Abstract
Therapeutic communities (TCs) have a long history in mental health care, and the approach is now used in the areas of personality disorder, intellectual disability, forensic services, addictions, education and psychosis. They form the basis for tier 3 personality disorder services when delivered as day services. TC principles have had an enormous impact on current psychiatric practice and were influential in the foundation of social psychiatry. This chapter outlines the history, principles and practice of democratic TCs (DTCs) and traces their impact on service development more broadly. It describes DTCs as a treatment method. It does not treat the use of TC approaches in education, intellectual disability services, addictions, or TC as a philosophy of care in any detail.
Introduction
Therapeutic communities (TCs) have a long history in mental health care, and the approach is now used in the areas of personality disorder, intellectual disability, forensic services, addictions, education and psychosis. They form the basis for tier 3 personality disorder services when delivered as day services. TC principles have had an enormous impact on current psychiatric practice and were influential in the foundation of social psychiatry. This chapter outlines the history, principles and practice of democratic TCs (DTCs) and traces their impact on service development more broadly. It describes DTCs as a treatment method. It does not treat the use of TC approaches in education, intellectual disability services, addictions, or TC as a philosophy of care in any detail.
Note: vignettes are given to illustrate aspects of DTC practice. They are taken from a DTC in the UK, and reflect some procedures and nomenclature specific to that TC.
TCs have been used as a leading treatment model in health care going back to the Second World War. DTC principles are used in education and with disturbed children and young people, to create mutually respectful communities in intellectual disability, and in prisons [1]. Hierarchical TCs, which emphasise mentoring and seniority, have been used in the treatment of addictions since the 1950s [2]. DTCs, emphasising democratisation and a flattened hierarchy, have been used to promote change and recovery in patients we would now recognise as suffering from medically unexplained symptoms, post-traumatic stress disorder, psychosis, personality disorders (PDs) and affective disorders. In the 1940s pioneers such as Wilfred Bion, SH Foulkes and Tom Main used these principles with soldiers invalided out of the war, and informed later work by Maxwell Jones at the Belmont Clinic/Henderson Hospital and later Dingleton Hospital in the Scottish Borders, and Tom Main at the Cassel Hospital in London, among many others. In the 1960s DTCs became associated with the anti-psychiatry movement, partly through the influence of RD Laing, and in the 1970s and 1980s experienced an enormous expansion across the UK and the USA, with large numbers of psychiatric hospitals and wards adopting DTC principles [3]. In 1978 the TC movement was instrumental in a major reform of psychiatric services in Italy (Law 180) in which the ‘democratic psychiatry’ movement resulted in the closure of the asylums, replacing many of them with TCs [4]. In the UK, interest in DTCs coincided with the discovery of phenothiazines, and was instrumental in the unlocking of mental hospital wards [5]. DTC pioneers such as Maxwell Jones and Tom Main, and the TC model, were instrumental in the establishment of social psychiatry [6].
Over the 1990s and 2000s DTC approaches in health care gradually focussed on the treatment of PDs, and all but a few residential services closed or became day services [7]. Government policies designed to improve PD provision led to an increase in outpatient and day DTC services for PD in the early 2000s [8].
At the time of going to press (2020), the number of DTCs in the UK National Health Service (NHS) probably number about 30 but are unevenly distributed geographically. There are in addition 15 DTCs operating in HM Prisons, including 3 for prisoners with intellectual disability and PD [9]. The need to adopt therapeutic approaches in psychiatric practice was highlighted in 1953 by the World Health Organization Expert Committee on Mental Health, which noted that the correct role of a psychiatric hospital was ‘that of a therapeutic community’ [10], while in 2019 the NHS Long Term Plan noted that ‘for people admitted to an acute mental health unit, a therapeutic environment provides the best opportunity for recovery’ [11, s3.102, p. 71]. The Enabling Environments initiative, part of the Royal College of Psychiatrists, provides a quality mark for services aiming to create or bolster their therapeutic and relational aspects, and grew out of the DTC approach. DTC approaches have given rise to innovative relational models outside psychiatry, including in homeless hostels (psychologically informed environments, PIEs), and probation hostels and prison wings (psychologically informed planned environments, PIPEs) [12]. DTC principles have been incorporated into quality assurance networks, often founded on peer review processes. The Royal College of Psychiatrists Accreditation for Inpatient Mental Health Services (AIMS) process, for example, recommends that staff should be trained in group methods, and that a patient community meeting be held regularly, with shared decision-making and spontaneous staff–patient activities, principles taken from DTC practice.
Theoretical Foundations of DTC Practice
Rapoport: An Anthropologist’s Observations of an Early DTC
In 1959 an American anthropologist and his team visited the Belmont (later Henderson) Hospital, a residential DTC, for a number of months in order to study and describe the interactions and social environment. He published Community as Doctor [13] the following year, which set out what he regarded as the four most prominent characteristics of the TC. These were observations rather than instructions, and were restricted to a single residential DTC in the late 1950s, but the four elements described below have come to be regarded as central features of DTC functioning.
Democratisation
Decision-making was devolved to the community, consisting of all patients and staff, with all participants having an equal influence over outcome. Decisions are taken in community meetings with all members present, and if necessary, can be voted upon. The process of reaching a decision is itself therapeutic, promoting empowerment, encouraging prosocial skills in a shared endeavour and giving each community member a stake in the common life. DTCs vary in the extent to which reaching decisions is prioritised over discussion.
Before acting on behalf of the group, a group member must seek a ‘vote of confidence’ and must not act without majority agreement. Tom was a timid man who had decided to chair another group member’s review after lots of group encouragement. When it came to time to start, he got cold feet. The group reminded him that they had all expressed, through the vote, that they were confident he could do it. The group stopped him backing out and he chaired successfully, later saying he felt this represented a breakthrough.
Permissiveness
Delinquent behaviour was not proscribed, but was tolerated with a view to understanding the underlying drivers and meaning.
Barry was a socially awkward character who expressed critical views about mental health problems (including denying his own), the value of groups generally and the TC in particular. He launched into tirades about authority and ‘young people’. Nevertheless, he did not offend individual group members. The group tolerated his rants, seeing them as a distancing strategy. Several months later he remarked this was the first group of people who had tolerated him long enough to get to know him properly. Other group members said they had learned patience with ‘off-putting’ people and felt pride in being welcoming.
Reality Confrontation
Delinquent behaviour, while tolerated, was also confronted by other TC members, both patients and staff. The impact of the behaviour on the community was regularly fed back to the patient.
Eva talked in group about her relationships with a series of men who inevitably treated her badly. Another group member wondered if such relationships might be another form of self-harm. Initially Eva seemed offended, misinterpreting him as blaming her. As they talked, she was able to consider his points and subsequently questioned her own part in maintaining her problems.
Communalism
The members of the community regarded themselves as mutually accountable, and spent formal (in-group) and informal time together.
Susie repeatedly missed group meetings, especially the morning community meeting. She said that was OK as she was the one missing therapy, ignoring the effects on others. She missed volunteering for tasks to help the group, and hearing other members’ problems. When she arrived, she expected help. Once this was explained she began to see the effects of her lateness on others, and to attend earlier.
Haigh’s Quintessence: A Developmental Model of Progression in DTC Treatment
In 1999 Rex Haigh, a British psychiatrist, developed a model to describe the stages of development that a member of a DTC typically goes through, mirroring the stages of development undergone in normal infancy [14].
Attachment
In the early stages of membership, members attach to the group as a whole, as well as the group members individually. The sense of belongingness this engenders becomes one of the motivators for change.
Laura was new to the community but volunteered to chair the morning meeting, despite her anxiety. Jim talked about his anxiety when he first chaired, helped by support from senior group members and practice. Next week, Laura sat next to Jim when chairing and on several occasions looked across to him as she faltered. Staff noticed him giving her a quiet nod at times and she chaired the meeting successfully.
Containment
This element stems from ideas about containment developed by Bion [15] (see Chapter …). TC structure, in particular mutual care and predictability, produces the safety and security necessary for therapeutic change, and minimises acting out.
Alice, a woman who often got into unsafe situations during crises, arrived in group highly distressed. The group helped her to fight the urge to constantly talk about what had gone on over the weekend and to focus on the planned structure of the day. Later she said this structure helped by giving time for her distress to settle, having protected but limited space to talk, and the encouragement to refocus on others.
Communication
Freedom of communication (see below), treating behaviour as a communication, and the Culture of Enquiry (see below) start to play an increasingly important role in the TC members’ journey by its mid-point.
In the morning community meeting group members are expected to give an update on any risk-related behaviour since last group. All are expected to participate in turn, and to be honest about risks. In large group one afternoon, Paul wanted to discuss his self-harm. While the group wanted to hear about this, they also highlighted him choosing not to disclose it earlier in the morning meeting.
Inclusion
All community members are included in the life of the community, the Living Learning Experience.
Sheila had a long history of rejection by services either due to mental health problems, the wrong diagnosis or her risk profile. In selection she discussed this rejection, along with other aspects of her problems that left group members wondering if the TC was right for her. She was offered a place, given the ‘benefit of the doubt’ and became a valued group member, benefitting greatly from the community. Several months later, during a period of depressed mood, she doubted whether anyone wanted her around. Several group members challenged this perception, reminding her that the community as a whole voted for her to join, just as it had for each member there.
Agency
As the TC member becomes more senior, democratisation and reality confrontation gradually mobilise his or her sense of agency. Members come to recognise their own ability to effect change and take responsibility for doing so.
John was open about his problems asserting himself with powerful authority figures, tending to become submissive. Encouraged by others, he volunteered to chair meetings and started to lead meetings without either dominating or deferring to staff and more experienced members. Later he was also able to help the group keep ownership of a problem, demarcating the limits of his authority by reminding the group that the decision was theirs not his.
The Four Principles of DTC Treatment: How TCs Work
More recently, the principles by which DTCs have their effect have been described in more detail [16, 17].
Belongingness
People who feel they belong, who have the sense that they are important to others and care about those others themselves are better able to regulate their mental state, learn and retain prosocial behaviours and are less prone to aggression and suicidal feelings [18]. Many people referred to DTCs are isolated, and the feeling of belongingness that they find in the community becomes a key factor in their willingness and ability to adopt new coping strategies.
Cathy had always felt alienated from society and been rejected by various institutions over time. Initially she saw herself as different from others and that the TC wasn’t really for her. During a meeting for people who had applied to join the TC, Cathy described life in ‘our group’. Afterwards the group remarked on this. She bashfully admitted she had started to think of the TC as her group and perhaps the first place she felt she belonged and felt accepted.
Social Learning
Higher animals, including humans, learn socially as well as through direct behavioural mechanisms such as operant conditioning. This process is central to the therapeutic effect of DTC treatment, and was described in detail by Clark [19]. TC members imitate more senior members, respond to praise and critical feedback and are sensitive to the actions of the staff.
Don had severe agoraphobia, avoided going to the shops and minimised time spent outside. An early goal was to volunteer as a group shopper. Reviewing this, he stated it was only possible if accompanied. The other shoppers observed that he went to another aisle of the store to fetch bread alone. He replied he had seen one of them do the same two weeks earlier and thought he’d try this. This small change presaged greater changes in behaviour and attitude later.
Narrative Development
Psychologically traumatic events can be difficult to incorporate into a person’s life narrative, or be incorporated in an unhelpful way, leading to maladaptive beliefs and behaviours. In talking and thinking about past events in the presence of non-judgemental others, their meaning changes, and can be incorporated into a self-concept that is more adaptive. For example, a woman who was raped as a child may think of herself as complicit and therefore guilty; it can take many retellings before this changes [20].
The Promotion of Agency, and Responsibility without Blame
Many patients, particularly those with PD, may feel powerless and that any change needs to originate outside themselves. This can be related to a history of childhood abuse and victimisation. Changes to maladaptive behaviours such as self-harm and abnormal eating patterns may get easier with insight and improvements in mood, but will still require the exercise of the patient’s will, and a sense of agency. In DTC, responsible agency is encouraged through the devolved and democratised structures of the community [17], but, crucially, is separated from the attribution of blame [21]. Blame is the normal accompaniment to responsibility when behaviour is harmful, in particular when it harms others, but blame is countertherapeutic and likely to lead to early loss from treatment. This leaves a dilemma: how not to blame someone, while retaining their sense of being responsible for their actions and therefore empowered to change. DTC practitioners practice responsibility without blame, in which members are treated as responsible for their actions and decisions, but are not blamed for them. An online course in this way of working is available at www.responsibilitywithoutblame.org/.
Justine often spoke angrily and condescendingly to other group members, leaving them feeling hurt or angry. Sometimes they would try to challenge her, but the conversation would get derailed by her distress at ‘all of you attacking me’. Eventually the group proposed to use the community’s ‘participation’ process – a contract to change behaviour that is obstructing good participation. Although she initially disagreed, by working on this specific behaviour she came to see that others telling her how they experienced her differed from criticising or attacking her. She realised that the only one who could change the way she spoke to others was herself.
Related posts:
Chapter 3 – Referral for Psychodynamic Psychotherapy: Processes and Considerations
Chapter 9 – Systemic Family Therapy
Chapter 10 – Cognitive Analytic Therapy (CAT):
Chapter 15 – Personality Disorder
Chapter 16 – Complex Post-traumatic Stress Disorder
Chapter 17 – Psychological Approaches to Medically Unexplained Symptoms
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