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| Simone, Amelia and Francesca - the Annual Forum organisers |
This is a talk given to the Sixth Annual Forum of the Visiting Programme for Democratic Peer Accreditation for Democratic Therapeutic Communities in Rome on 3 December 2022.
It is held each year in conjunction with Lega Coop (the Italian League of Cooperatives, one of three such 'unions of coops') and holds promise for the wider understanding of the need for Enabling Environments, and indeed Democratic Therapeutic Communities. See https://www.ilmargine.it/progetto-visiting-dtc/
It was a celebratory return after covid, but also had a darker side in reflecting about the trauma which we had all been through. Steve Pearce's death in March was also marked - and it was remembered how he was with us all at the previous Annual Forum, on the day Brexit finally happened and a few months before the pandemic started.
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The therapeutic value
of Democratic TCs group processes
to deal with massive trauma
Il valore terapeutico dei
processi di gruppo nelle Comunità Terapeutiche Democratiche per affrontare
anche i traumi massivi
Rex Haigh
Medical Psychotherapist, Group
Analyst, Founder and Senior Advisor to the ‘Community of Communities’ and
‘Enabling Environments’, Royal College of Psychiatrists Centre for Quality
Improvement, London.
Thank you so much for inviting me
back to Italy. I love coming here, and this is the first time I've been back to
your Annual Forum since Covid - and thankfully we are all now in a different world
where most of those problems – that have so seriously stopped real contact and
communication between us – are behind us. Although there are – of course – many
other very significant problems in the word we are now in.
But that is all too much to think
about right now, and I want to talk about how the principles of therapeutic
communities, which I think are valid for all aspects of human relationships and
rights, including social justice, as well as the emotional development of all
as us as individuals, families, groups and individuals. I particularly want to make theoretical links to
group analytic theory, with references to same academic papers, and the book
which I wrote with Steve Pearce a few years ago1. Very sadly, Steve died in March of a very nasty cancer,
or I am sure he would have been very keen to be here too.
In the last two years, of course, everything
has been disturbed by Covid. But one of the things I believe is that the principles
of therapeutic communities can help us all recover from the trauma and damage
that the pandemic has caused. So, in this talk I will use the ‘quintessence’
framework2 to look at some of the values and experiences
and methods we use in therapeutic communities – and think about how they relate to the group analytic and TC theory3, as well as to the disruption
we have all experienced with covid. This is all based on our need for human
relationships with each other, and to rebuild those relationships that have
been disrupted by the pandemic – and we need to build them back stronger than
before, to make up for the damage that has been done in the last three years.
I’m sure I have been here in the
past and spoken about the ‘quintessence’ model of therapeutic communities,
which is a developmental oneThis has been written up as ‘The Quintessence of
a Therapeutic Environment’ in the TC Journal, and it describes emotional
experiences that everybody, all of us, need to have a healthy emotional
development and what can go wrong with it when we experience adverse childhood
experiences. If it goes well for us – or at least ‘good enough’ – we emerge as
adults, who have a solid sense of self and understanding of our place in the
world, particularly in relation to others. If it does not go well, the
foundations of our personality development are a bit incomplete or shaky – and
we end up with those unmet emotional needs causing trouble for us throughout
our lives.
In this model there are five overlapping
experiences which are necessary for development: Attachment, Containment,
Communication, Inclusion and Agency. They are roughly developmental – ‘attachment’
is the earliest, as a very young baby, and ‘containment’ is what needs to
happen in the first one or two years of life. The whole world of ‘communication’
with other humans follows, through childhood into adolescence. Then we need to
negotiate the more subtle matter of how we become involved or included -
and find our place amongst other – which is a struggle we all go through in
adolescence. Finally, there is the adult position of achieving personal agency
– and it is impossible to say what age that is at, or even whether most people
ever get to it.
Attachment is about replacing the
placental and physiological bond of gestation with the emotional and nurturant
bond of motherhood, or perhaps parenthood. It is well described by Bowlby as
the ‘Secure Base’ and many people who have succeeded him and operationalised
the concept and done a great deal of research about it. It is about the
fundamental necessity of the intimate bond from the origin of life that all
humans need. In therapeutic communities, we rarely have people with secure
attachment – most of our members are anxious, avoidant or chaotic.
But it soon develops and requires
the negotiation of many more emotions, and survival of them. This is what I
think of as ‘containment’. This is best written about by Winnicott (the transitional
space and the capacity to be alone4) and Bion (intolerable
emotions, and the surviving of them5 - that the mother (or primary
caregiver) has to give. In group analytic terms, the group matrix includes unconscious
aspects of both attachment and containment. It is the group matrix within which the
members feel a strong sense of belonging, and feel safe: as
'... the hypothetical web of
communication and relationship in a given group. It is the common ground which ultimately
determines the meaning and significance of all events and upon which all
communications, verbal and non-verbal, rest', and stated it is ‘...not merely
interpersonal but could rightly be described as transpersonal and
suprapersonal.’6
A little later in development, the
developing human needs exchange of information, and the behaviour, thoughts, and
feelings that go with it. This is the process of communication. And at first,
it is nonverbal – which remains very important throughout all our lives - and
it gradually develops into the whole of language and the many ways in which
emotions are conveyed – as well as the facts and practical details of how to
live in the world. If we limit our thinking to the facts, behaviour and
thoughts of development, we are in the terrain of most psychotherapists who do
not address the unconscious and preverbal aspects of experience – such as
CBT-based therapies and psychoeducation.
In group analysis, some of the key
concepts relevant here are ‘The Basic Law of Group Analysis’, ‘location of
disturbance’, mirroring, resonance, amplification, and condenser phenomenon. These
are described in more detail later in the 2017 paper by Jan Lees, Sarah Tucker
and myself.
The Basic Law of Group Analysis
is that ‘Collectively the members constitute the very norm, from which,
individually, they deviate’, and that group members will work to weaken and
remove support from each other’s ‘neurotic’ or abnormal modes of exchange, and
will work to strengthen and support modes of exchange which are ‘normal’. This
is so because group members together share group norms, which are ‘collective’
and ‘permeate’ an individual member ‘all through…to his core’. These group
norms are shared at a deep level, and are often of the collective unconscious.
Location of disturbance:
Foulkes argued that ‘...the most important source of the disturbance is not
in the patient at all but is rather between the figures of his past and present
networks.’ Group members’
problems/symptoms/disturbances are not localized in the individual in isolation
but located in a social network. In
order to change, group members need to understand that their disturbance exists
between them and other people, not simply within them.
Mirroring is one of the
primary functions of a group - to mirror the self. ‘The group situation has been likened to
a ‘hall of mirrors’ where an individual is confronted with various aspects of
his social, psychological, or body image. Resonance means a sound
which creates another sound. In a group,
each individual reacts in their own way to issues that arise, enriching and
deepening the emotional experience.
Resonance refers to one’s own unique response to the feelings of another
group member or group issue. Amplification describes the exaggeration of
a set of responses within another group member and the group as a whole, and
happens when emotions are often unexpectedly felt more strongly when in a group
setting. For those who find it hard to
access emotions, amplification can be liberating, but it also needs to be
managed actively, especially in a new group.
Condenser phenomenon is
more complex. It describes the sudden discharge of deep and primitive material
following the pooling of associated ideas in the group. The interaction of members loosens up group
resistances, and there is a growning activation at the deepest levels. It is as if the ‘collective unconscious’
acted as an electical condenser quietly storing up emotional charges generated
by the group, and discharging them with the trigger of some shared group event.
It is often in connection with dreams and symbolism, which are productions of a
collective unconscious. These symbols act as condensers
and appear as symptoms or dreams, or something the group holds in common – can
be seen as completing the circuit which discharges the condenser.
Anti-group
So far, this is all in the service of
positive group dynamics, but we must not forget that there is a darker side, what
Jungians would see as the shadow. Using Kleinian psychoanalytic concepts, this
is about the powerful and destructive primitive defences, such as splitting and
projective identification - as well as less complex ones such as denial,
intellectualisation and acting out. Although I don’t have the time to describe
those now, Nitsun described them in group analytic terms as the ‘Anti-Group’7. He went on to argue that
processes and norms in a group are a miniature version of those in society, so
just as there is war, conflict, corruption and violence in society, the same
underlying forces and dynamics are present in groups. He also pointed out that
unconscious processes occur in all types of groups, whether or not the group
aims to explore and work with them. But
if these are not recognised and worked with, the group can potentially be
anti-therapeutic and even damaging. This is what he calls the ‘anti-group’, and
it is a potential presence in any group, and a threat to its effective working.
Destructive processes in groups
can include, for example, drop-outs, lateness and absence, monopolizing,
secrets, meetings outside the group, sub-groups, splitting, conductor’s
isolation and paralysis, irresolvable conflict, enactment of aggression,
bullying, scapegoating, enactment of erotic feelings, stuckness, and malignant
mirroring of disliked and hated attributes. They are things we are familiar
with in therapeutic communities.
Beyond the need for communication,
there is a domain of inclusion or involvement at a wider social level in which
the emerging adolescent discovers their place amongst others. This is about how
we can relate to others - and how others relate to us; about understanding our
own place in the social universe. Back in 1947 Lacan wrote of group functioning
in terms that remind us of the Basic Law of Group Analysis some years before
Foulkes wrote it:
‘Bion’s task is to organise the situation so as to force
the group to become aware of the difficulties of its existence as a group, and
then to render it more and more transparent to itself, to the point where each
of its members may be able to judge adequately the progress of the whole.’8
In 1983, De Mare says of
Foulkes’ group analytic principles:
‘it was this dialectic duality between
relationship and context that constituted the basis for his success.9’
Harrison has more
recently noted that the Maxwell Jones approach soon overshadowed the
‘earlier
and more complex model’10,
and as Bob Hinsehlwood
said in 1999, almost regretfully:
‘it seems that the group activity has to
be of a learning kind’11.
Very much more recently, Steve
Pearce wrote a chapter on ‘belongingness’ in our book (chapter 4) which brings
together many of the more social and conscious aspects of this, than the
unconscious and primitive ones of the analysts who were there at the beginning.
He incorporates theory from Maslow’s hierarchy in 194312 to Baumeister and Leary’s
extensive research into ‘the need to belong’, published in 199513. He also gives some detail
about the implications for practice in TCs, some of which I will mention later.
In this developmental model, the
final stage we see as the psychological work of a TC is for members to feel empowered
– and able to experience a sense of personal agency. This means that we are
able to act effectively - from a core sense of who we are (identity), and what
we want to do with our lives (purpose). In
this way, we find a place in the world - so we can be effective and autonomous people,
responsible for ourselves, but within networks of interdependence with other.
That is in families, communities, organisations and wider systems.
Again, Steve
Pearce wrote a special chapter on this in the book, chapter 5, called
‘Responsible Agency’, about some theoretical research he did with a senior
Oxford philosopher, Hanna Pickard14–17. In the chapter, he brings in
various strands of argument, including choice, motivation and exercise of the
will; adoption of the sick role; self-efficacy and self-esteem; empowerment and
co-production in recovery, shame – and the key concept for TCs of
‘responsibility without blame’. In a way, this is putting a substantial amount
of theory behind Rapoport’s original ‘permissiveness’ and ‘reality
confrontation’ principles18, which could otherwise be
seen as just descriptive and behavioural. Here is a quote from the chapter, which
conveys some of the subtlety of this:
In DTC unhelpful and unpleasant behaviour is tolerated
as long as it does not harm others (permissiveness), but it is also robustly
and regularly challenged (reality confrontation). Members are asked to reflect
on their choices, to think about the reasons for them, and to make efforts to
change their behaviour with the support of the other members and staff. The
emphasis is on developing the capacity to consider the impact of their
behaviour on those around them, initially the other TC members, but expanding
to those in their life outside the community; and to look forward to how they
might behave differently in future, rather than looking back at past mistakes.
This forward-looking approach has the tendency to shift the emphasis of the
conversation away from blame (the emotional reaction to past behaviour and its
consequences), towards responsibility (how will I act in future?). Staff ensure
that the tenor of the challenge is compassionate and forward looking, rather
than blaming or retribution focussed.
What has happened in covid is that
all the social aspects of how we meet these basic emotional needs have been
disrupted – to start an individual or group attachment, and to feel 01belongingness,
has hardly been possible. Many people have felt unsafe or uncontained –
especially with the triple threats of a deadly virus, a planet that is warming
up too much, and a war in Europe. Communication in a direct face-to-face way
has not been possible, although zoom has been a fantastic technological help.
Being included and involved with others has been much more difficult, and many people
have been left feeling disempowered with a profound lack of personal agency.
These are essential human
emotional needs that we all have: human rights, I would say. In therapeutic
communities we try to recreate them for people who have had them disrupted in
their own individual developments, but now we have all had them disrupted,
in our adulthood, in the last three years. Children may have been affected even
more. In TCs we work to help people who have been very troubled in their early
life. We hope to make it possible for people to feel a strong sense of
belonging, to feel power within themselves, are able to trust others, and have
a secure sense of their own identity. It is often very hard work in TCs.
Rebuilding it for everybody who has been traumatised by covid is perhaps not as
intense, but the principles are the same.
We recreate attachment by being
careful and sensitive about how people join our communities. So that they feel
welcome and so that they can immediately understand that the relationships
around them are positive, supportive and compassionate. The foundations of
trust.
The next is containment. In the
infant it is about the way a baby will be in utter and boundless distress - but
soon can be relieved by good breast that Melanie Klein describes. Later in
life, it implies that the emotional turbulence of conflict, disagreement, and
the rough and tumble of everyday life can be negotiated, and ‘held’, in a way
that people can emerge from the distress as stronger after managing and coping
with it. The most important tool for it in TCs is the shared understanding of boundaries.
One of those is at the end of members’ time in a TC. It is very important how people leave – and how we have
to mark and recognise how important that leaving is – how leavers will miss the
community and the people in it, and how all the people in the community are
losing somebody who has been part of it. It is often done with various rituals
including exchange of gifts, celebration meals and other activities.
For those of us working in
therapeutic communities, this is day-to-day business. There are often disagreements,
difficulties and conflicts that need to be navigated. The structures in place –
particularly the structures and groups for how and when conflicts are discussed
– establish a therapeutic space in which disagreements can be safely
negotiated. The practical details are often arranged through things like
community meeting agendas, or extra events like ‘crisis meetings’ or ‘learning
spaces’. The culture that emerges from this is one of safety: ‘however
difficult things get, and however hard it gets, we can get over it and be OK in
the end’. Now covid has damaged so much of the matrix which holds us in our
relationships, it is hard to see how we can establish analogous structures to
meet the public needs of everybody who has been affected – but I think there
are many public and charitable activities going on that try to do this.
Communication in a therapeutic
community is facilitated through the established structures. It is impossible to
NOT communicate issues of importance. ‘There is no place to hide’ as community
members often say – and when this is implemented successfully, the experience
is of openness (which also needs the principle of safe emotional containment to
be possible). There is opportunity and expectation in all the different
therapeutic spaces of honest and frank interchange between people. There is an
implicit and shared understanding, ‘we are all here to help each other and we need
to be honest and open’.
In TCs, involvement and
participation and inclusion are deliberately encouraged by doing things (apart
from therapy) together – preparing meals, gardening, playing games, waling in
the countryside, looking after animals and many other things. With covid of
course we have not been able to do these things together – either in TCs or in
normal life. But again, I think there are many efforts going on to build social
cohesion, and although this may always be the case, perhaps the seriousness of
the situation – including ecological and economic – will force some real
change.
Everyone has had to remain
isolated in their own world and house. Their whole way of being has restricted
the possibilities of people feeling empowered or people feeling that they are
agents of their own destiny - because this powerful force of covid, and the
necessary government restrictions that have gone with it. In some ways,
everybody has been unable to act in the way they need to. Perhaps more in TCs
than in normal life – for a small number of people with big problems - but
nobody has escaped the disruption, and we have a very large number of people
with quite big problems as well.
In the circumstances, we all need
to have these emotional needs met, and we must work out together the best ways
to do it. This is for the members and residents of our therapeutic communities,
but it is for all of us as families and staff, and that very large number of
people in the normal world as well. We need to feel that we belong, that we are
safe together, that we can be open about what we need to be open about, to be
involved with others, and to feel empowered to do things together.
That is a lot to ask in the world
today, but I do believe we can make a difference if we can establish it in
small settings around us – like through this meeting, and through many other
meetings of like-minded people and organisations, who all want something to
change.
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| The large group - sharing their experience of covid times |
From the following discussions at the Forum, there are three headlines that I take away:
- The Italian public and third sector services, particularly health, have had many staff leave, 'the Great Escape'. Educatori in TCs are paid about 1200 Euro per month.
- In the covid lockdowns, the staff in TCs were often more disturbed by it than the residents. The residents often supported the staff, reversing the 'traditional' roles.
- The whole methodology and procedure of the Visiting Project (now in its tenth year) is experienced as complicated, comples and often incomprehensible to newcomers. But many benefits, some of them quite unexpected, can follow.
As well as thanking the organisation for inviting me, and all the friends and colleagues there for their warm hospitality, I must give a special mention to my translator, Eduardo Mancuso. He translated the talk into concise Italian (which even I could almost understand) and we read it out alternately, one paragraph at a time. Never at an Italian conference before have I finished a talk exactly on time!
I will post a separate blog, after this one, with his translation.
