Troubled children and adults with issues ranging from
substance abuse to personality disorder all benefit from
therapeutic communities. Andrew Mickel reports on how service users
change their behaviour by taking control of their
situations
Therapeutic communities embody a curious mix of trendy and
unfashionable social care policy. By including service users in
planning their treatment, these communities have long done what the
user involvement movement now pushes for. But bringing people
together in an institution is very much out of tune with the idea
of inclusive services.
Fashionable or not, those who work in therapeutic communities
are near evangelistic about the good their organisations can do,
and are fighting back to ensure that they remain available as a
treatment option for the troubled teens, substance abusers, and
those with personality disorders or learning disabilities that they
Varied approaches
Therapeutic communities serve a range of people and have diverse
and independent origins, so their approaches vary. The key
commonality is community itself, says John Gale, chief executive of
CHT (Community Housing and
Therapy), a network of eight residential communities in the
London area for people with psychosis and homeless former military
personnel (see panel).
"The therapeutic communities approach is that other people can
be helpful [as treatment], whatever the disturbance is," he says.
"It assumes that disorders have some kind of relationship or social
factor - in other words, that other people will be part of the
disturbance."
Building relationships
To build a sense of community, users work alongside each other
and with staff to take control of their situation. "We try to give
them responsibility as much as possible," Gale says. "It means we
won't have cooks or cleaners; users do everything and run the daily
life of the unit. And you don't just sit around and debate your
childhood, but do things beyond that like going to the shops and
cooking a meal."
Taking an expansive view of what treatment entails evens out the
relationship between the service user and professional. Staff
liaise with community mental health teams to ensure progress is
made, and spend extensive time alongside clients, building a
relationship to try to re-acclimatise isolated individuals with a
community.
"Many people with psychosis will be isolated in their own
world," says Gale. "Patients learn to take an interest in each
other and learn to give advice to each other - they are more open
to that than from staff."
Cost of services
In the short term, such work doesn't come cheap. Each CHT
residential unit has about 12-15 service users, with eight staff
for each unit. The cost is justified by the decreased number of
admissions to general hospitals. A study at one therapeutic
community - south London's Henderson Hospital - in 1996 showed that
the costs of treatment paid for themselves within two years.
Currently, Henderson's residential service is suspended subject to
a consultation about its future, although its outreach service is
continuing.
Still, the expense is difficult to ignore: for example, it costs
£123,000 a year to send a child to the
Mulberry Bush School
in Oxfordshire. The community for troubled children aged five to 11
has 100 staff for the 35 children in its residential units.
"These children make such an impact they can not be included in
mainstream schools," says Angus Burnett, head of the school's
family and professionals team. "Although they're not given an equal
voice - they are emotionally damaged children - they do have a
right to be listened to."
Most children at Mulberry Bush have emotional problems that
would have been played out in either their old school or in the
family home, says Burnett. Being part of an organisation that can
monitor care in both scenarios can help them change their
behaviour.
But the high cost that entails makes therapeutic communities the
last option for local authorities with one eye on budgets. In the
past 20 years this shift towards parsimony has increased the chance
that Mulberry Bush will not fill its places and have to shut.
Network of therapeutic communities
To address this Rex Haigh founded
Community of
Communities in 2002, a quality improvement network for
therapeutic communities in the Royal College of Psychiatrists to
provide a solid evidence base to show the good they do to service
commissioners. "They were dying and withering on the vine,
suffering from an individualistic culture where group methods were
struggling," he says. "They were too complex and messy to be
commissioned. The idea that a lot of work would be put in by
clients for their recovery wasn't flavour of the month."
The organisation has brought together two-thirds of the
country's therapeutic communities, who raise standards by peer
reviewing each other's performance against the network's codes. The
success of the scheme has been recognised. In London, for example,
services describing themselves as therapeutic need to be
participating in the Community of Communities process.
High staffing ratios
Another network, the
Charterhouse
Group, is a think-tank style organisation for therapeutic
communities who work with children. The chair is Kevin Gallagher,
who is also chief executive of
Bryn Melyn Care, which
serves troubled teenagers in Shropshire and North Wales. He says
communities for children have specific problems to tackle: when
they arrive at Bryn Melyn, previous failed placements may have
already built up a history of sexualised behaviour, self-harming or
substance abuse, in addition to sexual, physical or family
abuse.
To help them requires close supervision and therefore high
staffing ratios. Each of the 25 homes in Bryn Melyn houses between
one and three young people. When they go to one of the
organisation's two schools, staff accompany them. But even in that
context, as many decisions as are reasonably possible are made by
children, from décor to after-school activities.
"The work is around thinking about the emotional needs of the
child and the adult, living together and working through conflict,"
Gallagher says. "I would draw some parallels with social pedagogy.
One of the principles is about the relationship and having
experiences [together]. That's very powerful for young people who
have had multiple failed placements to be able to learn from other
people."
With new umbrella organisations ensuring that standards and
effectiveness can be evidenced and pushed up, the future of some
forms of therapeutic community are now safeguarded, regardless of
what policy trends may try to dictate. But Sarah Paget, programme
director for Community of Communities, warns that policy trends
continue to endanger those who work with other groups, namely those
with learning disabilities. "There are policy directors who are
against service users living together," she says. "In care, it's
considered a success for people to live independently alone in a
flat with a microwave.
"Our ultimate aim, instead of living alone, is to live with
others."
case study
KWAME CENAC Ex-serviceman
A soldier's tale: 'It's like a little
family'
wame Cenac was a chef in the Royal
Logistics Corp in Germany, but was medically discharged from the
military service with a diagnosis of mental illness.
He returned to the UK, having spent more
than five years in the army far from his native St Lucia in the
Caribbean.
He ended up in a hostel in east London for
a month. "It was just a place with ex-servicemen wanting to sleep,
and as a hostel you are more likely to have guys taking drugs or
drinking," he says.
He transferred to Community Housing and
Therapy's Home Base unit in Hammersmith in January 2008. Both the
hostel and the Home Base unit specialise in supporting ex-military
servicemen, but the therapeutic community was better, says
Cenac.
"I've my freedom. At the other institution
you had to be in by 11pm and there wasn't a place to cook," he
says.
One-to-one sessions combined with group
therapy complement the space the unit gives him to pursue his own
interests. "It's like a little family, actually."
He is now planning to leave Home Base and
start a course in food and premises inspection in
September.
useful websites
• CHT
• Mulberry Bush
School
• Community of
Communities
•
Charterhouse
• Bryn Melyn Care
• Association of
Therapeutic Communities
This article first appeared in Community Care 30 April issue
under the title A Sense of Community