How therapeutic communities can help rebuild lives

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 variously help.

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.”

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