Answering Jo's three tricky questions

I'll keep this confidential and not reveal Jo's identity - suffice to say she is what I see as an energetic and dynamic force for really improving Gloucestershire's mental health services. I'm sure that for anybody reading this who knows the Gloucestershire set up, it will immediate click!

During a on online seminar today, she described the three problems with TCs that influential people in NHS management and local commissioning usually quote to discredit or oppose TC-based developments. They are:

• TCs only treat small numbers of people
• They are expensive
• They are old-fashioned

We had some useful discussion about it all, but I thought it would be a worthwhile exercise to record some thoughts in this blog about these three 'questions'  - as I think many people elsewhere, who are trying to set up progressive, democratic and relational services, will also face them.

1    Small numbers who benefit

Yes, the numbers in any single TC are small (not usually more than 20), and the throughput is often slow (perhaps one or two new people per month) but they can often help the people who bounce around other services and cannot find what they need in any of the mainstream therapies.  Their problems are often of a severity and complexity that means standarised and manualised treatment services and pathways are of no help at all, and can actually be experiences as harmful and even abusive. 

If these people are effectively engaged and helped, not only will that be of great personal benefit to them, but it will prevent a great deal of pressure on hard-pressed staff in mainstream services to 'do something' when they do not have the facilities or training to do so.

There are also indirect benefits of TCs that extend beyond helping the people who are in them for treatment. A therapeutic community that is well-integrated into a local mental health system can be hub activities that has profound effects on staff attitudes and working culture. This can be by directly providing training placements and experience for staff, but also by getting involved in wider initiatives beyond the clinical base - and spreading best practice in areas such as co-production, asset-based community development, stigma reduction, relational practice and democratic techniques in mental health.

The assertion that those with more complex problems, who often reject or may become worse in standard therapies, need more involved and complex treatments is supported by the Royal College of Psychiatrists' Position Statement on 'Services for People Diagnosable with Personality Disorder', PS01/20  

2    Expensive

Non-residential TCs are very much cheaper than repeated inpatient admissions. The cost for people who do not receive a treatment that they can engage well with is often considerably increased by demands on other parts of the health service (such as ambulance calls, and A&E attendances) as well as for pervasive impact across public services (such as child protection, criminal justice, housing and others). Numerous economic reports and studies have found large cost savings when comparing the time before admission to a therapeutic community and the time afterwards. For example, the micro-TC in Slough reported reduction from 4786 to 312 bed-days with its first 103 members (one year before and one year after the programme - nominal savings of £1.5m on beds alone).

The 2017 Oxford randomised controlled study also found significant reductions. See

Pearce S, Scott L, Attwood G, Saunders K, Dean M, De Ridder R, et al. Democratic therapeutic community treatment for personality disorder: randomised controlled trial. BrJPsychiatry 2017; 210: 149–56.     

3     Old-fashioned

This would be true if it were referring to the common misconception that therapeutic communities still work as they did in the twentieth century. In those times some could be characterised as insular, resistant to change and somewhat arrogant. However, much has changed in the last twenty years: new models have emerged that bring maximum cost effectiveness (by using less hours of clinical staff input), and sophisticated integration across health and social care ecosystems (through coproduction and asset-based outreach). 

See Haigh R. The New Day TCs: Five Radical Features. Therapeutic Communities 2007; 28: 111–26 and Pearce S, Haigh R. Mini therapeutic communities: A new development in the United Kingdom. therapeutic communities 2008; 29: 111–24.

The therapeutic philosophy behind therapeutic communities, particularly that of relational practice and democratic mental health, is congruent with many progressive movements in mental health that have arisen in the last century - from Psychiatrica Democratica in Italy, to user empowerment and the recovery movement today. The preventative nature of the treatment meets a public health need, and will be increasingly relevant as the damage to supportive relationships wreaked by covid becomes apparent. Also, the cross-sector integration that is possible with modern forms of TC can provide a 'social glue' foreshadows forthcoming developments in NHS community mental health provision.

Therapeutic communities are not just a treatment modality - they are a post-post-modern social movement. See Haigh R. Charismatic Ideas-Coming or Going? Therapeutic Communities 2005; 26: 367–84.