Friday, 20 January 2017

It's in the book...



Contents

PART 1: HISTORY


1. A History of Therapeutic Communities 18
Geel and the mentally afflicted pilgrims 18
Moral treatment 19
Therapeutic education and social pedagogy 19
Wartime UK experiments, 1939–45 21
Social psychiatry 22
Criminal justice and offending behaviour 24
Concept Houses, drug-free and addiction TCs 25
Antipsychiatry and ‘unlabelled living’ 26
Personality disorder TCs 26

PART 2: CONCEPTS

2. Why Therapeutic Communities 30
Critical theory 33
Antipsychiatry 34
Critical psychiatry 37
Biomedical domination and the role of the pharmaceutical industry 41
The loss of meaning and context 42
Reductionist research paradigms 44
Postpsychiatry 44
Other relevant ‘movements’ in psychiatry 45
The quintessence of a therapeutic environment 48

3. TC-Specific Theory 53
Specific therapeutic factors in democratic therapeutic communities 53
Therapeutic methods in democratic therapeutic communities 55
The function/structure-based approach – Rapoport 55
The culture of enquiry – Tom Main 57
Flattening of the authority pyramid and the analysis of all events – David Clark 57
A living learning situation – Maxwell Jones 58
The milieu and the use of member expertise 59
Confidentiality and respect/no secrets/openness 59

4. Belongingness 62
Belongingness and Maslow’s hierarchy of needs 62
Belongingness as a therapeutic factor 64
Therapeutic environments in which belongingness operates 65
Therapeutic communities and belongingness 66

5. Responsible Agency 71
The wedge theory of responsibility and choice 72
Self-efficacy 73
Empowerment 73
The nature of responsible agency 73
Willed action and the nature of desire 75
The muscle model of the will 75
Other techniques promoting responsible agency 78
Responsibility without blame 79
Links between blame and shame 82
Implications for DTC practice 82

6. Social Learning 85
Reinforcement 85
Social learning 87
Relevance to TC practice 92

7. Emotional Progression and Narrative 94
Emotional progression in DTC 95
Narrative formation 100
Emotional competence and mentalisation 102

8. The Use of Psychodynamic Theory and Techniques 105
Object relations theory 105
Splitting and borderline functioning 106
Unconscious defence mechanisms, and their relevance to TC practice 107
Paralleling behaviour 110
Interpretation 110
Transference and transference interpretation 111
Boundaries and containment 112
Therapist activity in democratic therapeutic communities 113

9. Group Analytic Influences and Theories 114
The roots of group analysis 114
The basic law of group dynamics 117
Key group analytic concepts relevant in therapeutic communities 118
Transference and countertransference in groups 122
Group analytic interpretation 123
Group-as-a-whole 123
Differences between therapeutic community groups and group analytic groups 124
Interpersonal group psychotherapy and Yalom’s therapeutic factors 125

10. Group Process and Systems 128
The primacy of groups 128
The impact of social psychology research on TC theory and practice 130
Leadership in DTCs 134
Systems theoretical influences 135
Systems theory in non-family groups 138

11. Evidence for Therapeutic Community Effectiveness 139
Concept (drug-free) TC research 139
Democratic TC research 141
TaCIT – a randomised controlled trial of democratic therapeutic community treatment 150
Future research directions 151

12. General Approach and Principles 152
Application of theory 153
Milieu therapy 153
Democratisation 153
Permissiveness 156
Reality confrontation 157
Communalism 157
Social analysis of events 158
Culture of enquiry 159
Freeing of communications 159
Flattened hierarchy 161
The living learning experience 162

PART 3: PRACTICE

13. Phases and Timing 164
Phase 1: Engagement and stabilisation 165
Phase 2: Assessment and preparation 174
Phase 3: Intensive treatment 177
Phase 4: Recovery and rehabilitation 180

14. Assessment and Selection 181
Dimensional approaches and severity 182
The importance of groups 183
Intolerance of groups 185
Members who may adversely affect the culture 185
The possibility of harm from DTC treatment 186
Heterogeneous group formation 187
Selection processes 187
Dropout from DTC treatment 188

15. Democratic Therapeutic Community Structure 189
Assessment and preparation 189
Joining and leaving 192
Therapeutic community size 195
Weekly structure 195
Daily structure 195
Special/crisis meetings 196
Mentoring and peer support 197
Meeting structure 199
Open groups 203
Work groups and activity groups 203
The place of play in DTC 203
Specialist psychotherapeutic approaches 204
Milieu time 205
Therapy breaks 206
Moving on groups 207
Follow-up 208

16. Boundary Maintenance 209
The implementation of boundaries in DTC 209
Time boundaries 210
Disturbances and distractions in groups 210
Hierarchy of consequences of boundary violations 211
Relational risk management and positive risk management 214
Concurrent psychological treatment while a member of DTC 216
Other boundaries 216
Drugs and alcohol in DTC 220
Medication in DTC 222
Abuse of prescribed medication and medicinal substances 227
Somatisation and somatoform disorders 228
Special treatment 228

17. Quality of Relationships and Therapeutic Method 230
A different kind of relationship 230
Flattened hierarchy 230
Authenticity 231
Working alongside 231
Acting ‘as if ’ 232
Uncertainty 232
Safety and transparency 232
Management of personal information for TC staff 233
Making the diagnosis of personality disorder 234
Co-morbidity with mental illness in personality disorder DTC treatment 236

18. The Use of Psychoeducational and Humanistic Methods 238
Mindfulness 238
Descriptions of approaches used in the large group 240
Action methods 241
Approaches derived from transactional analysis 243
Diagnostic personality disorder group 245
Family and Friends (carer’s) programme for personality disorder 245

19. Antitherapeutic Processes 248
The difference between group/peer pressure and TC process 248
Bullying and scapegoating 249
Subgroup formation 250
Persecutory interventions 251
On not ‘trusting the process’ (or group) 252
Summary 252

PART 4: ORGANISATIONAL ASPECTS

20. Organisational Relationships 254
Commissioning 254
Management 256
Governance and regulation 257
Referrers and colleagues 257
Local neighbours 258
Professional network organisations 259

21. Organisational Development 260
Planning a therapeutic community service for personality disorder 260
Formation of the team 262
Premises 264
Induction and initial training 265
Continuous improvement 266
Organic growth 267
Innovation 268

PART 5: TRAINING

22. Training – Introduction 272
Practitioner requirements 272
A curriculum of therapeutic community training 273

23. Experiential Training for Working in Therapeutic Communities 275
The living learning experience 275
Other group relations courses 277
Personal therapy 278

24. Supervised Clinical Practice 279
Pre-briefs and debriefs 279
Formal supervision 280 
Sensitivity groups and staff groups 280
Profession-specific supervision 281

APPENDICES

A1   Definitions 283
A2   Community of Communities 291
A3   Enabling Environments 302
A4   DTC Preparatory Group Documents and Policies 315
A5   DTC Programme Documents 322
A6   Moving On Group 342
A7   Family and Friends Programme 344
A8   Training Resources 346


Further Reading 360
References 361
Subject Index 376
Author Index 382