Thursday, 30 March 2017

Whatever happened to therapeutic communities?

Following the Community of Communities Annual Forum at the Royal College of Psychiatrists (a hectic and jolly affair, as has become the custom), Steve and I did our first formal launch of our labour of love, ‘The Theory and Practice of Therapeutic Community Treatment’. I say first because we are also planning a couple of others for later in the year (do come to Windsor...)

Young Sophie from JKP came along with a box of fifty, the great majority of which we managed to sell and sign. Steve and I started it all off with a few words – I was the ‘grumpy old psychiatrist’ who didn’t see that TCs should be entering all this business of manuals, and that it’s a textbook anyway. Steve countered that this is the modern way, the only way, and that now we all live in the squeaky-clean world of evidence-based practice, there is no alternative. Then we read a couple of nice passages from the book and cracked open the wine. Signing was great fun – probably the closest I’ll ever get to knowing what the life of a celebrity is like. I often wrote ‘this is not a manual’ inside the front cover, and Steve followed it up with ‘Oh, yes it is!”. Well, famous for fifteen minutes is good enough.

I am so often asked ‘whatever happened to therapeutic communities?’ or some variation of the question – usually in a rather apologetic way indicating that the questioner didn’t know that they actually still existed at all - that I decided to do a fairly short written answer, so I could point people to it. Before they read the book, that is. Here it is:

In the twentieth century, therapeutic communities in the UK established themselves as a radical alternative to mainstream psychiatry. However, some of the philosophical roots can be traced back much further. In the thirteenth century, ‘mentally afflicted pilgrims’ travelled to Geel, where the village community took them in and looked after them. After the Enlightenment, people with mental ill-health were defined as ‘mad’ and incarcerated away from society. The Quaker William Tuke’s response to this in the UK was to open The Retreat in 1796, and argue for the ‘moral treatment’ of people as human beings, rather than as animals to be tethered and caged.
 
There is also a long tradition of progressive residential education for children and young people, dating back to the late nineteenth century with the ‘Boys’ Republic’ in Chicago and the ‘Little Commonwealth’ in Dorset, run by Homer Lane, and Summerhill in Suffolk, set up by AS Neill and still operating today. Community meetings are held, and each child is allowed to choose what they learned and when they learned it. In the field of learning disabilities farming communities such as L’Arche and Camphill were established in the twentieth century, by Jean Vanier and Karl K├Ânig respectively; both organisations expanded internationally and still exist today.
 
The British ‘democratic therapeutic communities’ emerged from wartime military experiments and the heat of the 1960s and 70s social psychiatry movement: the doors of wards were unlocked, and therapeutic communities were firmly against medical orthodoxy, the power invested in hierarchy and status, and the use of physical treatments, such as newly emerging psychotropic medications. Instead, TCs promoted democracy, empowerment, treatment of equals by equals, and the importance of ‘being with’ rather than ‘doing to’. The main principles include challenge and confrontation in a flattened hierarchy, and culture of enquiry, where people feel emotionally contained and safe to do the necessary psychological work. Risk is contained through relationships, rather than protocols and procedures.

The programmes are group-based, and the community itself is the primary therapeutic intervention: all members of the community are responsible for the day-to-day running of the unit and decisions are made by consensus or voting; members cook, eat and spend social time together. One of the most important TC principles has always been ensuring that patients take the lead in their own treatment, as well as contributing to the treatment of others - in contrast to the paternalistic attitudes taken by mainstream services. TCs have extended this practice so that that ex-service users and experts by experience are encouraged to become involved in teaching, training, research, service commissioning and consultancy. More recently, these practices have been adopted by other services in all areas of health and social care.

Although this discussion mainly concerns democratic therapeutic communities for people with mental health difficulties, there is also a very large worldwide contingent of addiction TCs; although their origins were very different to ‘democratic’ TCs, some commentators have noticed that they are becoming increasingly similar.
 
What TCs do well is to adapt and change in response to challenges: their members are expected to do the same in their own lives. In the last thirty years, TCs have particularly had to adapt and change in response to increasingly austere economic policies and the emphasis on short-termism, as well as the rise of individualism and consumerism.

While the late 1980s and 90s saw the closure of many residential NHS TCs because of financial constraints, creative adaptations were taking place in order to survive. Two new national residential NHS TCs were set up to replicate the work of the flagship Henderson hospital; other NHS residential TCs responded to the challenge by converting to non-residential programmes, and a number of day TCs were established as part of the national personality disorder program in the early 2000s. Four new TC wings were established as part of a new purpose-built private prison; researchers in the TC field were awarded two major grants – one to undertake a systematic review of the evidence base in the TC literature, and the other for a multicentre comparative research study.
 
In response to increasing government regulation and inspection of care provision, TCs again responded creatively by devising an international network of peer review and audit, which was based on TC principles: the ‘Community of Communities’. It sets its core standards by democratic processes, involves current and ex-service users at all levels, and implements its audits in an inclusive and empowering way.
 
More recently, although British TCs continue to struggle to survive in the current political and economic climate, there are still some new and interesting developments in the TC field. One is the establishment of regular experiential training communities – the ‘Living-Learning Experience’ workshops. These were originally set up to give TC staff the experience of what it is like to be a member of a therapeutic community, but they have more recently been adapted for use in training for relational practice in groups, teams and organisations – and, in Italy, for entrepreneurs and business leaders. Although these events have been running in the UK for over twenty years, the programme and structure is being faithfully reproduced and used throughout Italy, increasingly in India and most recently in Portugal. In addition, particularly in Sicily, the government has encouraged the setting up and funding of new TCs. Several Italian centres have also set up networks adapted from the UK’s Community of Communities.
 
In 2007, the Community of Communities started a spin-off project called ‘Enabling Environments’. By distilling the underlying relational values from several years of TC audit data, ten ‘value-based standards’ were set. These represent the ways in which the therapeutic community ethos and atmosphere is established, but without any of the structural requirements of therapeutic communities – such as community meetings or specifially trained staff. They are therefore transposable to a wide range of settings where the quality of relationships is seen as crucial. This work, and the portfolio-based award to which it leads, now underlies new ways of working in the homelessness and prison sectors. Psychologically Informed Environments (PIEs) are transforming homelessness hostels, while Psychologically Informed Planned Environments (PIPEs) are doing the same in prisons and probation premises. Most recently, all UK ‘approved premises’, are being supported to become accredited Enabling Environments, and their use in other public service settings is being explored.
 
An additional extension of TC and EE practices is seen in ‘Greencare’, in all its forms. This entails including nature and the natural world as an integral part of therapeutic programmes: it can include therapeutic horticulture, animal assisted interventions, care farming and wilderness camping.
 
The most recent adaptations by the TC field have been in response to the dogmatic demands for evidence-based practice and manualisation. The first is the publication of the research findings of a modern randomised controlled trial of non-residential therapeutic community treatment for people with personality disorders (Pearce, Scott et al. 2017). The second is publication of the first handbook for democratic therapeutic community practice (Pearce & Haigh 2017).
 
Although the future remains uncertain, basic TC principles will endure - and TC practice will continue to change and adapt in creative and forward-looking ways.

Thanks to Jan Lees, who collaborated on writing this.
And apologies for the incomplete references – I’ll update it when I get a chance!

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