And sometimes it has not.

Today's world is an inclement, unfriendly place for the old style therapeutic community. I want to look back at the past, at the founding ideas, and to see how they might be relevant to today.

Inevitably, I will draw on my experience in only one country - Britain.

The early experiments

The sense of a community of belonging was strong in the aftermath of the Second World War. The mobilisation of the whole community of the nation had inspired co-operative and communal attitudes. Within mental health, those old traditional asylums provoked revulsion and protest. There was a realisation that not all living together was healthy or therapeutic. Goffman is the best known writer on "total institutions" as he called them. He captured the sense of a malignant institution. The asylums demolished the inmates. As persons they became sub-human.

During the war a new optimism had begun which looked to ways in which institutions could be made more effectively therapeutic. New methods were tried out, especially in the military and at the army hospital at Northfield. In the war, it was obvious that the social milieu was a direct factor in psychiatric casualties. The war caused mental illnesses. The search was for the factors that could make a social milieu therapeutic.

The early experiments were fairly simple ideas - we might call them a naive now. A characteristic of the old institution was picked out: and then reversed. If the old institutions were large then small ones were created.

Reacting to Goffman's (19**) critique of total institutions, day hospitals were set up - or night hospitals, and weekends hospitals when people came in when they were not at work. These experiments are now called partial hospitalisation in America and intermediate structures in Italy and in France.

If there is a tall hierarchy, then it needs to be flattened.

In fact, there are many other features that can be reversed in this way.

The question behind all this is: What are the ingredients of a therapeutic institution which mark it out as different from the old and damaging ones?

The therapeutic community movement has been foremost in seeking empirically based answers to that question. Forms of practice have been continually developed to test different ideas of what went wrong in the social milieu of a mental hospital (1). But it was easier to see what goes wrong rather than to put in place what will go right.

Deeper issues: Really there needs to be a much more penetrating insight into what was damaging in these large institutions, before a proper reversal of their funcioning could be planned. The beginnings of this were in Goffman's work, and also the observation in the 1950s on institutionalisation.

Dennis Martin made detailed observations on what he called 'institutionalisation' in the large and traditional mental hospital:
the patient has ceased to rebel against, or to question the fitness of his position in a mental hospital: he has made a more or less total surrender to the institution's lifeÉ He is co-operative. Here 'co-operative' usually implies that the patient does as he is told with a minimum of questioning or opposition. This response on the part of the patient is very different from that of true co-operation essential to the success of any treatment, in which the patient strives to understand, and work with, the doctor in his efforts to cureÉ (The( patient, resigned and co-operativeÉ to passive to present any problem of management, has in the process of necessity lost much of his individuality and initiative (Martin 1955, p. 1188-90).
This comes from Martin's original description. Personalities are distorted by the power relations, and the patient loses his capacity to understand and to take part in his own treatment.

With this analysis of the specific power relations between staff and patients there is the beginnings of a deeper understanding of processes which go on in damaging institutions. Tom Main offered his own description of this relationship:
only roles of health or illness are on offer; staff to be only healthy, knowledgeable, kind, powerful and active, and patients to be only ill, suffering, ignorant, passive, obedient and grateful (Main 1975, p. 61).
Both sides - staff and patients - are reduced to one-dimension. Both sides are active in creating this division.

Inside and outside: My argument is that there are multiple factors internally and externally which lead to the death of therapy. One of the most important of these is a community's problem is adjusting to changes in its environment. In other words, we are very alive to the milieu inside, and our communities take great care to look after the individuals in important ways. However, the community itself has a milieu. It lives (or dies) in relation to what is happening outside - within psychiatry or within social work, psychology etc.; and also it lives in a world where social attitudes and values change on a wide national and international scale.

These relations between the individuals, the TC milieu and the world at large is clearly very entangled. I want to try to create an orientation for us within this tangle.

Democratisation and enquiry

By 1960 the therapeutic community movement had developed in a much more sophisticated way. Both Tom Main and Maxwell Jones had made great developments in their own respective institutions, but these had been largely on an intuitive basis (Jones 19**, Main 19**). Maxwell Jones however was interested in more formal research into the way things had developed. He engaged an anthropologist, Robert Rapoport, to do empirical research - not on outcome, but on the characteristics of the milieu itself in which patients lived and tried to develop themselves (Rapaport 1960). Rapoport's most well-known conclusions were that staff in a therapeutic community tended to have sets of attitudes which boiled down to four fundamental principles in the community work. These principles were not explicitly talked of. He found them operating beneath the expressed opinions.

The four principles were Communalism, democratisation, permissiveness and reality-confrontation.

These principles have been repeatedly talked about and examined ever since. However, at the time that I began to develop a therapeutic community around 1970, the exciting initiative was permissiveness and democratization. This took up particularly Dennis Martin's concerns about the power relations, quoted earlier. The therapeutic community explored ways in which the patients/residents could take an active part in the decision-making, with real power. At the time these notions of therapeutic community were parallelled in other professions, for instance by the conceptualisation of empowerment by social workers.

At this time there was a profound general movement within the 1960s and 1970s in this direction. And the therapeutic community was swept along with it towards more equal power relations. The sixties ethos of freedom for the individual went well with the therapeutic community principles of democratisation and permissiveness.

In 1979 Nick Manning and I edited a book on therapeutic communities (Hinshelwood and Manning 1979) and I recall that the headline to one of reviews of that book was: 'Have you heard it all before'... Time was running out for the founding spontaneity of therapeutic communities. Time was running out too for the permissiveness and of the sixties generation. In that year, 1979, Margareth Thatcher was elected as Prime Minister in Britain, and she began a long onslaught against the creativity and values of the 1960s and 1970s in which the therapeutic community had flourished so well. In 1980 Ronald Reagan was elected in the USA. It is clear to everyone that it has been progressively more difficult to sustain democratic processes in society with a general acceptance of equality across the social spectrum, and more difficult to sustain therapeutic communities.

Since 1979, in Britain, there has been a radical change of attitudes in our society. We have different views on what human beings are, on how they should live together, and what values we support. Because of the dominance of the economic theory of monetarism and subsequent political policy in our country, human beings are now viewed as members of society in so far as they choose and consume. This has created a very different ethos. Equality only exists between those with the same amount of money, and the same amount of consumer-power. Money has become not only the main source of power, but consuming it has become the central value in our society. Permissiveness has been reduced to choosing what to buy.

This remarkable cultural change has affected the therapeutic community. We are now asked to define ourselves in the consumerist system. What good are we to the consumers (i.e. is the users of our services). Research is no longer into the nature of communities, as Rapoport's was. Research is to show our effectiveness, like a washing-machine, or the performance of a car. It has not proved possible to resist this pressure and a great deal of money is spent on outcome studies, and indeed on promotion and marketing.

It is not just that we want to do different research. A new climate of opinion has demanded new research of us. We are embedded in a set of different attitudes about human beings. Moreover these views are formed indirectly. They creep us, as it were, embedded within political policies, implied in advertising etc., etc.

It is not just that we now have to sell ourselves in a consumer market place. Our work is extremely dependent on what we think people are, and we cannot be immune from the views held by the world at large. We import attitudes which affect what we think we are doing with our patients. As a result, therapeutic communities now stress other things than democratisation and equal power-sharing. In particular, we talk of people having agency for themselves and their lives - but this is no longer in terms of power but, as consumers, people are expected to make their choices and to inform themselves to enquire what with money will buy.

I would suggest that this general redefinition of human beings as people who must enquire to make their consumer choices has led to a redefinition of what therapeutic communities are about. In other words the emphasis on Rapoport's principle of democratisation has yielded to an increasing emphasis on another of his principles - reality-confrontation. And it is an emphasis in a particular way; we talk now of a culture of enquiry (Main 19**, Norton 19**) (2).

Of course the consumer's enquiry is: What use is this thing? Therapeutic communities try to sustain a different angle: What is the meaning of this thing? And we may have some conflict here with social attitudes. But I claim it has been necessary to redefine our work with patients, partly in line with a redefinition by society of what people are.

I do not complain that this is necessarily a bad thing. It is after all one strand of Dennis Martin's point about true co-operation - that the patient attempts to understand. It is merely that we are bound.

Commercialisation

Briefly I will consider a second factor that contributes to the way we have adapted to consumerism. This is the effect of new drugs in medicine. The psychiatric wonder drugs began to come into use in the mid to late 1950s, a decade or so after the therapeutic community had started. The success of these drugs has been partly due to the marketing achievements of the drug companies, and the huge financial resources that they have had available to promote drugs. In their promotion, these companies implicitly promote much more. Firstly they offer a particular definition of what people are, and secondly they promote a definition of what professional care is.

In particular drug promotion offers a view of people as biochemical machines. Their wishes, thoughts and actions are predetermined by physical states of the brain and body. As a result medical care is redefined. It takes short cuts around the patients' personalities and goes straight for the physical causation. This tends to undermine views of people as having self-determination, or needing to empower themselves. And it tends to support those 'roles of health or illness' which Main described in the earlier quote. Thus the drug companies represent an attitude to patients that was also the attitude of the old traditional mental hospital. The pharmacological movement has had a great influence on how health workers think about their patients, and how they provide them with care.

In the 1940s and 1950s the therapeutic community set out to attack the old mental hospitals from the beginning, and therefore attacked those attitudes. With the coming of the psychiatric drugs, the therapeutic community has had to make an uneasy peace (3).

The provision of treatment within psychiatry has increasingly become a prescription of drug measures. Psychotherapy and the therapeutic community have been added, as it were to the phamacopeia. And within the therapeutic community both patients and staff often expect various therapies to be offered, as if they were drugs to be dispensed - according to the need of the patients. Patients have group therapy, art therapy, drama therapy etc. - even the 'large group'... In some measure the therapeutic community has redefined itself as a prescribed list of things to do the patient good. In the process the community has undermined itself. The notion of belonging and contributing gets cut away from the individual receiving care and attention in the community. Of course communities fight this way of thinking. But once set going this internal process can lead eventually to a progressive ritualization and strangulation of the therapeutic community work. And this needs constant attention (4).

Types of patient and the work

Finally I want to try to show how these changing patterns in the definition of human beings, and of the helping relationship, have altered our diagnostic categories; and how that, in fact, may help us to regenerate the therapeutic community movement.

The early emphasis on democratisation had less impact on psychotic patients. They suffered most from institutionalisation and remained powerless, obedient, and merely compliant, rather than truly co-operative. There are certain exceptions of course, where remarkable people managed to do really innovatory things in the large mental hospitals (Jones 19**, Clark 1996). The traditions of the therapeutic community movement were developed and sustained by small specialist units, which in those early days tended to be formed from a certain category of psychopathy - typically the anti-social one (Jones 19**, Craft 19**). And it seems to me that the communal aspects of an egalitarian regime were especially suited to people who preyed upon others - emotionally as well as materially. Transgressions, reparations and communal giving all seem to be an important learning opportunity for patients of this kind.

There has been a very significant change in the kinds of patients who predominate in our work today. Patients referred to us are now personality disorders, and especially those who seem to approach psychosis - the borderline personalities. These disorders,

rooted in very disturbed relationships, are interestingly more suited to a regime which is less occupied with communal involvement, and more to do with an enquiry and therefore the development of thinking. At the same time the pressure from psychiatry and from the sources of funding tend to demand that we make ourselves more relevant to just those who are more disturbed, and who are less amenable to the routine treatments of psychiatry. The pressure to treat personality disorders seems to fit with the general trend we have noted towards a culture of enquiry. In this sense we are, by chance perhaps, more adapted to working with those patients nearer to psychosis and who need more attention to their damaged capacities to think and enquire.

If so, it may be that we are on the way towards becoming a service that is truly relevant to psychotic patients, those most in need in those old mental hospitals which the therapeutic community set out to rescue.

Conclusion

I have suggested that the character of our therapeutic communities depends more than we acknowledge on the influences from outside ourselves, and circumstances which are beyond our control. I am not suggesting that we simply adapt to whatever trend is passing by - simply bending to the wind. Much of the therapeutic community idea is held tenaciously in spite of the inclement world around us. I am trying to convey that we tend to reinterpret ourselves in the current climate. I have tried to show that although Rapoport demonstrated four principles as a unique combination within therapeutic community ideas, we have tended to emphasise first one and then another of these, as the conditions outside have influenced us. First the democratisation, and latterly the culture of enquiry. Happily this is a change which may make us more able to respond to those demands which are likely to increase in the near and medium-term future as we are asked to take more and more difficult patients.

Notes

(1) The history of therapeutic communities has been a rapid succession of comings and goings. Many come and many go, but some communities have survived for long periods, and much research needs to be done on them to understand what it is they have which has enabled them to survive, whilst most die.

(2) The therapeutic community takes its place in a variety of other modalities that are generally referred now as reflective practices.

(3) The notion of the helpful prescribing doctor ministering to his helpless patient, has therefore merged with the move towards the individualism of the consuming human being.

(4) Main's argument for a culture of enquiry was that it attacked ritualisation and the blind performance of routines (Main 19**, Griffiths and Hinshelwood 19**).