Therapeutic community is a participative, group-based approach to long-term mental illness, personality disorders and drug addiction. The approach was usually residential, with the clients and therapists living together, but increasingly residential units have been superseded by day units. It is based on milieu therapy principles, and includes group psychotherapy as well as practical activities. Therapeutic communities have gained some reputation for success in rehabilitation and patient satisfaction in Britain and abroad. In Britain, 'democratic analytic' therapeutic communities have tended to specialise in the treatment of moderate to severe personality disorders and complex emotional and interpersonal problems. The evolution of therapeutic communities in the United States has followed a different path with hierarchically arranged communities specialising in the treatment of drug and alcohol dependence.
History
UK
The work conducted at Northfield Military Hospital during World War II is considered by many psychiatrists to have been the first example of an intentional therapeutic community. The principles developed at Northfield were also developed and adapted at Civil Resettlement Units established at the end of the war to help returning prisoners of war to adapt back to civilian society and for civilians to adapt to having these men back amongst them. The term was coined by Thomas Main in his 1946 paper, "The hospital as a therapeutic institution", and subsequently developed by others including Maxwell Jones, R. D. Laing at the Philadelphia Association, David Cooper at Villa 21, and Joshua Bierer. Under the influence of Maxwell Jones, Main, Wilmer and others, combined with the publications of critiques of the existing mental health system and the sociopolitical influences that permeated the psychiatric world towards the end of and following the Second World War, the concept of the therapeutic community and its attenuated form – the therapeutic milieu – caught on and dominated the field of inpatient psychiatry throughout the 1960s. The first development of therapeutic community in a large institution took place at Claybury Hospital under the guidance of Denis Martin and John Pippard. Beginning in 1955 it involved over 2,000 patients and hundreds of staff. The aim of therapeutic communities was a more democratic, user-led form of therapeutic environment, avoiding the authoritarian and demeaning practices of many psychiatric establishments of the time. The central philosophy is that clients are active participants in their own and each other's mental health treatment and that responsibility for the daily running of the community is shared among the clients and the staff. 'TC's have sometimes eschewed or limited medication in favor of group-based therapies. The availability of the treatment on the National Health Service in the United Kingdom has recently been threatened because of changes in funding systems. Researchers at the University of Oxford and King's College London studied a national democratic therapeutic community service over four years and found external policy 'steering' by officials eroded the community's democratic model of care, which in turn destabilised its well established approach to clinical risk management. Fischer, who studied this community's development at first hand, described how an 'intractable conflict' between embedded and externally imposed management models led to escalating organizational 'turbulence', producing an interorganizational crisis which led to the unit's forced closure. However, development of 'mini' therapeutic communities, meeting for three or fewer days each week and supported out of hours by various forms of 'service user led informal networks of care', now offers a more resource and cost effective alternative to traditional inpatient therapeutic communities. The most recent exponent, the North Cumbria model, uses a dedicated out of hours website moderated by service users according to therapeutic community principles. This extends the community beyond the face to face 'therapeutic days'. The website guarantees a safe group-based response not always possible with other systems. The use of 'starter' groups as a preparation for entry into therapeutic communities has lowered attrition rates and they now represent a cost-effective model still aimed at producing durable personal and intergenerational effects; this is at odds with the current trend towards the defensive needs of service providers, rather than service users, for less intensive treatments and management of pathways to control risk.
