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Public mental health and the new therapeutic community
Gary Winship and Rex Haigh
ABSTRACT: This paper examines the potential fittedness of the
therapeutic community (TC) approach to a wider vision of community care
and in particular the application of democratic principles in general
clinical psychiatric practice. We suggest that the idea of a 'third way for
mental health' requires a combination of both radicalisation and neo-
conservatism of the TC ideology (Hinshelwood, 1996; Cox, 1998). In
particular, the potential of new democratic practice emerging from the
political concept of 'dialogical democracy' is examined. (cf: Giddens,
1994).
A new welfare aaenda
The 'third way' for metital health care must lie on a different axis to the dichotomy
of the old socialist agenda of 'the nanny state' and the more recent philosophy of
individualism and victim blaming (DoH, 1997). A more complex interlace of
various connecting systems will emerge, including a rapprochement between
private and public ideology, health and social services. In transcending previous
divides in welfare ideology, localized democratic practices may have an important
role to play in countering the erosion of accountability which protects the public
interest (Hutton, 1999). The Government's plan for quality improvement in the
NHS (DoH, 1998) explicitly cites the need for a change of culture. However, if the
shift from a hierarchical culture of managerialism to a philosophy of social
organization is to be more than rhetorical, then success may depend on the
willingness of psychiatric service providers to commit to a grass roots type of
democratic engagement where the needs of the professionals will be balanced with
the needs of the patients. It is towards these open ends that a development of the
well known concepts of 'IC proper' and 'IC principles' towards a 'TC public'
might be appropriate.
Please address correspondence to: Gary Winship, Adult Psychotherapist, West Berkshire
Psychotherapy Service, 53-55 Argyle Road, Reading RG I 7YL. Email: gwinship@aol.com
Rex Haigh, Consultant Psychotherapist Winterbourne House 53-55 Argyle Rd, Reading RG1
7YL: email: rexhaigh@winterboume.demon.co.uk
Therapeutic Communities (2000), Vol. 21, No. 1
© The Authors
48
Therapeutic Communities (2000) Vol. 21(1) 47-53
The failure of community care?
Whether community care truly 'failed' is debatable. However, there can be no
doubting that community care has lost the battle of ideology. In 1983, anticipating
the expansion of community psychiatry, Tony Butterworth (a leading figure in
the development of Community Psychiatric Nursing) wrote: "The problem with
community care is that it has developed without a philosophy of its own"
(Butterworth and Skidmore; p 9). This ideological vacuum has never been filled.
Community Care has remained empty at its core — deplete of a trusted coherent
therapeutic philosophy (Cox, 1998). The realization that pharmacological means
have been used primarily as a preventative measure for controlling violence has
created increased anxiety in the public's mind. Whereas the foundations of
community care in the 1950s emerged from a core assumption inclined towards
exploring the potentialities of new understandings of the mind and brain, today
psychiatry is laden with a despondent air of limitations. Care has become a burden,
professionalism undermined and creativity largely exhausted. The dominant frame
has become the enumeration and control of risk and no longer the transformative
potential of humanity.
Protocols of chemical control have become part and parcel of a wider culture of
managerialism which has shifted the care emphasis further away from the needs of
the patient and closer to administrative control. This shift has caused a crisis of
confidence in the public domain. Where there has been poor compliance with
medication, as in the case of Christopher Clunis, a small but significant number of
random homicides have occurred (cf: Rogers and Pilgrim, 1996).
And in early 1997 a Holloway vicar was stabbed in the back by a man suffering
from schizophrenia when the vicar invited the man into his church to make him a
cup of tea. The general public might be forgiven for feeling that there has been a
lack of safe havens under the old regime.
Politics of self and community
The news, then, that the government was injecting "one billion pounds to end care
in the community" (Guardian leader: July 25, 1998; p.1) may not have come as
much of a political surprise. In his letter to the chair of the recently formed
reference group for mental health', the Health Secretary asserted: "Care in the
community has failed. Too many confused and sick people have been left
wandering the streets and sleeping rough." Calling for a radical overhaul of the
systems and organizations treating the mentally ill, the cash injection aimed to
"create more beds and a wider network of support for disturbed patients". The new
idea of mini asylums comes in tow with proposed changes.
That such a notion as a mini-asylum is posited suggests that the community care
system, with its lack of centredness, may have suffered from never attaining the
sense of object constancy offered by the old asylum system. Community care has
floundered without a secure enough base. If the family is a model for maturation,
Gary Winship and Rex Haigh
49
home being where we start from, then community care appeared to be a system of
reluctant fostering. The result has been an absence of communitarianism that has
seen diminished esteem for the social agents trying to offer patients a centre to hold
on to.
The 1980s and early 90s became the era of self, the reverence for privatisation
and the vilification of what was seen as public (Figlio, 1989). These were political,
social and cultural manifestations of an inward folding concept of sharing. In this
dissociated schema of individualism, the concept of society became no more than
an instrument of self-fulfilment, eventually paling away until, in some people's
minds, there became no such thing (cf; Rustin, 1990) Philosophy reflected in the
clinical lifeworld instilled a belief that patients could exist without communities
and institutions. The project of social identity swept into 'self care' which became
the revered aim of therapy. There were intense efforts to remove the concept of
interpersonal process from the clinical milieu along with any notion of
dependency, attachment and transference as permissible dynamics in the process of
treatment. This moral persuasion contested that those who were dependent on what
was described as the 'nanny state' were not good contributing citizens.
The public TC
The gathering mood of a society ripe for a new degree of social understanding,
with an urge towards national renewal and a new selfless society was forcibly
signalled by the electorate in 1997 who responded to the banner of revivifying the
corner stones of public service (health and education). What this has meant in
theory and practice has been more taxing to consider. The generation of social
administration (rather than managerial) may see a return to more gradualist
ideologies superseding the short termist vision of the previous government. In
clinical teams, this may be reflected in a more wide spread acceptance of treatment
intervention forming part of long-team plans, rather than brief symptomatic relief
with little likelihood of enduring change, in short: the possible rehabilitation of the
idea of therapy. How to develop an effective therapeutic community in the public
domain — a model which draws on what has worked in the past and one that is fitted
to the needs of our time — is the challenge ahead.
We suggest that the 'therapeutic community' (TC) approach is potentially well
fitted to the new health and welfare agenda and that the ideas of TC practice be
widely disseminated and incorporated into developing models of new community
care. The TC method is concerned with addressing the dynamics between various
health and welfare system participants, with the intention of maximizing
opportunities for patients to be offered definitive treatment and rehabilitation. The
professionals in the TC model act as interlocutors, by introducing therapeutic
systems which transform pathological patterns of relating (often derived from
previous damaged relations) into healthy and potentially sustaining relationships.
TC treatment seems well suited to today's world because it views the patient in the
50
Therapeutic Communities (2000) Vol. 21(1) 47-53
context of their personal and social environment and is orientated to holistic
psychosocial challenges even with the most intransigent patients including
borderline, drug addicted, personality and forensic disorders. The outcome of TC
treatment is ambitious, aspiring to social productivity, full employability and the
reduction of potential future health and welfare costs (Dolan
et al,
1996, Davies
et
al,
1998).
Historically, the notion of a 'TC proper' was a tetin used to describe a specialist
institution which was a dedicated therapeutic community with a set of inclinations
towards daily living therapy, with described themes of democratization (or flattened
hierarchy), communalism (living and sharing together), permissiveness and reality
confrontation (Rapoport, 1960). Some other psychiatric services began to apply TC
principles with great success, without actually referring to themselves as
therapeutic communities. However, these aspects of TC practice have been far from
ubiquitously adopted in psychiatry and the TC ideology has been almost
exclusively equated with in-patient treatment, although this has been challenged in
clinical practice (Haigh and Stegen, 1997; Knowles 1997).
Based on the expertise gained in residential treatment and the new variations (like
day hospital TCs and drop-in community mental health care team settings
(CMHTs)), we suggest that a third dimension of practice should be encouraged to
evolve alongside them. This would lead from the models of 'TC proper' and 'TC
principles' to a wider adoption of the TC method in a variety of branches of therapy,
a dimension or extension of practice which we refer to as 'TC public'. It would be
unwise to lend too much specificity to this term at the moment other than to say we
wish to initially convey three ideas. Firstly that TC ideology, although derived from
institutional practice, may be more easily fitted to the public and community
settings than at first glance. Secondly, to emphasise that TCs demand open and
socially reflexive systems of operation, which could provide a model for psychiatric
practice in an open society. Thirdly, that the proper place for the installation of the
TC idea is in the public domain where the cultural matrix is fundamental in
promoting therapeutic engagement.
The fundamental idea remains that rehabilitation and recovery rests upon the
successful internalisation of a type of relationship (embodying communitarian
principles) which the patient takes with them back into the public world from the
experience of therapy. In the first of these preliminary definitions above, as
Hinshelwood (1996) has pointed out, the therapeutic community method
specialising in group facilitation and organisational dynamics has a central role to
play in aiding the development of new ways of social organisation beyond
residential and acute settings, for instance in community settings such as day
hospitals and community mental health teams (CMHTs). Cox (1998), writing as the
Dean of the Royal College of Psychiatrists, prescribes the ideas from the
therapeutic community ideology to fill the vacuum at the heart of community
psychiatry. His paper; `ConteInporary Community Psychiatry: where is the
therapy?' conveys clearly that it is towards the concept of therapy that we should
Gary Winship and Rex Haigh
51
turn our attention. The idea of the open 'public TC' returns us to the notion of
democracy.
Justice and dialogical democracy in the TC
Giddens (1994) proposes that the democratic project can be advanced through the
increasing reflexivity offered by what he calls 'dialogical democracy'. Dialogical
democracy creates the necessary climate for active participant citizenship. Giddens
sees this as a grass root process whereby there is a filter up effect from local lobby
and pressure groups which becomes intrinsic to wider political process. How might
this apply to health care?
Therapy lies in the creation of an intersection between the everyday systems of
organization in the treatment milieu (including the micro-milieu of individual
psychotherapy) and the patient's own experiences of familial enfranchisement, or
lack of it. The dialogical process of therapy enables the patient to experience a new
synthesis of enfranchisement, replacing previously distorted experiences with new
opportunities to locate a sense of agency. In a therapeutic milieu where there is an
explicit commitment to exploring democracy, when the patient reports feeling a
sense of dis-empowerment or oppression in treatment, then the democratic
discourse of therapy is diagnostically viable as well as being potentially
transformative. In order to ensure that the patient's opportunity for empowerment
is maximised, the starting point is promotion of a culture of enquiry and openness
within the staff team. The examination of the staff hierarchy, by implication,
infouns the process of empoweinient in the milieu.
The idea of justice, fair play and entitlement is actioned and not treated as a mere
abstract account of the self, dissociated from social bonds. The therapeutic milieu
might therefore be continually re-appraising its ability to democractize itself
(`democratization of democracy' as Giddens calls it). As well as discovering the
limits of democracy, new more sophisticated models of social democracy may
emerge; consider for instance the concept of proportional representation which
might give TCs the opportunity to experiment with alternatives to the idea of basic
consensus decision making. Previous experiments in democracy in psychiatry
appear to have advanced or faltered depending on whether the politico-cultural
climate was conducive to progressive ideas. During the 1980s, fragmentation and
isolation characterized the TC movement as many institutions came under fire and
some, such as Peper Harrow, became high profile casualties. The reflective space
was too easily emptied by depression or fractured by psychotic thinking either from
within or without. The collision of the split hierarchical discourses of patients, staff
and managers was the basis of disaster, as Bion discovered at Northfield. It is the
collision of these discourses, in a culture that is willingly enquiring, which may
provide the basis for working towards adult engagement as new levels of
maturation begin to unfold. That is to say, staff and patients work together towards
maintaining a therapeutic milieu. For long term survival individual TC projects
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Therapeutic Communities (2000) Vol. 21(1) 47-53
need to be threaded to other like-minded enterprises in an open or public way.
With a wider defined concept of the TC 'public', the culture of managerialism
which has been bound by economic deteiminism can be challenged, shifting
accountability towards clinical work again. The fallibility of individual morality in
a paranoid hierarchy may be curbed through the enhancement of
res publica
coalitions, both at local and national levels. Institutional relations may act in
ombudsman-like ways ensuring standardised quality. For example, scrutinizing
practice in a TC may be an inter-TC task involving both patients and staff in a new
model of organizational consultancy, and such a process is being developed by the
Association of Therapeutic Communities. This is in keeping with the machinery of
`clinical governance', and the formation of the National Institute for Clinical
Excellence (NICE).
With hindsight, the failure of the democratic experiment in TCs previously was
the lack of amalgamation of experience and a shortfall of cross cultural coherence:
TCs struggled for survival on their own — often in rather anarchic and oppositional
ways — and many went to the wall. Or to put it another way, the stumbling block in
the way of generalisation of the democratic project in the first tranche of TCs was
the failure to undergo a period of what we would call 'clinical constitutionalism'.
Clinical constitutionalism
We suggest a multi centred collaboration is needed which culminates in the
development of a social contract and conceptual bill of responsibilities which
explicates aspirations for TC and psychiatric practice. It would be premature to say
much more about this other than to posit that a clinical constitution would mean that
executive power structures which govern clinical practice would be scrutinized and
framed in relation to the consensual will of both the patients and primary care
providers. We suggest that movement away from a paranoid, blaming, rights-based
culture is necessary; to one where everybody is more aware of their burden of
responsibility, both for their own feelings, thoughts, behaviour and for social
responsibility. To paraphrase John F Kennedy: 'ask not what others might do for
you, but what you might do for others'. A hierarchical schema of power and will,
such as this, is as much driven by the politics of scarcity as it is by the morality of
righteous suffrage. That is to say, the aspirations towards democracy are not only
ethically driven but also needs-based. Insofar as the welfare resources are always
going to be inversely proportionate to the need for welfare (at least for the
foreseeable future), we are impelled to develop ever more efficient partnerships
between staff and patients.
The urge toward democratic process or the opening up of channels of
communication is an impulse which directs milieux towards informal collectivity
or, as might be preferred, an evocation of a spirit of `communitarianism' (Etzioni,
1993). David Kennard has called this 'the therapeutic community impulse' (cf
Hinshelwood, 1996). The inclination towards group democratic processes and
Gary Winship and Rex Haigh
53
inclusivity is apparent in many walks of public life where, for instance, there is the
development of focus groups in policy making, the widening scope of citizens'
juries (Stewart
et al,
1994), the inauguration of a jury system to deliberate the
outcome of National Lottery grant applications and so forth. Democratic ideology
is becoming more relevant today and its procedures are appearing increasingly
elemental in convening the legitimate exercise of authority and power.
The TC approach is the only branch of psychiatry, to date, that has an explicit
historical interest in democracy. In moving towards a so called 'third way' in
mental health care, we suggest that democracy needs to be viewed as a core
contingent in what constitutes a viable treatment strategy. In turning our attention
towards a period of constitutionalism, the outcome may be a 'IC public' model for
a wider adoption of what constitutes good psychiatric practice.
References
Butterworth, A. and Skidmore, D. (1983)
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Cox, J.L. (1998) Contemporary community psychiatry; where is the therapy.
Psychiatric
Bulletin,
22; 249-253.
Davies, S., Campling P. and Ryan, K. (1998) Changes in patterns of service use following
treatment of personality disorder in a therapeutic community.
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Our Healthier Nation.
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Book reviews
Psychosocial Development During Adolescence:
progress in developmental contextualism
edited by Gerald R Adams, Raymond Montemayor and Thomas P Gullotta
Published by Sage Publications: Thousand Oaks / London / New Delhi (1996)
Paperback pp. 346. Price: £17.99, ISBN 0761905332
In 1973, John Hill wrote a paper entitled 'Some Perspectives on Adolescence in
American Society', which outlined the position of the Office of Child
Development in the US Department of Health, Education and Welfare. That
paper stressed the multi-faceted nature of adolescent development, arguing that
biological, psychological and social factors should not be studied in isolation,
but in relationship to each other. In particular, Hill argued that since
development is always embedded in the contexts of social class, ethnicity, race
and gender, it should be studied that way and not separated out. This perspective
has come to be known as developmental contextualism, and it is the general
view which informs the psychosocial approach to adolescent development taken
in this book.
The editors regard Hill's paper as a bench-mark in the study of adolescence, and
use it as a starting point for this collection of papers. Thus each paper addresses a
theme originally identified by Hill as central to the field: autonomy, sexuality,
intimacy, identity, achievement and independence of thought.
This is a densely informative book, consisting mainly of eight wide-ranging
research reviews. It provides a view of the state of research into adolescence up to
the mid 1990s and detailed information about approaches and findings. It will be
of interest to researchers in the field as it will point them towards the main studies
and illuminate methodological issues and problems. It could also be useful to those
who want to check up on the reliability of myths and facts: is it true, for example,
that there is a relationship between hormone levels and moodiness in adolescents?
The reviews are as follows: Silverberg and Gondoli look at the 'detachment
debate', the development of autonomy, and at how adolescents make decisions
in different areas of their lives. Herold and Marshall cover work on sexual
development and sexual identity, noting the introduction of new research
concerns, such as AIDS, date-rape and adolescent sexual offenses. Fischer,
Munsch and Greene look at the development of intimacy, noting that adult
intimacy can be healthy or unhealthy and that the research does not provide
enough clear evidence as to how these outcomes are achieved. Cote examines
approaches in sociology and psychology to see how identity is formed. He notes
the change in perspective from the stable self (1950s) to the mutable self and
notes that post-modernist views see identity as relatively unstable in the late
