From TC Open Forum
Tuesday 21 May 2013
Here please add requests for FAQs (Frequently Asked Questions) Here also please add information /links in answer to those requests
What is a 'Therapeutic Community?'
Where do the terms "hierarchical" and "democratic" therapeutic community come from?
Craig Fees 16.1.2006:
I personally have never seen a good explanation of where the terms "hierarchical" and "democratic" came from: who first used them, and why? But there is a practical, descriptive reality to both terms:
- Hierarchical: For example, in the 'hierarchical' tradition - which is associated most strongly with addictions -, a fairly rigid and visible hierarchy was a formal part of the therapeutic toolkit: It was used in the therapeutic process, to break down an addict's resistance to self-observation and social responsibility (these are my words; I'm sure others can give a clearer and better interpretation), to provide clear and achievable goals, to build up the individual's sense of membership, capacity and possibility, and to provide non-negotiable feedback, en route to a re-structured personality which could function both socially and autonomously drug-free and outside the therapeutic community. It was 'non-negotiable' feedback in the sense that an individual could rise up the visible hierarchy, with all of the trappings of privilege and authority and esteem, and then be busted back to a lower level for some fundamental infraction or misuse of trust and position. "Pull-ups" are part of this up-down-up system, in which there is risk for everyone involved - the person pulling-up and the person being pulled-up -, because both are on trial and test within the up-down movement of the hierarchical system; both are being watched and tested not just by themselves, but by the whole community. It is a community act, and in a healthy, well-functioning community, contributes to the growth of all, as well as to the general community culture. Where it went wrong, on the other hand (creating a PR difficulty for 'hierarchical' therapeutic communities, not least in the eyes of 'democratic' practitioners), it could go very wrong, and become oppressive and destructively authoritarian. However - for the community to work well, and in health - it had to be fundamentally consensual and mutually participative, which is to say, in another way, democratic.
- The term "hierarchical therapeutic community" currently seems to be giving way to terms which are less dependent on an oppositional relationship ('hierarchical' vs. 'democratic'), and more related to the specific presenting problem: e.g., "Addictions therapeutic community".
- Democratic: In 'democratic' therapeutic communities, on the other hand, there is rarely a claim to be non-hierarchical as such. The term heard most often is "flattened hierarchy". So it is not that the 'democratic' therapeutic community is non-hierarchical, as such; it is that it employs the structures and processes - and the rhetoric - of 'democracy' and personal and social engagement and responsibility as part of the formal therapeutic toolkit; it is the pole around which the community dances. This does not make them 'democratic' as such; there is an authoritarianism, both of powerful individuals and of the group; preferably explicit. And if the balance and tension between authoritarianism and 'democracy' goes wrong, the result can be just as disastrous as anything which happened within the 'hierarchical' tradition (put what happened in Synanon against the horrors of the Sullivanian Institute/Fourth Wall Theater, for example). But 'democracy' is a core working principle; and where there is authority and hierarchy, it is, in principle, subject to challenge, and even though reasserted (or perhaps, on occasion, 'if'), the working through of the issues and realities involved, and the experience of the real foundations for the authority and the hierarchy, are part of the 'therapy'. Mirroring the processes at work in the hierarchical tradition, it is therapeutic for the challenger, the challenged, and the community culture as a whole; and each is being tried and tested in the encounter (which may be around as simple a matter as whether a client will be able to go out shopping this morning or not, or be expected to come to a meeting).
- The danger for 'democratic' communities is that the authoritarianism and hierarchy are hidden, or obscured by the rhetoric and manipulation of the mechanics and appearance of democracy. And in that sense, and perhaps through the developing conversation between 'hierarchy' and 'democratic' traditions, the term 'democratic' is becoming slightly anachronistic; having served its purpose, in its time, it too may be disappearing.
What is a "Modified" Therapeutic Community?
See George De Leon (2005), "The Addiction Therapeutic Communites for Psychiatric Disorders", Therapeutic Communities 26:4, pp. 405-422.
Who would benefit from a Therapeutic Community?
How can I find a Therapeutic Community?
How are Therapeutic communities funded?
How to Start a Therapeutic Community
Are Therapeutic Communities Effective?
When was the term "Therapeutic Community" first used?
- Craig Fees 29 March 2005:
Although American Chuck Dederich is sometimes credited with having invented the term 'therapeutic community' to describe the work at Synanon in California in the 1950s, the more general consensus at the moment is that the term was coined in the special milieu created at the Northfield Military Psychiatric Hospital in Birmingham, England, towards the end of World War II, and was first published in an article about the work at Northfield entitled "The Hospital as a Therapeutic Institution" written by Tom Main for an issue of the Bulletin of the Menninger Clinic, published in Topeka, Kansas, in 1946. (Bulletin of the Menninger Clinic 10:3 (1946), 66-70. See Tom Harrison's book Bion, Rickman, Foulkes and the Northfield Experiments: Advancing on a Different Front, published by Jessica Kingsley Publishers, London, in 2000, and the ATC's journal Therapeutic Communities 17:2 (1996) and 17:3 (1996) for more detailed information and references on the 'Northfield Experiments'.). The term first arises in Tom Main's article as a section subheading -"A Therapeutic Community" - and is immediately followed by this paragraph:
- "The Northfield Experiment is 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. Ideally, it has been conceived as a therapeutic setting with a spontaneous and emotionally structured (rather than medically dictated) organization in which all staff and patients engage. Any attempt to permit or create such a setting demands tolerance, a willingness to profit by error, and a refusal to jump to conclusions; but certain matters appear to be plain. The daily life of the community must be related to real tasks, truly relevant to the needs and aspirations of the small society [It's interesting to note that William Caudill's influential book, The Psychiatric Hospital as a Small Society, published by Harvard University Press in 1958, was subsequently published in Buenos Aires as El Hospital Psiquiatrico Como Comunidad Terapeutica] of the hospital, and the larger society in which it is set; there must be no barriers between the hospital and the rest of society; full opportunity must be available for identifying and analyzing the interpersonal barriers which stand in the way of participation in a full community life."
That was published in America in 1946. Interestingly, an article on therapeutic camping appeared in America in 1947, by Eleanor Eells, entitled "From the Sunset Camp Service League: camp as a therapeutic community" (Nervous Child 6 (1947), pages 225-231. For Elizabeth Eells as a pioneer in therapeutic camping and American milieu therapy with children, see http://www.pettarchiv.org.uk/jointnewsletter/12.pdf). This suggests that she, or perhaps the journal editors, had read the 1946 British article and were influenced by it. There is another possibility, however, which is raised by the coincidence of "camp" and "community".
This is the fact that the term "therapeutic camp or community" was used in 1939 by the American psychiatrist Harry Stack Sullivan, in a lecture first published in the February 1940 issue of the journal Psychiatry, and published again after the war, in 1947, in the book Conceptions of Modern Psychiatry, published by W.W. Norton of New York (page 232; or see Sullivan's Collected Works, Vol. 1, p.232, also published by W.W. Norton.). The passage concerned is:
- "For this reason, and because there are now many instances of hospitalization of young patients in episodes that might well be quickly remedied if so drastic a change of social situation as admission to the mental hospital were not experienced, I am greatly impressed with the desirability of an innovation in the shape of special communities in which some of the great advantages of the mental hospital could be made available, without incurring the necessary exposure to factors that now make for permanent institutional adaptation of many patients. Something at least remotely like what I have in mind has already been accomplished by the Civilian Conservation Corps, the various camps of which would be a rewarding field for study. It is desirable, during the developmental stage of a therapeutic camp or community, that it be in cooperative relationship with an accessible mental hospital with good facilities for classifying patients, and a therapeutic staff."
There is therefore a third possibility: That Elizabeth Eells drew her usage from Harry Stack Sullivan, and that the British use of the term was influenced by Sullivan's, and was 'coined' following a reading of his article in the journal Psychiatry. A fourth possibility is that it was in general circulation at an oral level among psychiatrists and other mental health professionals in the 1930s and 1940s who were exploring and discovering the influence of environment and community on health, mental health and behaviour, and that these happen to be the first known settlings into print. Another possibility - and of course this would not negate any of the others - is that the term appeared in a text used to train doctors in the early 20th century, perhaps in translation from a classical Greek or Latin medical text; and was therefore part of a casually shared professional medical culture. This could explain why it is used, rather than overtly 'coined' - presented and defined -, both by Sullivan and by Main: To a generation or profession without that training it would have appeared, as it were, to have arrived new and fully clothed, without baggage and freshly minted: Immediately available, and adapted rapidly outside psychiatry, by residential social workers and educationalists, and by the new drug-addiction-treatment communities as pioneered by Synanon. But this, of course, is hypothesis.
In short, the 'origins' of the term have still to be settled.
What is Social Learning?
Social learning, also known as a living-learning process, was a concept developed by Dr Maxwell Jones, one of the founders of the therapeutic community. Change in this setting, he found, has five general conditions. It takes people who are ready to examine and modify their relationships; a supportive group setting where participants can communicate freely; confront appropriately one another at the apt moment; and a skilled facilitator. Given these general circumstances, change can occur consciously or retrospectively. Within this social matrix, events occurring in daily life (the beginning or ending of a relationship, a personal crisis, an act of kindness)—situations that interrupt the "trance of ordinary life,"— also offer opportunities for growth to come about.
To learn more about Maxwell Jones’s social learning, see his book, Beyond the Therapeutic Community—Social Learning and Social Psychiatry. Yale University Press, 1968; and Maturation of the Therapeutic Community. Human Sciences Press, New York, 1976.
A summary of projects employing social learning as the central concept is available as "Leaning to Live: Social Learning in Practice." It is an introduction to ten occasional papers describing projects in mental health, penology and education.
FAQ site specifically for Addictions Therapeutic Communities
The National Institute on Drug Abuse (NIDA) is part of the National Institutes of Health (NIH) , which is a component of the United States Department of Health and Human Services. Their therapeutic community FAQ page addresses the following questions, specifically for therapeutic communities for addictions:
- What is a therapeutic community?
- How beneficial are therapeutic communities in treating drug addiction?
- Who receives treatment in a therapeutic community?
- What is the typical length of treatment in a therapeutic community?
- What are the fundamental components of therapeutic communities?
- How are therapeutic communities structured?
- How is treatment provided in a therapeutic community?
- Can therapeutic communities treat populations with special needs?
- How else can therapeutic communities be modified?