A Therapeutic Community is a facility where a group-therapy model is used to treat personality disorder, drug addiction, compulsive self-harm, anxiety, eating disorders and various other disordered behaviours. The difference between normal group therapy and a therapeutic community is the residential with fairly intense interaction potentially at any time of the day or night.
Therapists, who can be doctors, psychiatrists and psychologists or psychotherapists usually live in the facility with the patients, in shifts and can be called upon to attend crisis meetings whenever needed. However, residents are encouraged to lead the therapy sessions, with little input from therapists. Residents are encouraged to take responsibility for their actions by other residents, and those not conforming to the community rules can find themselves sanctioned by the group.
Therapeutic communities have been used in Great Britain since the end of the Second World War, when they were used to treat soldiers returning from the Front suffering with Shell Shock.
In fact, an Englishman called Thomas Main, who was a member of the Royal Medical Corps, coined the notion and expression ‘therapeutic community’. He went on to work for thirty years at the famous Cassel Hospital in London, which is where the model was created – a democratic, patient led community with limited sanctions available.
Maxwell Jones and R.D Laing developed his ideas, amongst others. Therapeutic communities were popular throughout the Sixties, but their use has dropped off in recent years, largely due to cost. Despite this, the improvements seen in patients’ outcomes were well established, statistically. Recidivism dropped and a majority of community members reported a drop in their psychiatric problems, and better skills in dealing with them when they occurred.
In the United States the development of therapeutic communities has developed slightly differently. They tend to favour a more hierarchical structure, and drug dependence treatment centres and prisons are the main proponents of the treatment model. Today in the United States therapeutic ‘camps’ are also favoured for troubled teenagers, which perform a similar function with an added outdoor function. Structure and rules are important in therapeutic communities and residents are happy to keep the community functioning by the application of peer group pressure.
Often the use of drugs is not allowed in therapeutic communities – not psychiatric drugs or any other medication, including pain relief. This is because of the belief that people’s minds affected their bodies, and psychosomatic symptoms are the result. Residents are encouraged to talk about their feelings when they are feeling ill. The illness they are experiencing is often seen as a metaphor for trapped emotions.
If someone is bottling up their experience of child abuse, for example, and is not able to discuss it, their throat may hurt, as they struggle to keep the experience inside. Interestingly, there is quite a lot of anecdotal evidence that this approach works, with symptoms lifting as patients begin to talk. Another approach that many students find hard to understand is the non-intervention of staff in psychiatric crises. This is because the emphasis is for patients to manage their own and other people’s symptoms, to take responsibility for the care of others and for the community.
Unless there is a danger of physical harm to an individual, it is unusual for any action to be taken by staff at all. Thus patients are called upon to restrain other patients, take them to hospital after self-harming episodes, and work suicide watch shifts throughout the night.
Other approaches to therapy are Art therapy, gardening, and local conservation work. Strict cleaning and cooking rotas are set out, and adhered to, with patients taking turns to carry out the tasks needed to keep the community running.
A major part of treatment, however, centres around group therapy, with residents encouraged to discuss their problems in depth over weeks and months, asking for opinions and ‘feedback’ from fellow residents. These meetings can be whole community meetings, or smaller group meetings. Any incidents that happen during the day are discussed fully with the community and everyone is encouraged to let residents who have been disruptive know how the incident has left them feeling.
A powerful form of peer pressure thus exists within the community, and those who transgress – either in violence, self-harm or suicide attempts, are faced with the consequences of their actions on their peers.
In the UK the larger institutions, such as the famous Henderson Hospital in Sutton, have now been closed due to budgetary restraints. The model still exists but it is now atomised and seldom full time residential. Therapy is undertaken several times a week in smaller communities. More support is moving ‘online’, which extends the reach of the therapy, but is a pale imitation of the pioneering inpatient model. The North Cumbria model is one example of this practice.
In the USA, therapeutic community models were introduced to prison populations in the 1960s, most notably by the Asklepion Foundation. They used transactional analysis, the twelve step program, and other models to reduce re-offending, with some success. This was taken forward by the Virginia Correctional system, for example, right up until the 1980s. Other types of therapeutic community still exist in the United States, with many of the tenets used in prisons to treat alcohol and substance abuse.
Useful Links & Further Reading
World Federation of Therapeutic Communities : http://www.wftc.org/mission.html
Association of Therapeutic Communities: http://www.therapeuticcommunities.org/
Treatment Communities of America: http://www.therapeuticcommunitiesofamerica.org/main/