospital in London under John Steiner; Street Ward and Burnet House at Fulbourn Hospital in Cambridge under David Clark; Villa 21 at Shenley Hospital with David Cooper; Fair Mile Hospital in Berkshire with David Duncan; Phoenix Unit at Littlemore Hospital in Oxford under Bertie Mandelbrote; Ingrebourne Centre in Hornchurch under Richard Crocket; Forest Lodge at Claybury Hospital with Dennis Martin; the Connolly Unit at St Bernards in Ealing; and Francis Dixon Lodge in Leicester under George Spaull. The therapeutic communities also moved out of the hospital wards into the community, and began to be developed as day units. Marlborough Day Hospital was set up by Joshua Bierer in 1946; Paddington Day Unit became a somewhat infamous example of how things could go wrong (see ‘Antipsychiatry and unlabelled living’ section, below); the Red House in Salford under Bob Hobson; and the St Lukes and St Charles day TCs in Kensington and Chelsea led by Raymond Blake. The Fair Mile Hospital’s TC moved into the suburbs of Reading as Winterbourne TC in 1995 under Jane Knowles and Rex Haigh, and became a specific treatment programme for borderline personality disorder (Knowles 1997). It was the model on which several new services were based that were developed as part of the government’s 2002–2011 ‘National Personality Disorder Programme’ in community settings, including the Thames Valley Initiative, on which this manual is based (Haigh 2007b). Other non-hospital residential units also developed, for example, Richmond Fellowship Hostels (Jansen 1980). Although Richmond Fellowship now has a different function, mostly as a training and consultancy organisation, the therapeutic community ideas were taken up by Community Housing and Therapy, a charity that continues to run a number of rehabilitation communities in south-west London (Tucker 2000), and by Threshold, a similar organisation in Belfast (Kapur et al. 1997).

In 1965, David Clark wrote an influential paper describing the difference between specific treatment units: ‘Therapeutic Community Proper’, and the general use of the TC principles ‘Therapeutic Community Approach’ (Clark 1965). This presages the development, a little less than half a century later, of the formation of ‘Psychologically Informed Environments’ (PIEs), ‘Psychologically Informed Planned Environments’ (PIPEs) and ‘Enabling Environments’ (EEs), all of which are units explicitly using therapeutic community principles and value base (Johnson and Haigh 2011).

The period between the 1950s and 1970s could be described as the heyday of British social psychiatry, and the phrase ‘social psychiatry’ brought visitors from all over the world to see what was being done in British psychiatry. David Clark (Clark 1998) cites a 1953 World Health Organization Report (World Health Organization 1953) that encapsulates the impact of the work. It was written by an international panel, chaired by Kraus of Groningen and led by T. P. Rees of Warlingham Park Hospital, Surrey and Sivadon of Paris; its full title was ‘The Third Report of the Expert Committee on Mental Health’. It considered various subjects such as the prevalence of mental disorders and patterns in community mental health services, but the most striking part dealt with ‘essential mental hospital provisions’. They refer to the importance of the atmosphere of the hospital:

The most important single factor in the efficacy of the treatment given in a mental hospital appears to the Committee to be an intangible element which can only be described as its atmosphere, and in attempting to describe some of the influences which go to the creation of this atmosphere, it must be said at the outset that the more the psychiatric hospital imitates the general hospital as it at present exists, the less successful it will be in creating the atmosphere it needs. Too many psychiatric hospitals give the impression of being an uneasy compromise between a general hospital and a prison. Whereas, in fact, the role they have to play is different from either; it is that of a therapeutic community. (World Health Organization 1953, p.18)

They spelled out the constituents of this atmosphere and italicised the following:

1.Preservation of the patient’s individuality.

2.The assumption that patients are trustworthy.

3.That good behaviour must be encouraged.

4.That patients must be assumed to retain the capacity for a considerable degree of responsibility and initiative.

5.The need for activity and a proper working day for all patients.

They concluded ‘the creation of the atmosphere of a therapeutic comm-unity is in itself one of the most important types of treatment which the psychiatric hospital can provide’ (World Health Organization 1953, p.19).

Criminal justice and offending behaviour

Another development occurred in 1962, when Her Majesty’s Prison (HMP) Grendon opened in Buckinghamshire as a therapeutic community prison – not a drug rehabilitation wing (which would have been based on the Addictions TC model), but as a mental health unit. It is now formally part of the English Personality Disorder Programme, which started its existence as a solution for ‘dangerous people with severe personality disorder’ (West et al. 1979; Morris 2004). At the same time as HMP Grendon was established, Dennie Briggs opened Chino, a prison in California (Whiteley, Briggs and Turner 1972). Both were based on the Henderson model, which was a significant part of the social psychiatry movement. Others were opened at HMP Gartree and Barlinnie, and more recently a private sector prison, HMP Dovegate, opened four therapeutic community wings based on the Grendon model. Two further prison TCs have opened since 2000, HMP Blundesdon and HMP Send. Send is the only prison therapeutic community for women in the world. All 16 of the British...

Table of contents

• Cover
• Title Page
• Contents
• Preface
• Part 1: History
• Part 2: Concepts
• Part 3: Practice
• Part 4: Organisational Aspects
• Part 5: Training
• Appendix 1: Definitions
• Appendix 2: Community of Communities
• Appendix 3: Enabling Environments
• Appendix 4: DTC Preparatory Group Documents and Policies
• Appendix 5: DTC Programme Documents
• Appendix 6: Moving On Group
• Appendix 7: Family and Friends Programme Information Sheet
• Appendix 8: Training Resources
• Further Reading
• References
• Subject Index
• Author Index
• Acknowledgements
• Dedication
• Copyright
• By The Same Author
• Endorsement