Contents
PART 1: HISTORY
1. A History
of Therapeutic Communities 18
Geel and the
mentally afflicted pilgrims 18
Moral treatment
19
Therapeutic
education and social pedagogy 19
Wartime UK
experiments, 1939–45 21
Social
psychiatry 22
Criminal
justice and offending behaviour 24
Concept Houses,
drug-free and addiction TCs 25
Antipsychiatry
and ‘unlabelled living’ 26
Personality
disorder TCs 26
PART 2: CONCEPTS
2. Why
Therapeutic Communities 30
Critical theory
33
Antipsychiatry
34
Critical
psychiatry 37
Biomedical
domination and the role of the pharmaceutical industry 41
The loss of
meaning and context 42
Reductionist
research paradigms 44
Postpsychiatry
44
Other relevant
‘movements’ in psychiatry 45
The
quintessence of a therapeutic environment 48
3.
TC-Specific Theory 53
Specific
therapeutic factors in democratic therapeutic communities 53
Therapeutic
methods in democratic therapeutic communities 55
The
function/structure-based approach – Rapoport 55
The culture of
enquiry – Tom Main 57
Flattening of
the authority pyramid and the analysis of all events – David Clark 57
A living
learning situation – Maxwell Jones 58
The milieu and
the use of member expertise 59
Confidentiality
and respect/no secrets/openness 59
4. Belongingness
62
Belongingness
and Maslow’s hierarchy of needs 62
Belongingness
as a therapeutic factor 64
Therapeutic
environments in which belongingness operates 65
Therapeutic
communities and belongingness 66
5.
Responsible Agency 71
The wedge
theory of responsibility and choice 72
Self-efficacy
73
Empowerment 73
The nature of
responsible agency 73
Willed action
and the nature of desire 75
The muscle
model of the will 75
Other
techniques promoting responsible agency 78
Responsibility
without blame 79
Links between
blame and shame 82
Implications
for DTC practice 82
6. Social
Learning 85
Reinforcement
85
Social learning
87
Relevance to TC
practice 92
7. Emotional
Progression and Narrative 94
Emotional
progression in DTC 95
Narrative
formation 100
Emotional
competence and mentalisation 102
8. The Use
of Psychodynamic Theory and Techniques 105
Object
relations theory 105
Splitting and
borderline functioning 106
Unconscious
defence mechanisms, and their relevance to TC practice 107
Paralleling
behaviour 110
Interpretation
110
Transference
and transference interpretation 111
Boundaries and
containment 112
Therapist
activity in democratic therapeutic communities 113
9. Group
Analytic Influences and Theories 114
The roots of
group analysis 114
The basic law
of group dynamics 117
Key group
analytic concepts relevant in therapeutic communities 118
Transference
and countertransference in groups 122
Group analytic
interpretation 123
Group-as-a-whole
123
Differences
between therapeutic community groups and group analytic groups 124
Interpersonal
group psychotherapy and Yalom’s therapeutic factors 125
10. Group
Process and Systems 128
The primacy of
groups 128
The impact of
social psychology research on TC theory and practice 130
Leadership in
DTCs 134
Systems
theoretical influences 135
Systems theory
in non-family groups 138
11. Evidence
for Therapeutic Community Effectiveness 139
Concept
(drug-free) TC research 139
Democratic TC
research 141
TaCIT – a
randomised controlled trial of democratic therapeutic community treatment 150
Future research
directions 151
12. General
Approach and Principles 152
Application of
theory 153
Milieu therapy
153
Democratisation
153
Permissiveness
156
Reality confrontation
157
Communalism 157
Social analysis
of events 158
Culture of
enquiry 159
Freeing of
communications 159
Flattened
hierarchy 161
The living
learning experience 162
PART 3: PRACTICE
13. Phases
and Timing 164
Phase 1:
Engagement and stabilisation 165
Phase 2:
Assessment and preparation 174
Phase 3:
Intensive treatment 177
Phase 4:
Recovery and rehabilitation 180
14.
Assessment and Selection 181
Dimensional
approaches and severity 182
The importance
of groups 183
Intolerance of
groups 185
Members who may
adversely affect the culture 185
The possibility
of harm from DTC treatment 186
Heterogeneous
group formation 187
Selection
processes 187
Dropout from
DTC treatment 188
15.
Democratic Therapeutic Community Structure 189
Assessment and
preparation 189
Joining and
leaving 192
Therapeutic
community size 195
Weekly
structure 195
Daily structure
195
Mentoring and
peer support 197
Meeting structure
199
Open groups 203
Work groups and
activity groups 203
The place of
play in DTC 203
Specialist
psychotherapeutic approaches 204
Milieu time 205
Therapy breaks
206
Moving on
groups 207
Follow-up 208
16. Boundary
Maintenance 209
The
implementation of boundaries in DTC 209
Time boundaries
210
Disturbances
and distractions in groups 210
Hierarchy of
consequences of boundary violations 211
Relational risk
management and positive risk management 214
Concurrent
psychological treatment while a member of DTC 216
Other
boundaries 216
Drugs and
alcohol in DTC 220
Medication in
DTC 222
Abuse of
prescribed medication and medicinal substances 227
Somatisation
and somatoform disorders 228
Special
treatment 228
17. Quality
of Relationships and Therapeutic Method 230
A different
kind of relationship 230
Flattened
hierarchy 230
Authenticity
231
Working
alongside 231
Acting ‘as if ’
232
Uncertainty 232
Safety and
transparency 232
Management of
personal information for TC staff 233
Making the
diagnosis of personality disorder 234
Co-morbidity
with mental illness in personality disorder DTC treatment 236
18. The Use
of Psychoeducational and Humanistic Methods 238
Mindfulness 238
Descriptions of
approaches used in the large group 240
Action methods
241
Approaches
derived from transactional analysis 243
Diagnostic
personality disorder group 245
Family and
Friends (carer’s) programme for personality disorder 245
19.
Antitherapeutic Processes 248
The difference
between group/peer pressure and TC process 248
Bullying and
scapegoating 249
Subgroup
formation 250
Persecutory
interventions 251
On not
‘trusting the process’ (or group) 252
Summary 252
PART 4: ORGANISATIONAL ASPECTS
20.
Organisational Relationships 254
Commissioning
254
Management 256
Governance and
regulation 257
Referrers and
colleagues 257
Local
neighbours 258
Professional
network organisations 259
21.
Organisational Development 260
Planning a
therapeutic community service for personality disorder 260
Formation of
the team 262
Premises 264
Induction and
initial training 265
Continuous
improvement 266
Organic growth
267
Innovation 268
PART 5: TRAINING
22. Training
– Introduction 272
Practitioner
requirements 272
A curriculum of
therapeutic community training 273
23.
Experiential Training for Working in Therapeutic Communities 275
The living
learning experience 275
Other group
relations courses 277
Personal
therapy 278
24. Supervised
Clinical Practice 279
Pre-briefs and
debriefs 279
Formal
supervision 280
Sensitivity
groups and staff groups 280
Profession-specific
supervision 281
APPENDICES
A1 Definitions 283
A2 Community of
Communities 291
A3 Enabling
Environments 302
A4 DTC Preparatory
Group Documents and Policies 315
A5 DTC Programme
Documents 322
A6 Moving On Group
342
A7 Family and Friends Programme 344
A8 Training Resources 346
Further Reading 360
References 361
Subject Index 376
Author Index 382
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