THERAPEUTIC COMMUNITY

Introduction

The word milieu is French for” middle”.The English translation of the word is “surroundings, or environment”.In psychiatry, therapy involving the milieu, or environment, may be called milieu therapy ,therapeutic community, or therapeutic environment.

History and current status of the therapeutic community

The concept of therapeutic community was first developed by Maxwell Jones in 1953. He wrote a book entitled "Social Psychiatry" which was first published in England. Later on when it was published in the United States, its title was changed to "Therapeutic Community."

In 1958 a self-help organization in the United States called Synanon became the prototype for concept-based therapeutic communities for ex-addicts. These were user-run communities with a hierarchical structure, fierce encounter groups, and a simple explanatory model of addiction and its treatment (the concepts). Phoenix House and Daytop were two major programmes that grew from this, and today therapeutic communities modelled on them can be found in nearly 60 countries worldwide. Another development grew out of the antipsychiatry movement in the 1960s. These were small therapeutic communities created to demonstrate that psychosis could be managed with intensive therapeutic support rather than medication. These communities have been tried in the United Kingdom, Switzerland, the United States, and elsewhere.

Milieu therapy came into its own during the 1960s through early 1980s. During this period, psychiatric inpatient treatment provided sufficient time to imple­ment programs of therapy that were aimed at social reha­bilitation. Nursing's focus of establishing interpersonal relationships with clients fit well within this concept of therapy. Patients were encouraged to be active partici­pants in their therapy, and individual autonomy was emphasized.

The current focus of inpatient psychiatric care has changed. Hall (1995) states:

Care in inpatient psychiatric facilities can now be character­ized as short and biologically based. By the time patients have stabilized enough to benefit from the socialization that would take place in a milieu as treatment program, they [often] have been discharged, (p. 51)

Although strategies for milieu therapy are still used, they have been modified to conform to the short-term approach to care or to outpatient treatment programs. Some programs (e.g., those for children and adolescents, clients with substance addictions, and geriatric clients) have successfully adapted the concepts of milieu treat­ment to their specialty needs (Bowler, 1991; DeSocio, Bowllan, & Staschak, 1997; Whall, 1991).

Definition

A scientific structuring of the environment in order to effect behavioural changes and to improve the psychological health and functioning of the individual.

                          (Skinner ,1979)

Stuart and Sundeen defined therapeutic community as “a therapy in which patient’s social environment would be used to provide a therapeutic experience for the patient by involving him as an active participant in his own care and the daily problems of his community”.          

Two of the best-known pioneers of therapeutic communities, Tom Main and Maxwell Jones, defined them as follows.

An attempt to use a hospital not as an organization run by doctors in the interests of their own greater technical efficiency, but as a community with the immediate aim of full participation of all its members in its daily life and the eventual aim of the resocialization of the neurotic individual for life in ordinary society

Objectives

•     To use patient's social environment to pro­vide a therapeutic experience for him.

•     To enable the patient to be an active partici­pant in his own care and become involved in daily activities of his community.

•     To help patients solve problems, plan acti­vities and develop the necessary rules and regulations for the community.

•     To increase their independence and gain control over many of their own personal activities.

•     To enable the patients become aware of how their behavior affects others.

•     Basic assumptions

•     Skinner (1979) outlined seven basic assumptions on which a therapeutic community is based:

1.   The Health in Each Individual Is to Be Realized and Encouraged to Grow. All individuals are con­sidered to have strengths as well as limitations. These healthy aspects of the individual are identified and serve as a foundation for growth in the personality and in the ability to function more adaptively and produc­tively in all aspects of life.

2.    Every Interaction Is an Opportunity for Therapeutic Intervention. Within this structured setting, it is virtually impossible to avoid interpersonal interaction. The ideal situation exists for clients to improve communication and relationship develop­ment skills. Learning occurs from immediate feedback of personal perceptions.

3.    The Client Owns His or Her Own Environment. Clients make decisions and solve problems related to government of the unit. In this way, personal needs for autonomy as well as needs that pertain to the group as a whole are fulfilled.

4.    Each Client Owns His or Her Behavior. Each indi­vidual within the therapeutic community is expected to take responsibility for his or her own behavior.

5.    Peer Pressure Is a Useful and a Powerful Tool. Behavioral group norms are established through peer pressure. Feedback is direct and frequent, so that behaving in a manner acceptable to the other mem­bers of the community becomes essential.

6.    Inappropriate Behaviors Are Dealt with as They Occur. Individuals examine the significance of their behavior, look at how it affects other people, and dis­cuss more appropriate ways of behaving in certain situations.

7.    Restrictions and Punishment Are to Be Avoided.

Destructive behaviors can usually be controlled with group discussion. However, if an individual requires external controls, temporary isolation is pre­ferred over lengthy restriction or other harsh punish­ment.

Elements of therapeutic community

• Free communication
• Shared responsibility
• Active participation
• Involvement in decision making
• Understanding of the roles ,responsibilities ,limitations and authorities

Components of therapeutic community

 a) Daily community meetings

• These meetings are composed of 60-90 patients. All levels of unit staff are involved, including administrative personnel. Acute patients are not involved in the meetings.
• Meetings should be held regularly for 60 minutes
• Discussion should focus mainly on day to day life in the unit
• During discussion patients feelings and behaviors are examined by other members
• Frank discussion are encouraged ,these may take place with much out poring of emotions and anger

b) Patient Government or Ward council

• The purpose of patient government is to deal with practical unit details such as house-keeping functions, activity planning and privileges
• A group of 5-6 patients will have specific responsibilities, such as house keeping, physical exercise, personal hygiene, meal distribution, a group to observe suicidal patients. Staff  members should be always available
• All decisions should be feedback to the community through the community meetings

c) Staff meetings or Review

•  A staff meeting should be held following each community meeting (patients are excluded and only staff are present). In this meeting the staff would examine their own responses, expectations and prejudice.

 d) Living and learning opportunities

•  Learning opportunities are provided within the social milieu, which should provide realistic learning experiences for the patients.

Indications

 Universal indications for therapeutic community treatment are difficult to give. Modified therapeutic communities have been developed for people with different types and levels of psychiatric disorder, and even the same therapeutic community may fluctuate in its capacity to absorb difficult patients. An individual's suitability will need to be judged in relation to a particular therapeutic community at a particular time

Diagnosis: Dependence syndromes but currently abstinent; depressive disorders; severe or intractable neurotic, stress-related, and somatoform disorders; personality disorders , particularly cluster B 'dramatic-erratic' (dyssocial, emotionally unstable, borderline, impulsive, histrionic, and narcissistic)

Intellect: Average or above

Age: Under 40 years

Social behaviour: History of self-harm, some initial capacity for social involvement

Attitude to treatment: Seeing personal relationships rather than physical treatment or professional techniques as the most valuable source of help; willingness to acknowledge and talk about emotional problems with other patients in a group setting; preference for informal intimate open style of relating between patients and professionals

Contraindications

Diagnosis: Severe depression, current mania, paranoid delusions/paranoid personality

Social behaviour: Persistent need for others to provide external control of violent behaviour towards self or others

Attitude to treatment: Fixed belief that only experts can help

Selection procedures

Selection procedures are an integral part of therapeutic community practice, involving both the prospective member and existing residents as active participants in the process. Exact procedures vary; the following is one example.

1. The referred individual is sent some literature about the therapeutic community explaining how it works.
2. A preliminary visit or series of visits is arranged to give the individual first-hand experience of the programme and an opportunity to meet other residents.
3. A formal meeting takes place with the prospective member, involving a number of current residents as well as staff. The prospective member is invited to say why he or she wants to join the community and current members can ask questions.
4. A vote is taken by all those present on whether to accept the individual. It may be worth adding that if someone has come this far they are seldom rejected.

Some communities use preparation programmes as an integral part of the selection process, giving potential members the opportunity to drop out or maintain commitment up to the time when the decision is made.

Four principles of therapeutic community treatment

Democratization Every member of the community should share equally in the exercise of power in decision-making about community affairs.

Permissiveness All members should tolerate from one another a wide degree of behaviour that might be distressing or seem deviant by ordinary standards.

Communalism There should be tight-knit intimate sets of relationships, with sharing of amenities (dining room etc.), use of first names, and free communication.

Reality confrontation Residents should be continuously presented with interpretations of their behaviour as it is seen by others in order to counteract their tendency to distort, deny, or withdraw from their difficulties in getting on with others.

Length of treatment in a therapeutic community

In general, individuals progress through drug addiction treatment at varying speeds, so there is no predetermined length of treatment. Those who complete treatment achieve the best outcomes, but even those who drop out may receive some benefit. Good outcomes from TC treatment are strongly related to treatment duration, which likely reflects benefits derived from the underlying treatment process. Individuals who complete at least 90 days of treatment in a TC have significantly better outcomes on average than those who stay for shorter periods.

Traditionally, stays in TCs have varied from 18 to 24 months. Recently, however, funding restrictions have forced many TCs to significantly reduce stays to 12 months or less and/or develop alternatives to the traditional residential model .For individuals with many serious problems (e.g., multiple drug addictions, criminal involvement, mental health disorders, and low employment), research again suggests that outcomes were better for those who received TC treatment for 90 days or more.

Structure of the therapeutic community

TCs are physically and programmatically designed to emphasize the experience of community within the residence. The residential capacity of TCs can vary widely; a typical program in a community-based setting accommodates 40 to 80 people. TCs are located in various settings, often determined by need, funding sources, and community tolerance. Some, for example, are situated on the grounds of former camps and ranches or in suburban houses. Others have been established in jails, prisons, and shelters. Larger agencies may support several facilities in different settings to meet various clinical and administrative needs.

The treatment process: therapy, education and training

The elements of treatment at the TC typically include substance abuse treatment, education (General Equivalency Diploma or, in some cases, university courses), primary medical and dental care, vocational skills training (e.g. culinary arts, carpentry, general maintenance, mechanical systems, general contracting, computer skills, or substance abuse counseling), on- and off-site job placement, and in rare cases, on-site resident-run businesses. Other supports include legal services, advocacy, and life skills counseling. There is no formal religious component to treatment, education or training. In fact, experts caution against the introduction of religion as an aspect of daily life in the TC .

TC treatment can be divided into three major stages.

Stage 1. Induction and early treatment : This phase typically occurs  during the first 30 days to assimilate the individual into the TC. Once the intake process of interviews and assessments is complete, new arrivals to the TC are often housed in rooms with six to eight bunkmates. It is generally expected that new residents must be medically detoxified prior to beginning the program. Leader who is responsible for the orientation of the new resident to the rules and expectations of the TC.

Work is often identified as one of the central components of the therapeutic approach. As such, job assignments or “functions” begin immediately for new residents, usually with basic housekeeping or maintenance chores. The work-centered approach is intended to serve multiple purposes.

• First, by beginning with general maintenance work,  the resident acquires knowledge of the facility’s physical layout and organizational structure.
• Second, daily work is believed to instil an ethic of discipline and hard work that is desirable according to the TC treatment model.
• Third, putting new residents to work immediately reinforces the broader nature of the TC as a structured, merit-based program, where residents earn privileges and seniority by complying with all rules and behavioural expectations. In this case, the implied goal for the new resident is to move up a strict hierarchy of jobs and departments to more desirable positions.
• Lastly, the work is often physically demanding, leaving residents physically tired at the end of the day so that they have no time to think about leaving and returning to their previous  lifestyle.

Progression from phase one to phase two is be made on the recommendation of staff members and, to a lesser extent, the broader peer group, and  is typically judged on the basis of the individual resident’s attitude, work competence and peer relations.

Stage 2. Primary treatment

In Phase two the resident is expected to take on more responsibility for the welfare of others, particularly newcomers. At this stage, he or she is normally introduced to three vocational training areas. Training takes place during the daytime hours, with expected  study time in the evening. Residents typically begin courses to improve literacy, develop  computer skills and achieve a General Equivalency Diploma (GED). Residents are also typically expected to continue with their encounter groups, with the goal of adopting positive beliefs and attitudes toward themselves and others. By the end of phase two,  residents are normally expected to have completed their GED, choose one vocation training area in which to specialize, participate in encounter groups, deal with more daily responsibility, and adhere to the rules and regulations of the facility. Often  uses a structured model of progression through increasing levels of prosocial attitudes, behaviors, and responsibilities. The TC may use interventions to change the individual's attitudes, perceptions, and behaviors related to drug use and to address the social, educational, vocational, familial, and psychological needs of the individual.

Stage 3

Entry into phase three normally begins when the resident has applied for, and has been accepted to train in a vocational area on a full-time basis, with the intention of completing a certificate in the program or trade, and finding related work outside of the facility after leaving. Residents may be reimbursed nominally for their vocational work. The money is saved so they will have money to begin their new lives once they exit the program. During this phase, residents may be encouraged to attend social activities outside of the facility accompanied by other members, as well as re-establish contact with their   families of origin. A family reunification program is sometimes established.

Stage 4. Re-entry At this point residents typically share accommodations and bathrooms with a smaller number of residents in a more home like setting. It is believed that by this phase, residents have acquired skills and coping abilities to allow them to “re-enter” society.These skills often include a GED, vocational training, computer literacy, and relationship and coping skills. If any money has been saved for the resident, these funds will be released with the expectation that a bank account will be opened for living expenses

Education and Training

The elements of treatment at the Therapeutic Community typically include addiction treatment, education, primary medical and dental care, vocational skills training (e.g. cooking skills, carpentry, general maintenance, and computer skills), on- and off-site job placement, and in rare cases, on-site resident-run businesses. Christian run Therapeutic Communities will give some opportunity for residents to address their spiritual needs but will not insist that residents are Christians when they enter, or that they become Christians during their stay.

Staffing

TCs are often staffed by a carefully chosen group of professionals who receive training in the specifics of the TC model. Experts suggest that program staff should comprise a mix of self-help recovered professionals and other traditional professionals (e.g.  nurses, physicians, lawyers, case workers, counselors). An average resident to staff ratio was cited as approximately 15:1.

Staff roles

·         Participating as a member of the community

Staff share everyday tasks with residents, express their own reactions to situations, and accept challenge or criticism from residents. In this way the traditional ‘them and us' split between professionals and service users is broken down, and a sense of trust and intimacy develops enabling residents to experience and internalize different relationships with authority or parental figures. Staff and more experienced residents are also able to act as role models, by being open and honest. This carries the risk of staff becoming over involved, hence making training, supervision, and staff ‘maintenance' or sensitivity groups essential in this way of working.

·         Maintaining the structure needed for the community to be therapeutic

Structures include the time, place, and purpose of different activities, and where responsibility lies for different decisions. Clear structures are especially important for people with little control over their impulses, providing something which can gradually be internalized. A common finding is that therapeutic communities go through oscillations between periods when the structures are well observed and supported, and periods of more disturbed and destructive behaviour when structures come under great strain. At these times the staff must be able to take the lead to re-establish the structure and norms of the community, later letting go again when residents are able to resume shared responsibility.

·         Provision of learning experiences

A wide range of tasks and responsibilities can be available for residents, including organizing and preparing meals for the community, keeping the environment clean and tidy, showing round visitors and new residents, and contributing to one another's therapy. Some communities may have gardens to cultivate, or maintenance and administrative roles. All of these provide potential learning experiences on several levels: practical, social, self-esteem, and dealing with authority. The job of the staff is to maximize the opportunities for such learning rather than to ensure successful completion of a task. It may be difficult to accept that standing back is not abdication from professional responsibility, but a thoughtful provision of learning experiences.

·         Using therapeutic interventions in groups

The skills of working in small groups are relevant in therapeutic communities . A range of therapeutic orientations may be used (e.g. group analytic, psychodrama, transactional analysis, cognitive–behavioural therapy), as all offer ways of understanding current difficulties in terms of previous experiences. Staff members may offer interpretations of the meaning of these difficulties, but often it will be more effective when residents do this for each other, using their own experiences to offer interpretations to a fellow resident of why they found a particular situation difficult to cope with. Main has noted that, in the larger setting of the community meeting, the more effective interventions are often those which relieve tension through admission of ordinary thoughts and feelings rather than those which offer profound insights.

·         Attending to the dynamics of the community and to staff members' emotional involvement

It is important to guard against the risks of insularity that an intensive group experience can produce which can lead a therapeutic community as a whole to deny internal difficulties, such as when residents are beginning to act out in destructive ways, or when tensions between staff are denied or external criticism ignored. At the same time, individual staff members must be prepared to examine their own involvement in the dynamics of the community, and to use the opportunities in the appropriate staff meetings to do so.

·         Maintaining external relations

Staff need to ensure that the unit's role and requirements are well understood by referrers, colleagues, and those who manage the parent organization.

Resident roles

Resident involvement is a key aspect of therapeutic community treatment. The type and level of responsibilities given to residents will vary according to their needs and capacities, and the constraints of the organization. Autonomous units for severe and borderline personality disorders and for ex-drug addicts will be able to make fullest use of the roles and responsibilities outlined below. Units for patients with chronic mental illness and prison-based units will have more restricted opportunities.

·         Therapeutic role

Residents contribute to each other's therapy by giving honest feedback to fellow residents about their behaviour, and by supporting them at times of difficulty, drawing on their own experiences of similar situations. Resident feedback can often carry more conviction and credibility than the same information coming from staff members.

·         Socializing role

Residents play a significant part in inducting new members, and interacting outside formal group times is a required part of the living– learning situation. There is little opportunity for isolating oneself.

·         Decision-making

All residents take part in a number of decisions about fellow residents and the community generally. Decisions may include whether to admit a prospective member, what to do when a resident behaves destructively, and addressing organizational problems like untidiness or lack of facilities.

·         Individual responsibilities

Residents may also be given or elected to a range of posts within the community that provide experience of different kinds of responsibility. These can include organizing and carrying out the domestic requirements of the community such as meals, cleaning and maintenance, chairing meetings, showing prospective members or visiting professionals around, and acting as representatives for particular subgroups.

The daily regimen

A typical TC day begins at 7 a.m. and ends at 11 p.m. and includes morning and evening house meetings, job assignments, groups, seminars, scheduled personal time, recreation, and individual counseling. As employment is considered an important element of successful participation in society, work is a distinctive component of the TC model.

In the TC, all activities and interpersonal and social interactions are considered important opportunities to facilitate individual change. These methods can be organized by their primary purpose, as follows:

• Clinical groups (e.g., encounter groups and retreats) use a variety of therapeutic approaches to address significant life problems.
• Community meetings (e.g., morning, daily house, and general meetings and seminars) review the goals, procedures, and functioning of the TC.
• Vocational and educational activities occur in group sessions and provide work, communication, and interpersonal skills training.
• Community and clinical management activities (e.g., privileges, disciplinary sanctions, security, and surveillance) maintain the physical and psychological safety of the environment and ensure that resident life is orderly and productive.

Advantages of therapeutic community

• Patient develops harmonious relationships with other members of the community
• Gains self –confidence
• Develops leadership skills
• Learns to understand and solve problems of self and others
• Becomes socio-centric
• Learns to live and think collectively with the members of the community
• It provides opportunity to participate in the formulation of hospital rules and regulations that affect patient’s personal liberties like bedtime, meal time, weekend permission, control of radio or T.V, social activities , late night privileges.

Disadvantages of therapeutic community

• Role blurring between staff and patient
• Group responsibility can easily become nobody’s responsibility
• Individual needs and concerns may not be met
• Patient find the transition to community difficult

Role of the nurse

• Providing and maintaining a safe and conflict free environment through role modeling and group leadership
• Sharing of responsibilities with patient
• Encouraging patient to participate in decision making functions
• Assisting patients to assume leadership roles
• Giving feedback
• Carrying out supervisory functions

·          Conclusion

Several studies have found that this approach to treatment is successful in substantially improving the quality of life for members. A study of patients at the Cassel Hospital showed that 98% of patients 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 therapeutic community.

Discussion Question

Make a critical comment on your experience in the therapeutic community you had visited?

Reference

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3Michael G. Gelder, Juan J. López-Ibor, Jr. and Nancy Andreasen
New Oxford Textbook of Psychiatry Vol.2,(2002),oxford university press

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7www.nursing planet,therapeutic community,Retreived on 17.8.2011@12.10am