Therapeutic Communities

The basic idea of a therapeutic community is to create a life-like living situation (residential or several days a week) where people can practice the basic skills of living with other people. So how does that work? In its purest form the members of the community have all or most of the responsibility for its existence: cooking, cleaning, shopping and budgeting; dealing with visitors, deciding on new admissions, etc. Where the learning comes in is in having to cooperate with other people, deciding the rules, and what to do if someone breaks them, being able to give and take instructions, etc. And since this is therapy, members give and receive feedback on how they are doing and their effect on other members – in other words each member is also has a therapeutic role.

The role of staff varies – basically they need to oversee the process to see that it’s not going off in a negative direction, and help people make the best use of the opportunities the community offers. Different variations of the basic idea have developed for people with different kinds of problems. In its pure form many people with psychosis would find it too stressful. The two paragraphs below outline two variations, one for people experiencing first episode psychosis, the other originally developed to humanize the mental hospitals.

A small number of therapeutic communities have been developed in the UK, USA, Switzerland and Germany on the principle that first episodes of psychosis can be effectively treated in low-stress family-like settings providing round the clock personal support, with no or minimal use of neuroleptics. This has become known as the Soteria model. Two Soteria houses, in California and Berne, have been subjected to randomized or matched control trials comparing them with usual hospital treatment. One study found that completing subjects with schizophrenia exhibited a large effect size benefit with Soteria treatment, especially in the areas of psychopathology, work and social functioning. Length of stay in Soteria Berne was initially longer but this was subsequently reduced to less than the admission ward. In both studies the 2-year outcomes were at least as good in the Soteria group and less antipsychotics were prescribed for the Soteria group.p.( A 20-year study of an acute psychiatric ward in Finland found that people with acute psychotic episodes and borderline conditions seemed to benefit from the therapeutic community model with a high level of support, negotiation, order, and organization.

The therapeutic community approach was widely used in large mental hospitals to counter the effects of institutionalization and to mobilize the capacity of those suffering from chronic mental illness for social relationships, purposeful employment, and personal responsibility. The method was as much about improving the sense of purpose and morale of the staff and the general quality of life in the institutions as it was about clinical improvement, and its success was demonstrated in the way some many large old mental hospitals were turned into centres of excellence. With the re-provision of services for people with enduring mental illness in the community, therapeutic community principles have been found to be an effective way of structuring staffed hostels and homes. In one version of this, the ‘ward in a house’, the model is close to the original practice of the York Retreat, one of the antecedents of therapeutic communities.

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