The concept of the therapeutic community in British institutional psychiatry

• Main Author: Thompson, Richard Denzil
• Published: University of Bath 1976
• Subjects: 616.89
• Online Access: https://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.475100

This sociological study examines the origins, development and uses of the concept of 'therapeutic community' in institutional psychiatry. It is divided into four parts, the first two containing a survey of all the available literature referring to the use of 'milieu therapy' and 'therapeutic community 'strategies in the treatment of (functional) mental disorders, and the last two containing a description of the author's fieldwork, followed by a detailed analysis of the operational usage of the concept of 'therapeutic community' in selected British psychiatric institutions. Part 1 examines - and rejects - the claim for a distinctive sociological sub-discipline referred to as a 'sociology of psychiatry' and argues that 'dualism' in the theory and methodology of the social and medical sciences has served to confuse as well as delay the development of interdisciplinary cooperation between social scientists and the medical profession. In Part 2 the origins of the concept of the 'therapeutic community' are traced through a review of social medicine since 1790. Special emphasis is placed - in chapters 5 and 6 - upon 'milieu therapy' as a reaction to 'custodialism' in institutional psychiatry after 1939. Chapter 6 provides a general overview of the developing concept of 'therapeutic community' and argues that much of what has been taken for granted about types of social structure, treatment goals and modes of therapy, requires a more discerning evaluation. In its present form, the concept is both confused and misleading. Part 3 contains the results of the author's field research which was carried out in two stages over the period 1971-2. Stage 1 (Chapters 7 and 8) is concerned with establishing criteria of definition of 'therapeutic community' methods and shows that the staff of six selected psychiatric settings have a stereotyped image of the therapeutic community. The data suggest that the 'ideal type' community would consist of a relatively small unit (23 patients) that is located outside or away from the larger organisation to which it belongs, having semi-autonomous administration and the right to determine its own therapeutic policy. It would cater mainly for patients diagnosed as suffering from 'psychoneurotic' and 'personality disorders' although a 'therapeutic community' approach could be adapted to suit the needs of patients suffering from a wider range of disorders. Stage 2 describes a participant-observational study of a developing therapeutic community and evaluates difficulties encountered in growth and transition. Various techniques were developed for guaging changes in ward atmosphere and morale and these are explained in chapters 9-13 along with an account of the problems encountered by the author in attempting to compromise two different approaches - the search for an acceptable (i.e. empirically justifiable) research strategy and the need for full time personal involvement in the daily life of the ward. Part 4, contains summarial comments and general conclusions. It is the author's contention that the concept of the therapeutic community is seen to be progressive because it is ideologically opposed to traditional psychiatry. Due to its strong emotive overtones it takes on more the character of a 'symbol of progress 'rather than a blueprint for organisation. For this reason users of the term are advised to distinguish carefully between what is essentially a theoretical construct and specific applications of the concept to practical settings.