The Therapeutic Community
Two developments anticipated some of the basic ideas of the therapeutic
community:-
19th Cent. – moral treatment belief in treating the mentally ill in a
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humane and dignified way, creating an intimate family-like atmosphere, need for
kindness and tolerance. Faded with the rise of the large asylum and shift towards a
biological view of mental illness
2) Planned Environmental Therapy. In 1913 an American, Homer Lane,
invited to England to open a community for delinquent and disturbed adolescents: used
self-government as the basis for running the community. Influenced, A.S. Neill, Wills
and others. Wills developed "Planned Environment Therapy", including the principles
that punishment should never be used to correct a child's behaviour, all relationships
should be egalitarian and non-authoritarian, and therapy should be based on a loving,
accepting relationship between child and adults.
So the idea of an egalitarian community in which change is brought about through
caring, personal relationships, is not new as a way of responding to societies disturbed
and deviant members.
Therapeutic Community:- given name by Tom Main in 1946. He described the
development at Northfield.
"An attempt to use the hospital not as an organisation run by doctors in the
interests of their own greater technical efficiency, but as a community with the immediate
aim of full participation of all the members in the daily life and the eventual aim of the
resocialisation of the neurotic individual for life in ordinary society."
At same time Maxwell Jones was developing his ideas in London.
Basic idea:- patient involvement. Both experiments were showing that patients
could be helped more fully when professionals were willing to become less hierarchical
and patients were allowed to become involved in helping each other as part of a hospital
community.
From its early days as a radical movement, the Therapeutic Community has
evolved to become an established method.
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Important influences and ideas:-
1). Psychoanalysis
a) The creation of a free space within a structured boundary.
Structure:- place, staff, time of meetings, roles, rules. Within this structure
the individual is free to act as he wishes. Talk, silence, actions.
b) Transference. Others may be seen as an authority figure, or seen as
father, mother, brother, sister, etc. Or may replicate patterns of
relationships whole family relationships. Community and whole
transference's.
c) Defence mechanisms
d) Counter-transference
2) Theories of group functioning
Bion basic assumption functioning
Foulkes: group matrix, role of group conductor.
3). Studies of Organisations and Social Systems
· The finding that traditionally run institutions are harmful to patients social and
psychological well-being.
Goffman : Asylums
Barton : Institutional Neurosis
· Clinical findings that staff behaviour and expectations have a powerful impact on
patient's level of functioning.
Stanton and Schwartz covert disagreements within staff group can result in
collective disturbance among the patients.
· Finding that the unconscious group dynamics within the staff
team can have a powerful impact on individual staff members and the organisation as a
whole.
Menzies:- defences against anxiety.
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· Main:- staff dynamics around patients regarded as "special" by staff. These
patients can split staff into those who feel she is just playing up and needs a firm
approach, and those who feel she is misjudged and misunderstood. Each side see
the other as misguided. Main's solution:- to set up a staff discussion group.
Systems Theory
The individual can be seen as part of a system. So view that mental illness is
located not primarily in the individual but in the network of relationships of which he is a
part.
Relates to Foukes:- the neurotic is someone who has become isolated from his
social network "the deepest reason why patients can reinforce each others' normal
reactions and wear down and correct each other's neurotic reactions is that collectively
they constitute the norm from which individually they deviate". Through group
participation the disturbed individual gradually moves from his isolated position and
ideosyncratic norms towards the healthier, collective norm of the group.
In Practice
Four principles:-
1) " Democratisation each member of the community should
share equally in the exercise of power in decision-making about community affairs
therapeutic and administrative.
2) "Permissiveness belief that all members should tolerate
from each other a wide degree of behaviour that might be distressing or deviant in terms
of usual norms.
3) "Reality Confrontation" – belief that patients should be
continuously presented with interpretations of their behaviour, as it is seen by most others
to oppose tendencies towards denial, distortion, withdrawal or other mechanisms that
interfere with the capacity to relate.
4) "Communalism" belief that the therapeutic community
should be characterised by a tight-knit set of relationships, sharing of amenities,
informality, and freeing up of communication.
An important underlying principle:- all involved are encouraged to be curious about
themselves, each other, the staff, the management structure, psychological processes, the
group process, the institution, etc. "the culture of enquiry." Understanding is owned by all,
not seen as only present in professionals.
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For many patients, the process of emotional development has gone seriously
wrong with abuse, trauma, neglect, depravation, and loss leading to disturbances in
relationships. Therapeutic communities can facilitate emotional development, where
things that went wrong can be re-experienced and worked at.
Processes:-
- attachment (primary bond, losses as growth). Feeling of
belonging.
- containment ( maternal and paternal holding), safety in
groups, support, rules and boundaries.
- communication (play, speech, others as separate).
Openness.
- agency (establishing self as the seat of action).
Empowerment democracy, votes, decisions.
- Involvement (finding a place among others). Community
meeting, agenda, and structure, reality confrontation.
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