Therapeutic Community treatment offers a radically different group-based approach for serious neurotic, personality disordered and long-term mentally ill patients, in specialist units. Its principles can be applied to the therapeutic care of a wide range of patient groups in different settings. including the community. The therapeutic community embraces a set of methods which aim to treat people suffering from emotional disturbance in a communal atmosphere. Therapeutic Community principles are based upon a collaborative, democratic and deinstitutionalised approach to staff-patient interaction. Highlighting this approach, patients are generally referred to as residents or members of the community. Traditional staff/staff and staff/member hierarchies are replaced by a more liberal, humane and participative culture.

The Therapeutic Community (TC) offers a safe environment with a clear structure of boundaries and expectations where members have the opportunity to come to terms with their past through re-enactment within a treatment setting involving other members and staff. Group psychotherapy and traditional psychoanalysis are integral to the treatment, but TCs also offer the individual experiences to awaken creative and social abilities. Members tend to learn much through the routine interactions of daily life and the experience of being therapeutic for each other. Through this psychosocial therapy the aim is to encourage members towards a better understanding of their previous behaviour and to enable them to improve their inter-personal functioning, first within the therapeutic community and ultimately in the wider community. Encouraging and reinforcing the notion of personal responsibility and sharing, members and staff meet together on a daily basis to discuss the management and activities of the community, to assess applications for admission and to support leavers.

Members of Therapeutic Communities are not normally detained under the Mental Health Act; attendance is generally voluntary, and to benefit from participation in a TC the member must be positively motivated to change his/her behaviour, to co-operate in group therapy and to accept the rules of communal living.

Who are the Patients?

Patients of TCs are people suffering a range of mental health problems who are in a cycle of failure and despair, often suicidal. They are people who, without treatment, cannot hope for successful relationships or careers and may have exhausted the resources offered by other agencies. These individuals typically have long histories of emotional and relationship difficulties and associated problems may include drug or alcohol misuse, self-harm, obsessional-compulsive behaviour, or eating disorders. Schizophrenic patients can be greatly helped in therapeutic communities tailored to their needs.

Who may authorise or suggest referral to TCs?

Consultant Psychiatrists
General Practitioners
Social Workers
Nurses
Educational Psychologists
Clinical Psychologists
Occupational Therapists
Counsellors and Psychotherapists
Teachers
Probation Officers
Potential Patients

Where are Therapeutic Communities?

Therapeutic Communities exist in a variety of settings and range from small family-like communities to large psychiatric hospitals. Some examples are:

NHS Adult Psychiatry - e.g.
- a specialist residential unit
- psychotherapy departments and day hospitals
- other specialist psychiatric units (e.g. rehabilitation, alcohol)

Community based provision - e.g.
- local authority mental health hostels
- local authority mental health day centres
- adolescent units
- group homes for the long term mentally ill

Voluntary sector communities - e.g.
- halfway houses
- after-care hostels

Educational settings (both local authority and voluntary) e.g.
- schools for children with emotional disturbance and behavioural disorders
- schools for children requiring remedial teaching

Penal settings - e.g.
- probation day centres and hostels
- in certain prisons

A Therapeutic Community may be organised as a series of outpatient sessions, or may take the form of a Day Centre, a medium-long term residency or, in certain cases, a permanent home in the community.

The Association of Therapeutic Communities publishes a Directory of TCs in Great Britain indicating the types of reierrals they will accept.

Does it work?

Several studies* have found that this approach to treatment is successful in substantially improving the quality of life for members. Properly conducted TC regimes are capable of proaucing measurably effective outcomes in a number of member groups. A study (1) by the Cassel Hospital showed that 98% of members are too disturbed on admission to find employment, but that five years later 90% have jobs. Re-admission and re-conviction rates have been found to drop considerably after treatment in a TC.

What does it cost?

Direct cost comparisons between traditional and therapeutic community treatments are unsafe because of the many variables. TCs vary in their charges and funding arrangements and will provide details on request. However, a recent study (2) by the Henderson Hospital pointed out that "although a district health authority may save itself any immediate expense by refusing to fund appropriate expert treatment, the untreated patient will continue to remain a burden to professionals, often using psychiatric, social, probation and prison services for years to come".

The study found that after calculating the reduction in its patients' usage of health and social services after discharge the Henderson repays the investment made in each member after approximately 2.5 years. It concludes that short term savings on the treatment of personality disordered patients are thus a false economy.

The use of drugs may impede progress by obscuring the origin of some patients' problems, which are predominantly psychosocial. It is a principle of the therapeutic community to use a minimum of medication. This practice incidentally represents a considerable financial saving on psychotropic drugs used in more traditional treatments.

Extending the Method

In all residential situations a therapeutic community approach will bring more benefit than an authoritarian or 'laissez-faire' regime. There is a need for more Therapeutic Community development. The ATC would wish to encourage, support and at times offer consultation to such initiatives.

The Future of the Therapeutic Community

The closure of a large number of mental hospitals has led to the creation of a larger number of small units, frequently dysfunctional because of poor financial and staff resources.

The Therapeutic Community approach to the treatment of a wide range of displaced and psychologically disturbed patients can - and we believe should - be applied successfully in many of these units. The principles of collaboration and co-operation have been shown to produce positive results and to cost less in the long-term. TCs can return people into the wider community better prepared to make a real contribution in terms of social and family relationships and to gain employment .

Many patients need more care and support than the community can, or will offer. There remains the need for a spectrum of psychiatric treatments including the valuable benefits afforded by therapeutic communities. TCs have a unique contribution to make and can continue to grow even more outcome and cost effective with the full support of maximum professional referrals.

For mor informations you can require to the ATC:

- Details of ATC Membership
- Bibliography of TC Research
- ATC Directory of Therapeutic Communities
- "An introduction to Therapeutic Communities", by David Kennard

NOTES

* Bibliography available from ATC.

(1) Rosser R., Birch S., Bond H., Denford J., & Schachter J., (1987) "Five Year Follow-up of Patients Treated with In-patient Psychotherapy at the Cassel Hospital for Nervous Disorders", Journal of the Royal Society of Medicine, 80: 549-555

(2) "Are short term savings worth long term costs? Funding treatment for personality disorders.", Menzies D., Dolan B.M., Norton K., (1993) Psychiatric Bulletin 17, 517-519