Therapeutic community

The goal of therapeutic communities was to create a therapeutic environment that is freer and more controlled by the recipient, and also allows you to move away from the authoritarian and humiliating practices inherent in psychiatric institutions. The idea was to transform the rigid hierarchical organization of the institution, in which relations between the staff and the recipients of assistance developed a “vertical” type, into a “horizontal” organization, where relations would be equal. The main tasks of therapeutic communities are the patient's reintegration into society and the development of its ability to adapt ; not a cure for the disease per se, but the provision of space for the comprehensive development of the patient’s personality. As a therapeutic tool are the preservation of existing relationships with people around and the establishment of new ones ^[1] .

Key principles are as follows:

1. Recipients of assistance are active participants on whom the process of restoring their own mental health and the mental health of those who are near them depends.
2. Community household responsibility is shared between beneficiaries and staff.
3. Psychotropic drugs are not or rarely used in therapeutic communities, and group therapy is preferred.
4. Open, honest communication prevails between all members of the therapeutic community - staff and patients ^[1] .
5. The principle of democracy is the solution to all important issues, including budget planning, at a general meeting of patients and staff ^[1] .
6. The approach to treatment as a learning process, learning, which means learning to understand oneself, coping with strong feelings, communicating with the outside world and its representatives in everyday life, learning life skills necessary for independent living ^[1] .

The behavior of older participants and specialists forms an active motivation in a new person who has joined the group:

1. Behave in accordance with community rules.
2. Trust others.
3. Talk about your problems and worries.
4. Demonstrate your participation as an active member of the community.

Patients are involved in the maximum possible participation in the daily life of the therapeutic community (in particular, compiling a list of products and their purchase, managing the budget when choosing products, organizing leisure activities, maintaining order in the room, etc.). Many therapeutic communities publish their own newspaper. Considerable attention is paid to the “appropriation” of the space of the room where the patient lives. Patients are actively involved in building their personal space: how to choose and arrange furniture, how to decorate a home to their own taste ^[1] .

The concept of patient care is considered differently: in the therapeutic community, this is not work performed instead of the patient, but help provided to him when he independently performs his work. For example, a nurse’s job is not to wash the patient’s floor instead of hallucinations , but to help him finish his work alone or with the nurse if his condition worsens ^[1] .

Therapeutic Communities in Europe

The term “therapeutic community” was introduced in 1946 by the English psychiatrist Tom Mayne, who understood by it the features of the organizational approach, a certain set of principles and methods of providing care to patients. After 12 years, the same term was used by Maxwell Jones to refer to the model of care at Henderson Hospital in London . The term “therapeutic community” has also been applied to a number of communities, alternative to traditional psychiatric hospitals and conducting their work under the banner of the reform and human rights movement ^[1] .

The source, the forerunner of the modern model of therapeutic communities, was the emergence of the Moral Treatment movement in England in the 18th century, which was first used in the York Retreat Psychiatric Clinic, founded at the end of the 18th century. At the beginning of its history, Retreat was more of a shelter than a hospital, it did not use most of the measures of restraint that existed at that time, and the idea of ​​equality of all people, regardless of their mental state of health, formed the basis of relations between staff and patients. Great attention was paid to encouraging patients to meaningful and paid work ^[1] .

Another source of therapeutic communities is the First Nordfield Experiment, which arose during World War II . In 1940, Sigmund Fawkes assembled a group of patients and invited them to talk to each other, "freely associating together." In the winter of 1942-1943, Wilfred Bion and John Rickman organized care for patients in a military hospital, which was based on the principle of group psychotherapy . It was the group of W. Bion and J. Rickman that later would be called the First Nordfield experiment. The experiment was conducted in several wards of the Northfield Hospital in Birmingham . Patients (soldiers who became ill with one or another disorder) were trained in military specialties, they were assigned responsibility for the order in the wards. In a separate chamber self-government was introduced, the practice of making independent decisions, sharing responsibility ^[1] . Much attention was paid to group therapy, and each patient had to enter at least one group. According to Bion, the small group was most useful in terms of therapy: it provided the patient with a neurosis recognition, support, and work in the small group led ultimately to catharsis , cure. The neurosis of each of the soldiers was considered the common enemy of the group, against which they fought together with psychiatrists ^[5] .

Thanks to well-organized work, the majority of patients were rehabilitated and returned to the front, but due to weakening hospital orders anarchy and lack of discipline arose, and as a result the project was closed ^[5] .

A few months after the termination of the First Nordfield experiment, work on the principle of a therapeutic community was organized within the framework of an entire hospital, which was called the Second Nordfield experiment ^[1] . The project was led by Harold Bridger, and E. Miller, A. Torrey, T. Mayne and Z. Fawkes also participated in it ^[5] . The therapeutic community created by them lasted about four years (from 1942 to 1946) ^[1] . One of the project's innovations was the so-called hospital club - an empty room and a converted room for meetings of groups of patients. Many creative groups arose in Nordfield: their own magazine, newspaper, musical ensembles, theater groups, dance groups, gardening, etc. Patients worked outside the hospital - in garages, farms , offices and firms, orphanages. Toward the end of the war, hospital practices became more and more democratic, patient activity in organizational matters was encouraged, and the hospital was transformed into a self-governing community ^[5] .

The Maxwell Shaw Jones (1907-1990) is called the pioneer of the practice of therapeutic communities. In the first half of the 1940s, he organized group therapy meetings at the Mill Hill Military Psychiatric Hospital in London, and after the end of the war he created a similar project in the former prisoner of war rehabilitation unit at Dartford South Hospital, a suburb of London. There were 300 beds in the ward; Jones divided 300 patients into small social groups of 50 people, each of which was a structural unit of the department. Groups of patients gathered for meetings daily; labor rehabilitation and the inclusion of soldiers in the life of a large society also played an important role ^[5] .

In 1947, Jones received a new appointment - he became the head of the department of technogenic neurosis of the hospital in Belmonte, and it was the project organized in this department that made Jones famous throughout the world as the initiator of the therapeutic community movement. In the department there were chronically sick unemployed and poor, persons with personality disorders, disadapted in a technogenic society. Becoming the head of the department, Jones destroyed the hierarchy and role structure in it: free communication was encouraged without roles and hierarchies, there were numerous groups and associations (therapeutic groups, labor workshops, social groups), there was no rigid regime, strict regulations. The rules boiled down to attending community meetings every morning at 8.30 and every night at 21.00 to be ready for bed and put on pajamas. In addition to psychiatrists and nurses, the department staff included psychologists , social workers , workshop teachers, and others. The main group work tool was a variety of group meetings, community meetings, including discussions on pressing social issues; lectures; meetings at which organizational issues were resolved, etc. ^[5]

In 1962, Jones became the head physician of the Dingleton Psychiatric Hospital in Melrose , a town south of Edinburgh . In a new experiment, he repeated his past achievements: role stereotypes were overcome, patients actively participated in their own treatment and also took part in solving the problems of their comrades, and numerous group meetings and seminars were organized. But in addition, Jones sought to transform the institutional structure of the hospital, adapting it to the goals of the therapeutic community. A Steering Committee of employees was created, organizational issues were resolved in a collegial way. For the first time, Jones also organized a group of former hospital patients and a dormitory for eight male patients working outside the hospital. In this project, Jones paid more attention to interaction with society outside the hospital than in the previous ones ^[5] .

Influenced by M. Jones, Maine, Wilmer and others (Caudill 1958 ; Rapoport 1960 ), who summarized the results of critical publications on the existing system of psychiatric hospitals (Greenblatt et al. 1957 , Stanton and Schwartz 1954 ), on social and political trends that have penetrated the world Psychiatry at the end of World War II and with its end, the concept of a therapeutic community and its weak version - a therapeutic social environment began to be popular and in the 60s of the XX century took a significant place in outpatient psychiatric practice.

In 1962, the well-known representative of antipsychiatry, David Cooper, organized in one of the departments of the London psychiatric hospital in Shanley the therapeutic community "Villa 21" , functioning for four years. The experiment involved patients diagnosed with schizophrenia and personality disorder . Cooper aimed to prove that the widespread belief that the doctor should certainly play the role of the group leader, and the supervisory function should be performed by the nursing staff and, if you do not force patients to obey the daily regimen and do not control its execution, patients will ignore the daily routine and cannot to function as an organized group are actually prejudices. In the framework of the Villa 21 project, the role of a leader in the therapeutic process and a controlling role in the daily life of the community should in some cases be assumed by patients. Over the four years in the functioning of “Villa 21”, a change of roles took place: patients began to take an active part in their treatment and in the life of the department; despite the fact that no one was following the regimen, the patients themselves continued to follow the accepted routine. Similarly, the prejudices associated with the prescription of compulsory labor as a mechanism for institutionalizing patients did not materialize. Cooper, describing the results of his experiment, noted: “In fact, over the past two years no one has received serious bodily injuries from patients, none of the young patients became pregnant, although they often visited their friends in the department and also went outside the hospital with them” ^{[ 5]} .

In 1965, the famous British psychiatrist and one of the leading representatives of antipsychiatry, Ronald Laing, created with the participation of his colleagues and like-minded people a therapeutic community in the Kingsley Hall building in London, not associated with any psychiatric hospital and not included in the healthcare system ^[5] . In this community, doctors and patients were on an equal footing ^[6] . Here, people with schizophrenia were given the opportunity to "go through" their psychosis , without suppressing it with psychopharmacological drugs, shock therapy and other similar means, with the friendly support and care of the entire community. Moreover, former psychotics often became "guides" for beginners ^[7] .

Kingsley Hall's life was not strictly regulated; there was a kind of anti-rule, according to which all the rules can be questioned. It was only necessary to participate in dinner at a huge old wooden table in the lobby, as well as - to a lesser extent - participation in morning group discussions. In the community building, public lectures were held on the topics of psychiatry and antipsychiatry, seminars; Kingsley Hall residents met with artists, politicians. Kingsley Hall became not just a therapeutic community or anti-hospital, but a genuine counter-cultural center - the center of musicians, poets, artists, left-wing radicals and hippies , a point of revolution in London in the 1960s. The Kingsley Hall community existed for five years and was closed in 1970 ^[5] .

In 1973, Laing follower Joseph Burke In the Victorian building in the north of London, he created the Tents community of community doctors and patients, who later grew into the Tents crisis center. Those with mental illness were called “guests” in the Burke community. There were no restrictions for the guests in the “Tents”, and they represented various social strata : the building was inhabited by simple workers and pop stars, housewives and psychologists, representatives of religious and ethnic minorities. To get to the "Tents" was possible only on a voluntary basis. The Shatra crisis center is still functioning today, although in 2009 it was transformed into the Arbours Association. The Association unites three therapeutic communities focused on the development of personality and the maintenance of free self-realization; each community consists of 7-8 people and two supervised therapists ^[5] .

В Италии один из первых экспериментов по созданию терапевтической общины был проведён в начале 60-х годов XX века в психиатрической больнице Гориции Франко Базальей ^{[8] [9] [10]} . Его идеей, новаторской для своего времени, был отказ от изоляции, которая считалась единственным способом проводить лечение и реабилитацию психически больных.

Эксперимент, начатый Базальей в 1962 году , завершился приблизительно через 15 лет принятием Закона 180 (который также называется Законом Базальи), предусматривавшим преобразование психиатрических больниц в открытые терапевтические учреждения. После принятия Закона 180 терапевтические общины распространились по всей территории Италии. Их предметом работы были не только психические расстройства, но и девиантное поведение и наркозависимость ^[11] .

Терапевтические общины в США

Американская традиция терапевтических общин имеет несколько иные истоки, чем в Европе ^[5] : термин «терапевтическая община» стал применяться к возникшим в США в начале 1950-х годов коммунам для людей с зависимостью от психоактивных веществ , таким как Синанон, Дейтоп и Феникс-хауз. Поскольку идеологические принципы работы терапевтических общин для пациентов, страдающих хроническим алкоголизмом и наркоманией, оказались принципиально иными и в основу их легли строго иерархичные отношения между членами общины, они получили дополнительное обозначение иерархических, или концептуальных, терапевтических общин (в противоположность демократическим терапевтическим общинам) и не являются терапевтическими общинами в строгом смысле этого слова ^[1] .

В конце 60-х годов XX века Фонд Асклепия посодействовал созданию терапевтических общин в исправительной тюрьме Марион и других учреждениях, где применялись трансакционный анализ , игра Синанона, программа двенадцати шагов и другие терапевтические методы. Некоторые из данных программ, такие как «Дом мысли» при исправительной системе Вирджинии , продолжались до середины 1980-х годов и продемонстрировали снижение рецидивизма на 17% при сравнительном исследовании наркозависимых, совершивших преступления, и насильников, которые принимали участие в программе в течение года или дольше. Терапевтические общины на иной основе в настоящее время используются для лечения наркотической зависимости в исправительных учреждениях нескольких американских штатов, включая Пенсильванию ^[12] , Техас ^[13] , Делавэр ^[14] и Нью-Йорк ^[15] . В Нью-Йорк-сити терапевтическая община для мужчин размещается в исправительной тюрьме Артура Килла на Статен-Айленде , а терапевтическая община для женщин составляет часть Бэйвьюской исправительной тюрьмы на Манхэттене ^[16] .

Одной из своеобразных терапевтических общин стал центр «Уиндхос» Эдварда Подволла. На Подволла серьезно повлияли идеи Лэйнга, но он расходился с ним по поводу оценки психоза, который Подволл считал негативным опытом. Однако, по мнению Подволла, даже в состоянии самого тяжёлого психоза у человека остаются «островки здравомыслия», позволяющие ему ясно воспринимать реальность. Зацепившись за эти «островки», человек способен достичь ремиссии , особенно при доброжелательной поддержке со стороны социального окружения. Но помещение в психиатрическую больницу, по мнению Подволла, только мешает запустить этот восстановительный процесс, что ухудшает состояние человека. В психиатрической больнице пациент сталкивается с изоляцией, подчинением, пренебрежительным отношением, отсутствием личного пространства, жёсткой иерархией. В результате этих факторов естественные способности человека к восстановлению подавляются, а симптомы становятся более выраженными. В центре «Уиндхос» были предприняты усилия, чтобы создать комфортную обстановку, где к пациентам относятся с уважением, всячески культивируют установку на достижение полного выздоровления. Отличие «Уиндхоса» от множества других терапевтических общин заключалось в том, что пациенты много общались с обычными людьми, а не только с себе подобными. Подволл считал, что для самостоятельной жизни в обществе нужны навыки установления связей с различными людьми, а их развития не добьёшься, если пациенты будут замкнуты только на общение с другими пациентами ^[5] .

В настоящее время терапевтические общины являются неотъемлемой частью национальных психиатрических служб Великобритании, Германии , Норвегии , Швеции , Греции , Финляндии и Италии . Существует целая сеть терапевтических сообществ, объединённых в Международную ассоциацию. Одна из важнейших задач ассоциации — изучение эффективности (в том числе экономической) деятельности терапевтических общин на основе доказательной медицины . Имеются подтверждения безусловной экономической эффективности терапевтических общин в системе тюрем, а также для людей с личностными и поведенческими расстройствами ^[1] .

Из-за изменений в системе финансирования доступность этих терапевтических услуг в рамках программ Национальной службы здравоохранения в Великобритании сейчас под вопросом. Тем не менее развитие терапевтических миниобщин, функционирующих в течение трёх или более дней каждую неделю и пользующихся поддержкой различных неофициальных сетей взаимопомощи (которые занимаются, например, консультативной помощью по телефону, помощью в быту или предоставлением информационных материалов), открывает больше возможностей по сравнению с традиционными терапевтическими общинами, функционирующими в условиях стационара. В новой модели общины на севере Камбрии значительную роль играет веб-сайт, который модерируется получателями помощи согласно принципам терапевтической общины. Веб-сайт расширяет возможности общины за пределы личных «терапевтических встреч», обеспечивая надёжную групповую поддержку, не всегда возможную при других принципах работы.

• Сотерия
• Деинституционализация психиатрии

• Manning N. The therapeutic community movement: charisma and routinization . — London: Routledge, 1989. — 246 p. — ISBN 0415029139 .
• World Federation of Therapeutic Communities (WFTC)
• European Federation of Therapeutic Communities (EFTC)
• The association of therapeutic communities (ATC)
• The Institute for the History and Work of Therapeutic Environments (IHWTE)
• Therapeutic Communities of America
• Hopewell, A Therapeutic Farm Community for Adults with Serious Mental Illness
• European Federation of Therapeutic Communities, A network of drug-free therapeutic communities
• Therapeutic Community Open Forum (Wiki site)
• Planned Environment Therapy Trust Archive and Study Centre