Saturday, 29 November 2014

British TCs for Italians

And so to Rome again...
To the second conference of the international network of democratic therapeutic communities, where Jan Lees and I have been asked to explain what British TCs are all about to an Italian audience.
It was another standing room only conference, at an adolescent TC about five miles out of the centre of Rome - but clearly, from the state of the decor and furnishings - a state sector TC.
But a good day seemed to be had by all.

Here's our prezi:

And the text, which we needed to have pre-written for the live interpreter:

Therapeutic Communities in the UK 1942-2014

Slide 2
Although TCs in the UK can trace theoretical and philosophical roots back several centuries, and across countries, the British Democratic Therapeutic Community Model is considered to have developed in its current form during the Second World War, with the work at Northfield of Bion, Rickman, Bridger and Main, and Maxwell Jones at Mill Hill.

Until recently, there were two models of TC operating in the UK – the British democratic therapeutic community model, and what was once known as the American model – also known as concept-based, and hierarchical TCs, but now widely referred to as addiction TCs. In the past, these models were regarded as very distinct, but more recently they have begun to become more similar – democratic TCs are increasingly treating people with substance misuse issues, and forensic histories, and addiction TCs are increasingly treating people with mental health as well as substance misuse issues. Rex and I named these cross-over TCs ‘Fusion TCs’, in a paper we wrote for the TC journal in 2008, and the similarities and differences are discussed at length there.

Slide 3
There are seven types of TC in the UK. There are mental health democratic TCs, which are part of the NHS; there are mental health democratic TCs, which operate in the not-for-profit sector; there are democratic TCs in the Prison Service; there are TCs for children and young people, etc., and residential schools, run along modified democratic TC principles; there are TCs for people with learning disabilities; there are addiction TCs; and there are other ‘lifestyle’ TCs, which include intentional communities, faith communities, greencare etc.

Slide 4
A we have already mentioned, British democratic TCs have their roots in a number of fields – in the ‘moral treatment’ ideas and practice of Pinel in France, and Tuke at The Retreat in York; in the ‘progressive education’ field, with the work of Homer Lane, David Wills and A. S. Neill; in the experiments in rehabilitating psychologically wounded soldiers in both World Wars, but particularly Bion, Rickman, Main, Bridge and Jones, and after the war, with the founding of Henderson Hospital by Max Jones, which became de facto ‘the British democratic TC model’; the setting up of HMP Grendon – the only prison to have therapeutic communities, and no other prison provisions; the Cassel Hospital, set up by Tom Main; and many others all over the UK.

Slide 5
The British democratic TC model was based on, amongst others, the following principles: it was to be an anti-medical model; hierarchies were to be flattened, and it was to be as egalitarian as possible – no uniforms, no name tags, no deference to rank or status; everything that happened in the TC was to be available for treatment, and to become part of the treatment – Jones’ ‘living-learning experience’ in the ‘here-and-now’; there was to be a constant ‘culture of enquiry’; there was to be shared decision-making, based on the democratic principle of one person, one vote; peers would be therapists for each other, and taking this therapist role was part of the treatment; in its purest form, there was to be no individual therapy, and all treatment would take place in large and small social and therapy groups. Rapoport, in his study of the Henderson Hospital – the Community as Doctor - in 1960, suggested there were four themes to the principles and practice of the British Democratic TC – permissiveness – initially at least , tolerating most behaviours from TC members in order to gain a picture of them and their difficulties; reality confrontation – to then face TC members with their behaviours and the effects on others, and help them consider other ways of relating to others; democratisation – allowing TC members to be actively involved in the day-to-day running of their TCs, and to take roles related to these tasks, which would increase in the level of responsibility over TC members’ time in treatment; and communalism – whereby all tasks – whether treatment, work or social, were shared amongst all TC members and staff, and were done together – including cooking and eating, and cleaning the loos.

Slide 6
TC fortunes have oscillated considerably over time. The 40s saw the beginnings of the British democratic TC; the 1950s saw the development of social psychiatry, which Max Jones argued was an extension into the community of TC ideas and practices; the 1960s saw the development of the anti-psychiatry movement, which fitted well with TC principles; and many TCs were set up in the 1960s and 1970s. However, by the 1980s, because of economic pressures, and an emphasis on individualism rather than community and society, TCs began to be closed. The 1990s saw the closure of nearly all NHS residential democratic TCs – there are now none left; however, the 2000 (noughties) saw some growth in prisons TCs, and other TCs through the National PD programme. Although modified TCs – especially day TCs - had been around for some time, in the 2010s their potential has been developed and expanded.

Slide 7
These changes, and particularly the closure of residential TCs, have led to the development of what we refer to here as ‘reduced dose’ TCs, particularly in the NHS. The 5-days a week – day TC - had been around since the 70s, operating from 9.30-3.30, Mondays to Fridays, and some British TCs adapted and changed from residential to day TCs, which helped them survive longer. However, even these struggled in times of economic stringency, and the desire for quick, cheap fixes, so many of these were reduced to 3 days a week, which allowed staff two days to do other activities, such as assessment and preparation groups, which were set up to try and improve retention. Since then, and largely as a result of the National PD programme in the UK, 2 day and 1 day mini-TCs, or 1 day and one out-patient group, have been developed. Latest variants include TCs which only last for 2 hours a week – called the micro-TC, with an argument that the TC is carried in the head, but also many other activities happen during the week, but without staff present.

Slide 8
Hub and Spoke TCs came about as a direct result of the National PD initiative, with its exhortation to be more creative with services, but particularly to try and increase access to services, particularly in more remote areas. The hub is a central TC – usually for 2-3 days a week – in a large town or city. The ‘spokes’ are one day a week TCs in several smaller towns. The same staff work in the TC hub and in the different spokes. This helps make therapy more accessible across a wider area.

Slide 9
The National PD Programme also prompted further creative adaptations to TCs – ‘itinerant’ and ‘virtual’ TCs. Cumbria developed a TC which met in a rural area for one weekly community day, and for the rest of the week, the community participated in an on-line moderated secure group. Edinburgh service users set up a purely virtual TC – it was an on-line community only, with agreed rules, like other TCs, together with occasional social activities.

Slide 10
Since 1978, the British Association of Therapeutic Communities has run ‘transient training TCs’, and for the last 20 years they have also helped run these in Italy. These TCs are 3-day, stand-alone, residential TCs for TC staff, to give them a living-learning experience of what it is like to come into a TC as a member. They are facilitated by experienced TC staff, and involve intensive group work – community meetings, small therapy groups, cooking groups, and creative and social activities. Like any TC, the whole group is responsible for what happens in the TC, including food, leisure time, choice of small groups, and what to do in case of crises.

Slide 11
We also believe that there are other treatment environments currently being developed in Britain which are not directly organised as TCs, but where the providers and staff have a ‘TC in their heads’. These include therapeutic environments; PIEs – psychologically informed environments for homeless hostels; PIPEs - psychologically informed prison environments - for prisons; and therapeutic child care; all of which are now being quality assured by the British Royal College of Psychiatrists. All of these are called Positive Environments, which is a new, beginning initiative, again within the Royal College of Psychiatrists.

Slide 12
With continuing adaptations and modifications of TC provision in Britain, I became clear that Rapoport’s themes were becoming out-dated, and that there was a need to develop a new theoretical basis that could cover these changes. It needed to be based on what were currently felt to be the necessary developmental experiences needed by TC members (based on various psychological theories), and particularly that we all need to experience primary emotional development for good mental health. What we recreate in a TC is secondary emotional development.

Slide 13
In 1999, Rex Haigh published a chapter in Therapeutic Communities. Past, Present and Future, called The Quintessence of a Therapeutic Environment – Five Universal Qualities. This work was partly an attempt to update Rapoport, but also to distill the common factors of any TC or therapeutic environment. These five universal qualities were defined as attachment, or encouraging a sense of belonging, and helping the patient reconstruct a secure attachment, so these can be used to bring about changes in relationships and patterns of behaviour; containment, or creating a culture of safety, of holding and of boundary-keeping, whereby difficult experiences and feelings can be tolerated and processed; communication, or a culture of openness – making contact with others, talking about experiences and feelings, and being able to symbolise them, and feeling understood, and building relationships; involvement, or a culture of participation and citizenship, and interdependence – the living-learning experience, where everything that happens can be used to therapeutic effect; and lastly agency, or a culture of empowerment, particularly in relationships, where the patient is their own expert, and a therapist for their peers, as well as being able to take positions of authority and responsibility, and make decisions about their treatment and how it is delivered.

Slide 14
Another new development in the TC field in Britain in the 2000s (noughties) was the development of the Community of Communities project, for quality assurance and improvement in TCs. This provides a national peer review process, which is more in keeping with TC principles and practice. Standards are democratically derived through representative groups of TC staff and service users, and are regularly reviewed and change by these groups; TC staff and members visit each others’ TCs and review them, and the reviews are reported back to an Annual Forum. This peer review process has now been rolled out through all the Royal College of Psychiatrist quality improvement networks, and covers many types of TCs as well as other therapeutic environments which are not pure TCs but any TC member would recognise elements of the environment.

Slide 15
The old asylums of the 19th and early 20th centuries in Britain used to provide farm working or horticultural therapy as part of their treatment programmes. These elements of treatment largely disappeared with the closing of the asylums, but recently have been undergoing something of a revival as greencare. Greencare is based around a relationship with nature and the earth, involves horticulture and farming, as well as animal therapy, and the use of therapeutic spaces. Greencare is increasingly being taken up by TCs, as well as many other treatment services, as an anti-dote to the industrialisation and capitalisation of mental health. For example, this year a horticultural unit in Cumbria has started a one day a week TC alongside their huge greencare project – 10 acres of fruit and vegetables. Rex and Jan are also directors of Growing Better Lives, a greencare TC project, based in a yurt near London.

We think all these developments demonstrate the creativity and adaptability of the TC as a mode of treatment in Britain.

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