How TCs Work

TCs vary and it is often best to speak directly to the TC you are thinking of joining. In most cases you will need to be referred by a doctor or social worker but there are some that will take self-referrals.

In the NHS TCs working with people diagnosed with a personality disorder generally use a complex admission procedure, rather than straightforward inclusion and exclusion criteria.

This results in diagnostic heterogeneity, and none claim to treat exclusively borderline personality disorder, although recent work has demonstrated that the admission characteristics of members show high levels of personality morbidity, with most exhibiting sufficient features to diagnose more than three personality disorders, often in more than one cluster.

The admission phase includes engagement, assessment, preparation, and selection processes before the definitive therapy programme begins, and is a model of stepped care, where the service users decide when and whether to proceed to the next stage of the programme.

A voting procedure by the existing members of the community, at a specifically convened case conference or admissions panel, is normally used to admit new members.

Programmes and their various stages are time-limited, and none of the therapeutic communities specifically for personality disorder are open-ended. Some have formal or informal, staff or service-user led, post-therapy programmes.

There are various theoretical models on which the clinical practice is based, drawing on systemic, psychodynamic, group analytic, cognitive-behavioural and humanistic traditions.

The original therapeutic community model at Henderson Hospital was extensively researched in the 1950s using anthropological methods and four predominant ‘themes’ were identified: democratisation, permissiveness, reality confrontation, and communalism.

More contemporary theory emphasises the role of attachment; the ‘culture of enquiry’ within which all behaviours, thinking and emotions can be scrutinised; the network of supportive and challenging relationships between members; and the empowering potential of members being made responsible for themselves and each other.  This has been synthesised into a simple developmental model of emotional development, where the task of the therapeutic community is to recreate a network of close relationships, much like a family, in which deeply ingrained behavioural patterns, negative cognitions and adverse emotions can be re-learned.

The only way to really find out, though, is to visit one – whether as somebody wanting to go through a treatment programme, as a mental health professional or a commissoner of services.

Early fore-runners of therapeutic communities, such as village communities like Geel in Flanders, existed at least as long ago as the thirteen century.

‘Mentally Afflicted Pilgrims’ (who we would probably classify as learning disabled today) went to worship at the shrine of St Dymphna there – and villagers would take long-term care of them, measuring their success by the amount of weight the pilgrims gained! Elements of this philosophy could later be seen in the work of the Quakers in founding the Retreat in York, and in the twentieth century with Steiner’s ‘anthroposophy’ and the international development of numerous Camp Hill and L’Arche communities specifically for people with learning difficulties. However, these are not normally called ‘therapeutic’ communities – but ‘intentional’ communities.

The history of children’s TCs can easily be traced back tat least as far as 1977, when Homer Lane started ‘The Boys’ Republic’ in Chicago – for wayward boys in his charge. He later set up ‘The Little Commonwealth’ in Dorset which closed in some disarray (a common pattern in the TC world). Later developments in the therapeutic childcare field were led by A S Neill who founded Summerhill in 1924, George Lyward at Finchden Manor, and people including Marjorie Franklin and David Wills with the Q-camps and Hawkspur Experiment between the World Wars. Many of the modern generation of children’s TCs are thriving by following the same treatment philosophy, but (at least in the UK) have a complex array of legislation and inspection to contend with – such as CSCI and OFSTED, as well as commissioning which demands value for money and evidence that their extra quality and costs are justified.

Those for the treatment of adult mental health ailments first emerged in a recognisable form in England during the Second World War, at Northfield Military Hospital in Birmingham and Mill Hill in London. The leaders of the Northfield “experiments” were psychoanalysts who were later involved in treatment programmes at the Tavistock Clinic and the Cassel Hospital, and had considerable international influence on psychoanalysis and group therapy. The Mill Hill programme, for battle-shocked soldiers, later led to the founding of Henderson Hospital and a worldwide “social psychiatry’ movement, which led to considerably more psychological and less custodial treatment of inmates of mental hospitals everywhere. The number of the specific TC units reached a peak in the 1970s, and fell for the following decades – although a new variant of TC, working with day treatment programmes instead of residential ones, has grown in numbers since the 1990s and is now finding a specific place in the treatment of ‘personality disorders’.

In 1958, a new kind of therapeutic community was created in America, by the forceful personality of its originator: Chuck Dederich.  He started by setting up a weekly group for helping ex-AA members and ex-addicts in his own flat, based around free association, confrontational ‘reality attack’ therapy groups or ‘synanons’, and educational seminars, particularly based on philosophical ideas. This was the beginning of Synanon, and it was the first of what came to be known as ‘concept-based’, ‘hierarchical’, ‘behavioural’ or ‘programmatic’, and more recently ‘addiction’, therapeutic communities. TCs based on these ideas have spread across the globe, those in North America still adhering to many aspects of the original model – and those elsewhere more substantially modified and adapted to different cultural requirements. There have been several cross-fertilisations between the two major traditions since the early days, and this continues.

‘Democratic TCs’in custodial settings, based on the Social Psychiatry model such as in the Henderson,  were first established at HMP Grendon Underwood in 1962, and several others have come and gone since. Of those that still survive, HMP Gartree established a TC wing for life sentenced prisoners in 1993, and HMP Dovegate was opened in 2001 with four TC wings for forty men each. The first women’s prison TC started in 2004 and is at HMP Send. All 14 prison TCs are now coordinated as a joint venture between the Department of Health and Ministry of Justice as part of the national programme for ‘Dangerous and Severe Personality Disorder’ (DSPD). Their original work to establish humane and psychologically informed regimes within prisons, where officer and prisoners enjoyed reasonable human relationships with each other, and robust group therapy could take place within prison confines, remains largely intact – although the language now used (and throughout the prison system) is about ‘criminogenic factors’, ‘offence-related behaviour’ and ‘accredited programmes’.

Staff teams in therapeutic communities are always multidisciplinary, drawn mostly from the mental health core professions including direct psychiatric input and specialist psychotherapists.

They also frequently employ “social therapists” who are untrained staff with suitable personal characteristics, and ex-service users. The role of staff is less obvious than in single therapies, and can often cover a wide range of activities as part of the sociotherapy.

However, clear structures – such as job descriptions defining their different responsibilities, mutually agreed processes for dealing with a range of day-to-day problems, and rigorous supervisory arrangements – always underpin the various staff roles.