Underpinnings of the therapeutic community individualgroup dialectic, between clinical organisation and daily life

Underpinnings of the therapeutic community individualgroup dialectic, between clinical organisation and daily life

Abstract

This contribution offers a general overview that departs, above all, from a relationship with the Mito&Realtà network, and describes the underpinning of the community architecture, highlighting the basic arrangement and internal articulations that work together to achieve the clinical, rehabilitative and social aims that form its mission. The TC is presented as a complex organism and course of treatment defined in space and time, and that develops from an initial moment of reception (trial period, assessment process and rehabilitative therapeutic contract), into individual, group interventions (assemblies, meetings, various group typologies) and interventions with families, a phase of insertion, attachment and start of detachment from the social network. Great importance is placed on daily life and the climate as background for integration and transformation, beginning with the results of the international literature and recent infant research studies on processes of affective attunement, rupture and reparation.

 

Intro

The Therapeutic Community (TC) is a living organism, an orchestration of multiple instruments and players (workers, residents, family members, referrers, natural networks, etc.). An institution, therefore, aptly evoked by the above-cited image suggested by Anna Ferruta of a solid but light and mobile architecture. I will attempt, in this contribution, to describe the underpinning of this architecture, highlighting its foundations and the distribution of its interior spaces, which combine to allow it to accomplish its clinical, rehabilitative and social aims. Beyond its specific objectives, it is important to categorise the various therapeutic communities (TCs) according to their diverse features.

There are those for adult, adolescent and minor-age residents, psychotics, mothers and children, battered women, and so forth; typologies both long-lived as well as those that have sprung up recently across the country. An overview, in other words, prompted by knowledge of the communities of the Mito & Realtà network that, for some years now, have been elaborating indicators that could constitute a common denominator for an Italian “community model”.

Despite the diversity of types of underpinnings and organisation (privately accredited or public), they do share an initial fundamental: their democratic foundation. This consists of a distinct yet conversant clinical and administrative leadership, a staff that functions as a “followership” (1) that promotes and supports its multiple activities with a group co-responsibility oriented toward the integration (2) and maintenance of a safe and protective emotional/affective climate for residents and workers alike. (Correale 1990; Obhlozer, Perini 2001, Perini 2012; Ferruta 2012). Communities with clear confines but permeable and open to continuous theoretical/clinical encounter with other TCs and to integration with the local or broader regional, national and international social fabric (Barone, Bruschetta 2015). 

For those seeking integration, the therapeutic community offers a course of treatment with a definite time and space in which to develop that continuing dialect between individual intimacy and private listening and group experiences that foster encounter with the other (both symbolic and real) in the multiple behaviours and projects that continuously intersect in daily life. Thus, on the one hand, it offers a “custom-fit” evolutionary project with a personalised central reference point (caregiver or psychotherapist) aimed at cohesion, strengthening of the self and acquisition of the ability for reflection.

On the other, a group dimension that can increase a sense of belonging and responsibilization as the premise for a gradual receptiveness to connection with the social and family networks outside the TC. It is on this difficult co-existence and oscillation between the Self and the Other that the majority of the treatment’s efficacy depends, even with inevitable upsets that range from shut-down and withdrawal to enthusiastic and often explosive immersion (Napolitani, 1987). 

Residential treatment immerses us in a highly complex and multidimensional situation that requires a specific kind of organisation. Indeed, a patient in a community undergoes various “interventions” contemporaneously: psycho-pharmaceutical, individual and group therapy, psychosocial rehabilitation, family intervention, the influence of the milieu on the natural course of the disorder, contingent events, and so forth. It is therefore necessary in a TC that we speak of “therapeutic relations” rather that of the “therapeutic relationship” (Maone, 2011).

In any case, however, even for more serious patients, the quality of the interpersonal relations is revealed as the core of the practice, and favourable results stem from a wide range of settings and patient populations. Therefore, the question is to articulate these multiple settings flexibly according to the phase of the personalised and shared therapeutic course of treatment, utilising the potential of both individual and collective spaces fully. 

On what does the successful development of this individual-group dialectic depend? 

According to international studies (Priebe, Gruyters, 1993; McCabe, Priebe, 2004), and countless years of treatments administered and patients released, the prerequisites are the shared involvement of the patient, family, referral service and TC group in the project’s construction, and the therapeutic alliance that is forged in the preliminary phase that every community that calls itself therapeutic must seek to ensure…

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Marta Vigorelli

Marta Vigorelli

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Therapeutic communities and group analysis

Therapeutic communities and group analysis

Introduction

This paper will review the literature on democratic therapeutic communities and group analysis, and highlight the theoretical and clinical similarities between democratic therapeutic communities and group analysis. The paper will compare classic therapeutic community and group analytic concepts, with illustrative case material. There are many similarities between therapeutic communities and group analysis, but there are also significant divergences, particularly in practice.

This paper provides an additional theoretical basis for therapeutic community practice, and highlights both the need for a greater theorising of therapeutic community practice, and the importance of group-based approaches in mental health. The paper is the first to review the relevant literature, and to compare theory and practice in therapeutic communities and group analysis, highlighting their common roots in the Northfields Experiments in World War II. Democratic therapeutic community (TC) practice and group analysis (GA) in the UK grew from the same roots in the war-time Northfields Experiments. “[] from this hotbed of experimentation had come both group analysis and the idea of the therapeutic community,” (Clark, 1987, p. 5).

Pines stated that Foulkes began to practise GA in 1939 (Pines, 2009), although Mannheim (1939) was the first to use the term “group analysis”, a fact which Foulkes himself acknowledged (Winship, 2003, p. 38). Harrison said that “During 1942, Foulkes elucidated the concept of group transference (Foulkes and Lewis, 1944)”, while over the winter of 1942-43, Bion and Rickman developed what became known as the First Northfield Experiment (Bion and Rickman, 1943; Bion, 1946, 1961; Harrison, 2000, p. 13). According to Harrison, Bion and Rickman turned “psychiatry upside down” by “forging an alliance with the patients (sick soldiers) in order to defeat the problems of mental ill-health”, and instigating daily group discussions for the whole ward in what was primarily a communal living environment; and that the two Northfield Experiments “implemented entirely new methods of group psychotherapy. 

These included dealing with the reality of ‘here-and-now’, making the examination of members’ interrelationship the centre of therapy, allowing the psychodynamics to reveal themselves, and working with the group transference. Leadership was another focus […]” (Harrison, 1999, pp. 19-20).

Main also said that Northfield was where the concept of the TC was born (Main, 1983, p. 203). Even Lacan, who visited London for five weeks in 1945, and effusively detailed a long conversation he had with Bion and Rickman, described them as “pioneers” of a “revolution”, and talked of Bion undertaking “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 […]” (Lacan, 1947, p. 17).

Foulkes worked at, and was involved with, both developments at Northfield – the TC and GA, although he left TC work, and was no longer directly involved with in-patient psychotherapy, but concentrated on GA, and the Group Analytic Society. Foulkes acknowledged the links between the TC and GA in many of his writings, and described his development of small group therapy, and of working with the ward as a community, and later the whole hospital (Foulkes, 1983, 1984, 1986, 1990b; Foulkes and Anthony, 1965).

De Maré talked of meeting Foulkes at Northfield in 1944, and stated that Foulkes was “the only person who witnessed the ‘Northfield experiment’ (2nd) throughout, from his instituting it in July 1943 to his demobilisation in December 1945” (De Maré, 1983, p. 218). However, according to De Maré, Foulkes did not become fully aware of the first experiment until Rickman revisited Northfield in 1944 (De Maré, 1983, p. 223). De Maré suggested that Foulkes approached the second experiment in “an entirely different and more circumspect manner”, by regarding the total situation – the whole hospital, and all the hospital staff – as his frame of reference, and Phase B of the second experiment involved, initially, a whole
ward as a community being conducted on small-group lines, and then all wards being conducted along group lines (De Maré, 1983, pp. 223-5).

De Maré concluded that “it was this dialectic duality between relationship and context that constituted the basis for his (Foulkes) success, and particularly the application of what Foulkes called ‘group analytic principles’ to an entire context, which resulted in the ‘large-scale transformation of a whole hospital’ – the first therapeutic community’ as described by Main” (De Maré, 1983, pp. 224, 226; Main, 1946, 1977).

TCs and GA also had common personnel initially – Foulkes, Bridger, De Maré at Northfield – and later, Clark at Fulbourn Hospital, Pines at the Cassel Hospital, Roberts at Ingrebourne Centre, Blake at Kensington and Chelsea Day Centres, Whiteley at Henderson Hospital, Kennard at Littlemore Hospital, Haigh at Winterbourne TC and, more recently, Pearce at Oxford Complex Needs Service (Pines, 1999).

Of these, Whiteley has been the most prominent in linking TCs and GA. However, as Harrison noted, “Some therapeutic communities were inspired by Northfield; but the influence of Maxwell Jones (Mill Hill Hospital, Belmont Hospital, Henderson Hospital and Dingleton Hospital) tended to overshadow the earlier and more complex model” (Harrison, 1999, p. 29). Nevertheless, Hinshelwood observed that “The engagement in a group learning process has become a core feature of therapeutic communities. It is the group activity as much as the learning one which is crucial – although it seems that the group activity has to be of a learning kind” (Hinshelwood, 1999, p. 40).

© The International Journal of Therapeutic Communities 2017

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Rex Haigh

Rex Haigh

He studied social sciences as well as medicine as an undergraduate. After working as a GP, he trained as psychiatrist, then as an NHS medical psychotherapist and group analyst–becoming a consultant in Berkshire in 1994, where he has been based since. At the Royal College of Psychiatrists, he was the founder of ‘Community of Communities’ quality network in 2002 and the ‘Enabling Environments’ award in 2008. He was appointed as Honorary Professor of Therapeutic Environments and Relational Health at Nottingham University’s School of Sociology and Social Policy in 2015.

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Therapeutic communities enter the world of evidence-based practice

Therapeutic communities enter the world of evidence-based practice

Summary

This editorial provides the modern-day context for a long-established psychiatric treatment, democratic therapeutic communities. As this treatment is now such a small field in psychiatry, readers may not have enough background to be able to place the research in a suitable context. This includes the previous gap in experimental research, the difference between the modern model and the one used in the 20th century and the general field of personality disorder evidence.

© The Royal College of Psychiatrists 2017

Modern-day therapeutic communities

For psychiatrists who remember democratic therapeutic communities in their heyday, they were based on Rapoport’s four themes (democratisation, permissiveness, reality confrontation and communalism) which he identified at Henderson Hospital in the late 1950s. Although the service in Pearce et al’s study is based on some of these fundamental principles, they are overlaid with several decades of development and modification.

Newer therapeutic communities now bear few superficial resemblances to these residential services, which were formed in the heat of the social psychiatry revolution of the 1950s and 1960s. No wholly group-based residential therapeutic communities now remain in the National Health Service (NHS), and all of those that still function are day units, as in this study. The laissez-faire attitude of ‘leave it to the group’ rarely prevails, there is a high level of structure and order, and there is very little opaque psychoanalytic interpretation delivered by remote therapists.

Modern therapeutic communities have a strong emphasis on empowerment, openness and ‘ordinariness’, which soon dispel any notions of therapeutic mysteriousness and charismatic leadership. They are tightly managed services with clear admission, review, progression and discharge protocols.

In 2002, one of the first quality networks of the Royal College of Psychiatrists’ Centre for Quality Improvement (CCQI) was the ‘Community of Communities’. It helped democratic therapeutic communities to agree the nature of best practice and to consistently deliver it.8 Part of this process involved the distillation of ten core values that underlie the measurable standards.

These would be entirely familiar to early therapeutic community pioneers: a culture of belongingness, enquiry and empowerment; democratic processes whereby no decisions can be made without due discussion and understanding; and the fundamental importance of establishing and maintaining healthy relationships (which are not always comfortable and are seldom without conflict). This work has also led to the ‘Enabling Environments’ award at the Royal College, and the development of ‘psychologically informed planned environments’ (PIPEs) in criminal justice settings, and ‘psychologically informed environments’ (PIEs) in the homelessness sector.

 

Their role in treatment for personality disorder

The publication of outcome studies for personality disorder treatment have had something of the quality of a ‘horse race’ or ‘beauty contest’ in the past decade. New treatments have been constituted from various old psychological theories, which have been branded and packaged, then manualised and researched with much energy and competitiveness.

In this way, they have been suitable for ‘selling’ to mental health commissioners as simple value-free ‘commodities’ or ‘products’. In a way, Pearce et al’s study indicates that therapeutic communities have now entered this race. However, it is worth proposing that their study is not of a simple ‘brand’ of treatment, but of a therapeutic philosophy with a long and distinguished heritage, which has now been adapted to fit into the wider ‘whole system’ of a 21st-century mental health service.

Therapeutic communities offer a democratic way of conducting therapeutic business, demand specific attention to the coherent and coordinated use of the different therapeutic approaches, and deliberately provide an overall therapeutic environment.11 These do not often happen in other therapies.

Therapeutic communities also specialise in being able to treat those who have a particularly severe presentation of personality
disorder, such as in prisons. This severity can be measured by diagnostic criteria, comorbidity, risk, complexity or unmanage- ability. The therapeutic environment, including techniques such as peer mentoring and deliberate informality, facilitates engagement of people who would otherwise be ‘untreatable’.

Also, by managing risk primarily through continuing, empathic and intense therapeutic relationships, therapeutic communities can manage levels of risk that would be unacceptable in other services. This study demonstrates that democratic therapeutic communities have now started to accumulate the evidence to earn a place in the therapeutic pantheon for moderate and severe personality disorder.

 

References

Pearce S, Scott L, Attwood G, Saunders K, Dean M, De Ridder R, et al. Democratic therapeutic community treatment for personality disorder: randomised controlled trial. Br J Psychiatry 2017; 210: 149–56.

Lees J, Manning N, Menzies D, Morant N. A Culture of Enquiry: Research Evidence and the Therapeutic Community. JKP, 2004. 

Lees J, Manning N, Rawlings B. Therapeutic Community Effectiveness: A Systematic International Review of Therapeutic Community Treatment for People with Personality Disorders and Mentally Disordered Offenders. University of York Centre for Reviews and Dissemination, 1999. 

Rapoport R. Community as Doctor. Tavistock, 1960. 

Haigh R. The new day TCs: five radical features. Ther Communities 2007; 28: 111–26. 

Pearce S, Haigh R. Mini therapeutic communities: a new development in the  United Kingdom. Ther Communities 2008; 29: 111–24. 

Pearce S, Haigh R. A Handbook of Democratic Therapeutic Community  Theory and Practice. JKP, 2017. 

Haigh R, Tucker S. Democratic development of standards: the Community of Communities – a quality network of therapeutic communities. Psychiatr Q 2004; 75: 263–77. 

Haigh R, Harrison T, Johnson R, Paget S, Williams S. Psychologically informed environments and the ‘‘Enabling Environments’’ initiative. Hous Care Support 2012; 15: 34–42. 

Haigh R. Industrialisation of therapy and the threat to our ethical integrity. Personal Ment Health 2014; 8: 251–3. 

Haigh R. The quintessence of a therapeutic environment. Ther Communities  2013; 34: 6–15. 

Department of Health. Recognising Complexity: Commissioning Guidance for  Personality Disorder Services. Department of Health, 2009. 

Article author

Rex Haigh

Rex Haigh

He studied social sciences as well as medicine as an undergraduate. After working as a GP, he trained as psychiatrist, then as an NHS medical psychotherapist and group analyst–becoming a consultant in Berkshire in 1994, where he has been based since. At the Royal College of Psychiatrists, he was the founder of ‘Community of Communities’ quality network in 2002 and the ‘Enabling Environments’ award in 2008. He was appointed as Honorary Professor of Therapeutic Environments and Relational Health at Nottingham University’s School of Sociology and Social Policy in 2015.

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Learning from Action method on the boundary between the GR and the TCs’ culture

Learning from Action method on the boundary between the GR and the TCs’ culture

Introduction and roots | Dia 1, 2 and 3

This documents stems from my desire to reflect on the Learning from Action method that’s an innovative exploration of GR event,  and its meaning in the Group Relations and Therapeutic Communities cultures, following from R. Hinshelwood, E. Pedriali and L. Brunner’s previous contributions on this kind of learning experience, published in 2010 on the OPUS journal.   

Learning from Action stems from the meeting between the  GR model and the TCs culture, and is aimed at exploring activities and actions of daily life as a form of unconscious and non verbal communication.

Dia 2

The idea for this residential learning experience came in 2000 from the encounter between Hinshelwood and Pedriali, who lead the first 7 editions of this event that has been always in Italy. Since our colleague and friend Pedriali sadly passed away in 2009 the workhops came to halt. During a International Memorial Conference i have organized on behalf of Il Nodo Group Association in 2010 in Milan with as key note speaker Kennard Triest Hinshelwood and others, there was much discussion around this methodology. I felt the call to prevent the death of this initiative. Il Nodo Group that is 17 years that organize GRC in Italia, welcomed my interest in exploring this innovative GRC. 

The first 7 editions of the workshop had Hinshelwood as director and Pedriali as associate director. In a new series of events Hinshelwood continued to be the director and I took the role of associate director. More recently I became director of the last 4 events and G. Boldetti a woman director of TC for adults took the role of associate director, meanwhile R.Hinshelwood has the role of scientific supervisor.  

 

Aims, structure and primary task | Dia 4

LFA conference offers partecipants an opportunity for direct learning through 3 days of community living. It is designed in order to develop new thoughts and practises for those who work in residential institutions, and within mental health services, in various roles such as consultants, psychologists, psychotherapists, psychiatrists, neuropsychoatrists, social workers, etc. 

Dia 4 This Working Conference* has a double porpose:

  1. To train partecipants to observe and learn to understand the “language of actions” dia 5
  2. To explore and become aware of the interpersonal, inter groupal, organizational, institutional dynamics and  factors, manifest of latent, which are active in decision making processes.

Janet Chamberlain, past nurse at the Cassel Hospital and staff member in both the first and the second series of Working Conference, commented on the conference in 2013: “Shared activities followed by reflective spaces provide an opportunity to experience becoming part of something (a group, a new community), whilst at the same time thinking about the issue of responsibility, decision making and the role of the staff within the process.”

The main themes for the Learning from Action Working Conferences are: decision making and accountability.

In the course of the Conference  3 activities sub groups are formed(usually 10-15 partecipants each group of activities), which take charge of practical tasks, in order to fulfil the survival needs of the temporary learning community. Such activities are: 

Dia 6

  • Meals preparation
  • Management and cleaning of communal areas…

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Luca Mingarelli

Luca Mingarelli

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