Certain beliefs about human relationships and the nature of therapy are central to therapeutic communities.

1 Staff are not completely ‘well’ and residents are not completely ‘sick’. There is a basic equality as human beings between staff and residents, who share many of the same psychological processes and experiences.

2 Whatever the symptoms or behaviour problems, the individual’s difficulties are primarily in his or her relationships with other people.

3 Therapy is essentially a learning process, both in the sense of learning new skills—how to relate to others or deal more appropriately with distress—and learning to understand oneself and others.

A study of one of the best-known therapeutic communities, Henderson Hospital,⁽⁴⁾ identified four principles or ‘themes’ that have come to be widely associated with therapeutic community treatment.

Four principles of therapeutic community treatment

The generalizability of these principles to newer therapeutic communities is now being questioned and others are developing theoretical frameworks for different therapeutic communities.⁽⁵⁾ In 2002, a quality network including most British therapeutic communities started, the ‘Community of Communities’, with the explicit aim of defining good practice and improving it. In 2006 the first version of ‘Core Standards’ was published.⁽⁶⁾ This comprised 16 standards which were derived from consensus and consultation exercises to determine what practitioners and service users thought reflected the underlying values of therapeutic communities.

Box 6.3.9.1 illustrates a sample of eight of the standards. Note that ‘all community members’ should be taken to include both resident or client members, and staff.

Communities providing sanctuary for mentally ill people have been known as far back as the fourteenth century at Geel in Belgium. In 1796 the Retreat was opened by the Quakers in York, England, where personal relationships and social expectations in a family-like atmosphere enabled previously dangerous and unpredictable individuals to control and modify their behaviour.⁽⁷⁾ This model, known as ‘moral treatment’, strongly influenced the creation of asylums in Britain and the United States in the first half of the nineteenth century. In the early twentieth century, pioneers in therapeutic education, inspired by a Christian belief in the therapeutic power of love and by Freud’s new method of psychoanalysis (see Chapter 3.1), created residential schools for maladjusted children that demonstrated most of the practices and attitudes outlined above.⁽⁸⁾ The modern equivalent of communities such as Geel can be found in the intentional communities run by third sector (voluntary) organizations such as l’Arche and the Camphill communities for people with learning disabilities. (The term ‘intentional community’ avoids language that implies clinical responsibility or a focus on therapy or change, and has been defined as ‘a relatively small group of people who have created a whole way of life for the attainment of a certain set of goals’.) A number of therapeutic communities for children and young people now exist as voluntary organizations in the educational sector, as progressive schools, and as long-term treatment units for very disturbed children.

The history of mental health therapeutic communities for adults began during the Second World War, when the psychoanalyst Wilfred Bion was put in charge of the training wing at Northfield Military Hospital in Birmingham, England. His brief attempt in 1943 to establish a therapeutic community failed, but was soon followed by others who were more successful: Tom Main, S. H. Foulkes, and Harold Bridger at Northfield, and Maxwell Jones at Mill Hill Hospital, London. In dealing with psychiatric casualties among soldiers they developed a radical new approach, which was first described in a series of papers in 1946. One of these coined the term ‘therapeutic community’.⁽¹⁾ Main and Jones continued to develop different versions of this new method after the war, Main as director of the Cassel Hospital and Jones at Belmont Hospital Industrial Neurosis Unit, which was renamed the Henderson Hospital in 1958. The Cassel Hospital continues as an inpatient psychotherapy hospital, and Henderson Hospital replicated itself in 2000 to serve national needs for ‘severe personality disorder’ provision by founding Main House in Birmingham and Webb House in Crewe.

The creation of the National Health Service in 1948 provided the stimulus to address the major problems of institutionalization revealed in a number of studies of large mental hospitals in the United Kingdom and United States.^(9,10) In the 1950s and 1960s social psychiatry was in the ascendancy and a number of these hospitals developed what Clark called the ‘therapeutic community approach”.⁽¹¹⁾ In the 1970s and 1980s concepts of collective responsibility fell from favour and individualism prevailed, with a decline in the fortunes of therapeutic communities. The 1990s and 2000s have seen a revival of interest in therapeutic communities within more specific mental health contexts, including prisons, personality disorder services, and for the management of people with enduring mental illness in the community. The problem of degraded and poorly functioning inpatient units is now being addressed by attention to establishing and maintaining ‘therapeutic environments’ in acute settings, in a direct parallel to the ‘therapeutic community approach’ 40 years earlier.^(12,13)

Alongside these developments two other types of therapeutic community have emerged. In 1958 a self-help organization in the United States called Synanon became the prototype for concept-based therapeutic communities for ex-addicts. Phoenix House and Daytop were two major programmes that grew from this, and today therapeutic communities modelled on them can be found in more than 50 countries worldwide.⁽³⁾ A development that grew out of the antipsychiatry movement in the 1960s is known at Soteria. These are small low-stress family-like environments where psychosis is responded to with intensive therapeutic support rather than medication. These communities are mainly found in Europe.⁽¹⁴⁾

Therapeutic communities have drawn on the concepts of psychoanalysis, group analysis (see Chapter 6.3.6), humanistic and integrative psychotherapies, and on sociological studies of mental hospitals which identified phenomena such as the total institution⁽¹⁰⁾ and patterns of behaviour associated with psychiatric treatment in institutions.⁽¹⁵⁾ They are also underpinned by studies of the impact of unconscious processes in organizations,^(16,17) and by anthropological studies such as that of Rapoport⁽⁴⁾ which found a typical pattern of oscillation in the therapeutic community.

A developmental model based on the ‘required emotional experiences’ of attachment, containment, communication, inclusion, and agency has been proposed by Haigh.⁽¹⁸⁾ This identifies ways in which a range of psychological theories and approaches are relevant to therapeutic community practice, and illustrates how they are replicated in the structures and culture of a therapeutic community. It also proposes that disturbance of ‘primary emotional development’ (which all humans undergo early in life) can to some extent be made good by a satisfactory experience of ‘secondary emotional development’ in a therapeutic community.