Thoughts about Forensic TCs

After escaping from having to write a chapter for them, Richard and Geraldine twisted my arm to knock out a thousand word Foreword for their forthcoming book - at extremely short notice.

The book is 'Forensic Therapeutic Communities: A Global Perspective' from the Issues in Forensic Psychology series, edited by Geraldine Akerman and Richard Shuker.

It's to be published by Wiley-Blackwell - and I'd expect it to be out towards the end of the year, knowing how slowly these things go. As a bit of pre-publicity to whet appetites, here is my Foreword...

As most people who have spent time in them realise, therapeutic communities a largely hidden jewel in the panoply of modern interventions for complex mental health needs. As one of those people, with many hours of time inside, I know that extraordinary things can happen in them, that people’s lives are often transformed (staff members as well as client members), and that there is a quality of relationship between the participants that simply does not exist in other settings. But this is not good enough for the modern thirst for a specific type of evidence: we must work harder. This book is part of that effort.

A major problem with therapeutic communities is that nobody really knows just what kind of animal they are, and there is no universally accepted definition. Perhaps this is one reason why they are largely hidden from wider understanding and acceptance. I believe it is entirely reasonable to describe them in at least seven different ways – all of which come from widely different frames of reference.

Most simply, they are treatment units – brick walls containing prison wings, custodial units, hospital wards, clinics, hospitals, day centres, schools, or whatever. People go into them, something happens, and they come out.  There are several different histories and types of these; they have a great deal in common but so many differences that no single definition would fit them all. Secondly, they are a theoretical model of care, with explicit therapeutic principles based on established psychological and sociological theories. This is the main tradition from the British version of ‘social psychiatry’ following the wartime Northfield Experiments, which continues to this day in different sectors. Thirdly, they are an intensive form of group psychotherapy defined and recognised by democratically co-produced quality standards. The ‘Community of Communities’ network at the Royal College of Psychiatrists uses this approach.  Fourthly, they constitute an evidence-based treatment “brand” with an extensive qualitative evidence base going back many years, and at least one recent, modern, randomised controlled trial. This is a difficult area, particularly because their status as a recognised ‘treatment’ has recently been denied. Fifthly, they could be described as programmes which are delivered by staff who have certain competencies, gained through suitable selection, training, support and supervision. The systemic nature of the resultant team cohesion and common sense of purpose delivers a unique sort of therapy. Sixthly, they arise from a technology of planned environmental engineering which results in a milieu which is conducive to personal growth and self-actualisation or individuation. This is akin to the work of ‘Enabling Environments’ and what I have called the ‘TC in the Head’ or the ‘TC without walls’. Finally, and somewhat related, they could be seen as a radical and subversive ideology: a social movement demanding a social movement a different way for humans to relate to each other. This is beyond post-modernism, as there is a clear ‘grand narrative’ – of relationship. This means that relationality has priority over individuality, as with the ‘foundation matrix’ in Group Analytic Psychotherapy – or waves and particles in physics. This way of thinking recognises the duality of individual minds and the relationship between them, but focuses on the waves. It is in tune with modern consciousness studies, and progressive ideas about how radical change is needed if humanity is to survive – particularly concerning the relationship we have to our natural environment. 

Perhaps these could be called the ontological (what are they?) and epistemological (how can you know what they do?) problems. But if the definition of therapeutic community is does not include all these angles, and possibly others, we will be losing something of their essential, and edgy, nature. Similarly, if we irrefutably prove that one type of therapeutic community leads to a reliable change in one variable, we risk losing the breadth and depth of the approach, through standardisation and regulation. This wide scope of this book ensures that it does not make those reductive oversimplifications.

 Then there is the problem of history, and what is usually called ‘baggage’ – and how it affects the political context of therapeutic community work. In some countries, different sorts of wildly diverse units, clinics and facilities all call themselves ‘therapeutic communities’. Some do this proudly, with high clinical standards, transparent and accountable published processes, university collaborations, and highly trained staff. Others have little understanding of the meaning of the name or the depth of history in therapeutic communities and simply think of the term as a useful name with which to market their services. In other countries, the name itself carries an unspoken stigma that conveys a whiff of disreputableness, tainted history and deliberate failure to face the reality of modern life. Here, only the most confident therapeutic communities can proudly assert their identity. The communities described in this book are amongst these, and can perhaps offer encouragement and support to those wanting to tread a similar path towards excellence – and membership of the extended family.

 It is a paradox that the type of therapeutic communities that have always appeared to be most secure in their continued existence are those that are growing in what might be considered the stoniest and inhospitable soil – the criminal justice system. It is a paradox because it is extremely difficult to see how it is possible to give people in state custody a sense of openness, empowerment and personal dignity in settings which demand almost total social control and lack of freedom. Perhaps it is the very rigidity of the system – security over therapy – that ensures that, once therapeutic communities become part of the establishment, it is almost impossible to get rid of them all (though individual ones may have insurmountable local difficulties, of course), however counter-cultural they may appear. But it happens, and often in innovative and effective ways: this book gives a wide range of examples of what is possible.