Chapter
Three – The Emergence of Therapeutic
Communities and Community Mental Health –
History, Types and Significance
OVERVIEW
This chapter provides a background to my research into Neville’s
pioneering of therapeutic communities and community mental health in
THE EMERGENCE OF POPULAR/FOLK AND
SCIENTIFIC MODELS
Throughout human history there have been popular/folk models
about mental malfunction based upon culturally derived belief systems (Engel 1977). Prior to the Twentieth Century, in the United Kingdom, the
United States of America and other places, individuals with mental
malfunctioning experienced harsh inhumane treatment (Roberts 2005a; Roberts 2005b). Physical and mental
abuse was commonplace. There was wide use of straight jackets and heavy arm and
leg iron bands and chains (Roberts 2005a; Roberts 2005b). Kennard writes of what was called as early as 1796 ‘moral
therapy’ as an early precursor to notions of therapeutic community (2004, p. 298):
The application of therapeutic
community principles to work with the chronic
mentally ill is, in many ways, the closest version of therapeutic community modality to one of its most important predecessors, Moral Treatment.
This was the term used to describe a model of care first developed in 1796 by
the Quaker William Tuke at The Retreat in York (Tuke 1813; Borthwick
A., Holman C. et al. 2001).
In keeping with Quaker ideology, the mentally ill were
accorded the status of equal human beings to be treated with gentleness,
humanity and respect. This was quite revolutionary at the time, and The Retreat
also gave priority to the value of personal relationships as a healing
influence, to the importance of useful occupation, and to the quality of the
physical environment. Much of this early vision of a humane treatment for
mental illness was lost as the 19th century progressed and the mentally ill
were housed in increasingly large and impersonal asylums (Kennard 2004, p. 298).
In
What he observed was a strict non-violent,
non-medical management of mental patients came to be called ‘moral treatment’
though ‘psychological’ might be a more accurate translation of the French
‘moral’ (2005).
Notwithstanding the ‘humaneness’ of the approach, Pinel
condoned the use of threats and chains when other means failed (Dr. Grohol's Psych Central 2005).
Moral
treatment was also used by Sir William and Lady Ellis in
the 1900s (History of
Occupational Therapy in Mental Health 2005) who came
to be in charge of England's county asylums. Under the Ellis’, asylums as ‘community’ had a family atmosphere and the
men and women were encouraged to enhance their previous trades or establish new
ones in order to support purposeful activity. Sir and Lady Ellis were able to
prove that the mentally ill were not dangerous with tools, and were far less
dangerous than other unoccupied individuals. The Ellis' were also responsible
for developing the idea of an ‘after care’ house, very similar to the halfway
houses of today. These places functioned as stepping-stones from total care to
limited assistance living care.
The Religious Society of Friends founded
The York Retreat and the
In the later 19th and the early 20th centuries
psychiatry was in the process of seeking links with academic disciplines.
Medicine was doing the same thing (Engel 1977; Bloom 2005). While medicine had been evolving within biological
frameworks, Rudoph Virchow
writing in 1848 wrote that ‘Medicine is a social science’ (Rosen 1974).
Bloom identifies the rise
of biopsychosocial approaches in psychiatry in the 1920’s and traces the
professional links made by psychiatrists to evolve their specialty in the
1920s.
Bloom (2005, p.77) states:
Collaboration
between sociology and psychiatry is traced to the 1920s when, stimulated by
Harry Stack Sullivan and Adolph Meyer, the relationship was activated by common
theoretical and research interests. Immediately after World War II, this became
a true partnership, stimulated by the National Institute of Mental Health, the
Group for the Advancement of Psychiatry, and the growing influence of
psychoanalytic theory.
Bloom continues (2005, p. 81):
One piece of evidence of this development
was the emergence of the new subspecialty of social psychiatry. Initiated in
Colloquiums were held in 1928 and 1929 under the auspices of the American Psychiatric Association Committee on Relations with the Social Sciences. As well as psychiatrists, the colloquium attendees were psychologists, political scientists, anthropologists and sociologists. These two colloquiums helped forged psychiatry’s links with the social sciences.
In the context of this reaching out
to the social sciences and as an indication of the acceptance of psychiatry by
the medical profession in the 1920’s the APA chairperson White stated during
the 1929 Colloquium:
The specialty of psychiatry is
almost universally neglected by medical education (White 1929, p. 136).
Bloom (2005, p81.) quotes Grob
(1991) writing that it was,
…..the triumph of the psychodynamic approach….that
set the stage for the collaboration and cross-fertilization of psychiatry with
the behavioural and social sciences in the 1950s.
The effects of a sociology that focused on issues of health and illness proceeded to grow in medical education, research, and the treatment of mental illness until 1980, when a distinct shift of emphasis in psychiatry occurred.
After the rise of biopsychosocial approaches
in the 1920’s there was a move away from the biopsychosocial
to a biopharmacological model in the 1980’s (Bloom
2005, p. 77):
In
its role as educator of future physicians, post-war psychiatry developed a
paradigm of biopsychosocial behaviour but, after
three decades, changed to a biopharmacological model.
The
definition of mental illness as a deviant extreme in developmental and
interpersonal characteristics lost favour to nosological
diagnoses of discrete or dichotomous models. Under a variety of intellectual,
socio-economic, and political pressures, psychiatry reduced its interest in and
relationship with sociology, replacing it in part with bioethics and economics
(2005, p. 77).
Speaking of the 1950-1970 period Bloom (2005, p. 82)
discusses important changes in psychiatric approach and educational method:
…the focus was on human behaviour,
and the theoretic model was psychodynamic. George Engel, in what he called the biopsychosocial model, gave voice to this point of view
more than any other single voice.
Engel and others argued for both medicine and psychiatry to
be modelled on the biopsychosocial:
To provide a basis for understanding
the determinates of disease and arriving at rational treatments and patterns of
health care, a medical model must also take into account the patient, the
social context in which he lives, and the complementary system devised by society
to deal with the disruptive effects of illness, that is the physician role and
the health care system’s. This requires a biopsychosocial
model’ (1977, p. 32).
Bloom refers to Mechanic (1999) writing of the biopsychosocial being based on
a continuum and the biopharmacological being based on
discrete or dichotomous model. Mechanic
describes two definitions of mental health:
One presented a continuous model of
mental health and illness, the other a discrete or dichotomous model of mental
illness. In the first, mental health and illness are the opposite ends of a
continuum; the second rejects such a continuum, instead fitting a medical model
of specific disease categories with measurable symptoms (Bloom, 1997, p. 78).
Engel makes the point that:
Other factors may combine to sustain
patienthood even in the face of biochemical recovery.
Conspicuously responsible for such discrepancies between correction of
biological abnormalities and treatment outcomes are psychological and social
variables (1977, p.132).
In the Seventies the debate about appropriate models for
both psychiatry and medicine continued. Some argued the medical model is not
relevant to the behavioural and psychological domains.
Disorders directly ascribable to
brain disorder would be taken care of by neurologists, while psychiatry as such
would disappear as a profession (Engel, 1977, p.129).
In the late 1970’s one view of psychiatry
documented by Engel was:
Psychiatry has
become a hodgepodge of unscientific opinions, assorted philosophies and schools
of thought, mixed metaphors, role diffusion, propaganda, and politicking for
‘mental health’ and other esoteric goals (Engel 1977, p. 129).
Today psychiatry has typically maintained a biopharmacological model as a biomedical sub-specialty (Bloom, 2005).
The next section explores what was actually happening to
people suffering mental malfunction since the late 1800s.
NINETEEN AND TWENTIETH CENTURY
PRACTICE
USA
In the Nineteenth Century, the
The publication by Clifford Beers of his expose of his USA experience in
the state asylum system, ‘A Mind That Found Itself’ (1908) had a wide and immediate impact both in America and overseas towards
reforming and humanizing mental health practices. In the same year Beers
founded the Connecticut Society for Mental Hygiene, and the following year
founded the National Committee for Mental Hygiene. This entity merged with others in
the
Early Australian Experience
The
Central Sydney Area Mental Health Service’s (2004) ‘History
of Rozelle Hospital (formerly Callan
Park)’ reports that:
Social deviants were often treated brutally and
alcoholism was rife in the new colony. Governor Bourke in 1820 wrote that ‘a
lunatic asylum is an establishment that can no longer be dispensed with.
The
Australian experience followed that of the
Psychiatry in
·
1788 to
1839 - The Primitive Era. (The Beginnings)
·
1839 to
1860 - The Moral Treatment Era. (The Romantic)
·
1860 to
1945 - The Physical Treatment Era. (The Classical)
·
1945 to
the present day - The Modern Era. (The Revolution in Therapy)
On 1 July, 1876, Manning was
appointed by the Colonial Government as the Inspector of the Insane for mental
institutions in NSW (The Central Sydney Area Mental Health Service 2004). Manning was noted for his humanitarianism. His constant desire was to
ensure that his patients received treatment for their illnesses rather than
confinement in a ‘cemetery for deceased intellects’.
Despite overcrowding with 1,078
patients being recorded in 1890, the Hospital (Callan
Park) at the turn of the century was considered to be one of the ‘finest
Institutions in the Commonwealth for the housing and treatment of persons,
suffering from mental disorders’ (Leong 1985).
Photo 1.
Photo of Callan Park (Leong
1985)
Two World Wars and the Great
Depression brought social upheaval and hardship and further overcrowding.
Demands for financial austerity eventually lead to
Kenmore Psychiatric Hospital in Campbelltown which opened in January 1895 following a building program which started in
1893 and expanded to have over 1,800
patients (Mitchell 1964).
Other large asylums were also built
in
There is no doubt in my mind that the patients are kindly treated, and
that any attempts to ill-use them would, if they came to the knowledge of the
superior officers, be most vigorously dealt with.
Asylums in
UK
Throughout
the Nineteenth Century many madhouses and asylums were built and regulated
under various Acts of Parliament (Mind 2005). For
example, the 1828 Madhouses Act, regulated conditions in asylums including the
moral conditions. Official visitors were required to inquire about the
performance of divine service and its effects. In 1832 this Inquiry was
extended to include ‘what description of employment, amusement or recreation
(if any) is provided’.
The
last of the (large) mental hospitals to be built in England and Wales was in
the early 1930’s (Roberts 2005a;
Roberts 2005b).
EVOLVING THERAPEUTIC COMMUNITIES
This section discusses the rise of
therapeutic communities, the ways in which therapeutic communities differ from
asylums and the psychosocial healing potential of communal living.
Kennard refers to the link between
community and healing:
The idea of a
community as a place of healing for the troubled mind is probably universal and
as old as society itself. One of the earliest recorded intentional uses of a
community in this way was Geel in
Kennard identifies the founding of
the Little Commonwealth by
Lane was an
American who had experience as an educator at the George Junior Republic, a
reformatory system developed in the United States, and was invited to advise on
the setting up of a home for delinquent adolescents in Dorset in south west
England. For 5 years the Little Commonwealth housed around 50 youngsters,
mostly aged 14–19, who participated in a carefully structured system of shared
responsibility. Lane wrote that the chief point of
difference between the Commonwealth and other reformatories and schools is that
in the Commonwealth there are no rules and regulations except those made by the
boys and girls themselves. All those who are fourteen
years of age and over are citizens, having joint responsibility for the
regulation of their lives by the laws and judicial machinery organized and
developed by themselves (Kennard 2004, p. 296).
This is an early example of the interconnected psychosocial process of marginalized
people on the fringe of society co-constituting themselves in the process of
establishing and maintaining their lore, norms, law, self governance and shared
community.
A biopsychosocial
approach addressing general health was the 1935 ‘Peckham Experiment’ at the Pioneer
Health Centre in
According
to the Southwark Council Website (2005) this centre was:
…a unique attempt to raise public health through a combination of
education, community care and preventative medicine.
The experiment came about in response to worryingly low levels of
health and fitness amongst low-income inner-city families. Doctors Scott
Williamson and Innes Pearse
(a husband and wife team) believed that social and physical environment could
have a direct affect on health - and looked to prove it.
Just as we now join gyms, 950 families signed-up, paying one
shilling a week to relax in a club-like atmosphere where physical exercise,
games, workshops and relaxation were all encouraged. The families were
constantly observed by Williamson and Pearse's team
of doctors - and attended thorough medical examinations once a year.
The experiment was a bold departure in the medical field in the
1930s, concentrating on a preventative, rather than a curative approach to
health - and its setting was equally pioneering. The well-lit and open-plan
design of the building (designed by Sir Owen Williams) was far ahead of its
time, providing an ideal environment for observation and relaxation.
One
historical record describes the large Pioneer
Health Centre’s
as having:
…. an out door area for roller-skating,
cycling and sports. Inside the
building, you notice that large windows allow you to see the activities of the
gym, swimming pool, games area, nurseries, dance floor, cafeteria, theatre,
library and workrooms from almost any point in the building. The facility is
fully equipped with a modern laboratory and medical staff. Many areas are
designed with rollaway rooftops to allow fresh air, and sunshine when
available. The centre is designed to accommodate leisure activities of 2,000
families (Chek 2005).
Membership of the centre entitled
all members of the family to participate in a wide range of sports, pastimes,
crafts, social and learning activities as well as community dining.
Photo 2.
The Purpose Built Peckham Centre
- (Peckham
Health Centre 2005)
The
centre research showed significant improvement on a range of medical and
wellbeing indices compared with baseline entry levels.
The experiment continued until 1950, concluding that: ‘It is not
wages that are lacking ... but quite simply ... social opportunities for
knowledge and for action that should be the birthright of all; space for
spontaneous exercise of young bodies, a local forum for sociability of young
families, and current opportunity for picking up knowledge as the family goes
along’ (Chek
2005).
Peckham is an early example of
social learning in transitional community.
Kennard (2004, p. 304) refers to the 1939-1945 period in England and the
development of therapeutic community:
What seemed to happen at this moment in history was that a particular
constellation of human ideology, wartime necessity, psychoanalytic insights and
open mineded pragmatism came together and coalesced
into a new form of treatment.
Kennard (2004, p. 299) writes that following World War Two the zeitgeist for the mentally ill began to change:
‘Factors which can be seen to have contributed to this included the
founding of the English National Health Service, the emergence of sociological
studies of the toxic nature of large institutions, and the (re)discovery of a
humane and egalitarian model of care in the shape of the therapeutic community
experiments during and following the Second World War.
Bloom
(2005 p.80) refers to the link between personality and society:
The core of both social and psychiatric theoretical speculation
stimulated by the war was that the social structure and personality are linked.
Differing in its particulars but similar conceptually was the interpretation of
the hospital as a therapeutic community.
UK
The Second World War created a context that contributed to major change
in the treatment of the mentally ill. By the end of the Second World War both
There, a group of psychoanalysts and group therapists working with
demoralized psychoneurotic ex-soldiers developed a new pattern of institutional
life (Clark, 1974, p. 29).
Weisaeth and Eitinger (1991) make the point that:
Although it is well known that the principles of forward
psychiatry were rediscovered in WWII, not everyone is aware that modern
treatment principles such as the therapeutic community and group therapy were
also developed by psychoanalysts in the British Army. The late Tom Main's ‘The
Ailment and Other Psychoanalytic Essays’ (1989) provides important information about this.
The conventional asylum of the day replicated most of the rigid
life-controlling daily routines of the returning soldiers’ former
prisoner-of-war camps. Main’s aim was to re-socialize the hospital’s patients
via ‘full participation of all its members in its daily life’.
The Northfield Experiment is an attempt to use a hospital not as an
organization run by doctors in the interests of their own technical efficiency,
but as a community with the immediate aim of full participation of all its
members in its daily life and the eventual aim of re-socialisation of the
neurotic individual for life in ordinary society (Clark 1974, p. 29; Main 1989).
Some psychiatrists caring for these ex-soldiers recognised that major
changes to ‘treatment’ had to occur for these people to ever be able to return
to functional living in society. Psychiatrists began exploring community-based
approaches to reconnect these former soldiers with society. Given the community
approaches being used, these units became known as therapeutic communities.
Maxwell Jones is recognized as the main developer of therapeutic
community (Jones 1953; Jones 1957). In contrast to the conventional asylums, Jones
writes of starting at
By great good fortune I was asked to organize a treatment unit for
British ex-prisoners of war who had just returned from the prison camps in
And so, almost imperceptibly we moved from the idea of teaching with a
passive, captive audience, to one of social learning as a process of
interaction between staff and patients. By the end of the war we were convinced
that people living together in hospital, whether patients or staff, derived great
benefit from examining, in daily community meetings, what they were doing and
why they were doing it (Jones 1968, p. 16-17).
Kennard writes of wide interest in Jones’ work (2004, p. 299):
Right from its
early days Maxwell Jones’ experiment at
In stark contrast to conventional asylum top-down autocratic structure,
Maxwell Jones writes of re-constituting towards democratic egalitarian
structure/processes having three main objectives – communication,
decision-making and culture:
…the establishment of two-way communication involving as far as possible
all personnel, both patients and staff; decision making machinery at all
levels, so that everyone has the feeling that he is identified with the aims of
the hospital, with change, and with its success and failures; the development
of a therapeutic culture reflecting the attitudes and beliefs of patients and
staff and highlighting the importance of roles and role relationships (Jones 1968, p. Xlll).
These changes in communicating, decision-making and culture were core
shifts in changing from top-down expert driven hierarchy to a democratic
egalitarian holarchy (each participant as networked
part of the whole) with a community focused structure:
In a therapeutic community communications at all levels are made as
efficient as possible, and decision-making by consensus is aimed at.
In a therapeutic community, a unilateral decision, no matter how wise,
is seen as contradictory to the basic philosophy (Jones 1969, p. 48).
In this shift to a flatter structure, Jones suggests that a more apt
name for the leader is ‘catalyst or charismatic leader’ (Jones 1969, p. 24).
Two-way communication and all-inclusive meetings change the notion of
‘confidentiality’. Information is to be kept confidential within the community,
not just within the patient-psychiatrist relationship (Jones 1969, p. 54).
In his book ‘Administrative Therapy’, D, H. Clark (1964) writes of using meetings and other aspects of administration as an
integral aspect of patient change, what he called ‘Administrative Therapy’.
Maxwell Jones expands on these re-socializing themes:
The psychiatric hospital can be seen as a microcosm of society outside,
and its social structure and culture can be changed with relative ease,
compared to the outside. For this reason ‘therapeutic communities’ to date have
been largely confined to psychiatric institutions. They represent a useful
pilot run preliminary to the much more difficult task of trying to establish a
therapeutic community for psychiatric purposes in society at large (Jones 1968, p. 86).
In a conversation I had with Alfred
Clark (June 2004) he recalled the term ‘civil
reconnection’ for what the
Jones saw therapeutic community as an adjunct to existing processes:
It does not amount to a treatment methodology in its own right
but complements other recognized psychotherapeutic and pharma-cological
treatment procedures (1969, p. 86).
Jones and others recognized potential in hospital social restructuring:
A hospital has the advantage of being a small community where it is
possible to organize the social structure so that it enhances social learning (1969, p.91).
Jones called this setting up a ‘living-learning’ situation:
The term is meant to convey the concept of social learning as it applies
to the problems of everyday living (1969, p. 87; Kennard 2004).
Jones adds that along with structure - roles, role relationships and
culture may be involved in re-socialising:
The concept of the therapeutic community stresses the importance of
social structure; it underlines the need to focus on roles and role
relationships and to evolve a therapeutic culture (1969, p. 86).
David Clark, in writing the history of
…mixed-sex wards, no staff uniforms, ward meetings, staff discussion
groups and open and free discussion between professions. There was plenty of
encouragement for patients to help each other and to talk openly with staff, as
well as active involvement of, and discussion with relatives of patients (1996).
Other aspects were:
Doctors’ Sensitivity Meeting on Fridays (with its
egalitarian sharing), the Hospital Innovation Project, and the culture of
growth.
Basic premises of the therapeutic community are the abolition of
hierarchy and authority, the establishment of all contributions as equally
valid, the tolerance of open confrontation and challenge, and the
acknowledgement of patients’ responsibility for their own lives and for the
running of their wards (1996).
Patients became change-agents of self and others. Patients also became
community leaders.
The task of senior officers like myself, the
power holders in the organisation, was supportive – creating an atmosphere
where hope could develop.
It taught us to value the contributions of all the people who worked
with patients and showed us the immense power of social forces in the life of
the ward (Clark 1996).
David Clark writes of Maxwell Jones:
Jones himself said that the distinctive aspect of the method was ‘the
way the institution’s total resources, both staff and patients, are
self-consciously pooled in furthering treatment (1974, p. 29).
Jones contrasts therapeutic community with conventional treatment.
In therapeutic communities - active rehabilitation,
democratisation, permissiveness and communalism replace the conventional custodialism and segregation, old hierarchies and status
differentiation, customarily limited ideas and the specialized role of the doctor
(1968, p. 87).
Jones refers to meetings playing a central role:
An essential feature of the organization of a therapeutic community is
the daily community meeting. By a community meeting, we mean a meeting of the
entire patient and staff population of a particular unit or section. We have
found it practicable to hold meetings of this kind with as many as 80 patients
and up to 30 staff; we think that the upper limit for the establishment of a
therapeutic community in the sense that the term is used here is around 100
patients…it is desirable for the community meetings to be followed by meetings
of these smaller groups (1968, p. 87-88).
David Clark writes of
The centre of Belmont Life was the morning meeting, attended by all
members of the community, where all matters of general interest were analysed.
There was a system of feedback of the events of the 24 hours. This was
followed, always, by a staff review session, where the main meeting was
analysed and personal contributions and reactions assessed (1974, p. 30).
Rather than been seen as a negative, crisis situations were used to
foster change:
The social organization inherent in therapeutic community settings –
both inside and outside the hospital - strongly facilitates the productive
resolution of crisis situations by confrontation (Jones 1969, p.86).
The therapeutic community process was largely
responsible for the return of war neurosis soldiers to mainstream society. According to Jones, at
…the group that benefited most from the therapeutic communities were the
patients (and staff) trapped in long-stay wards. By 1980 most of those patients
had left hospital (1996).
USA
Kennard (2004) refers to the writing of Boston psychiatrist Bockoven
(1956) who described ‘the heavy atmosphere of hundreds of people doing nothing
and showing interest in nothing’ in American hospital wards in the1950s.
Sandra Bloom (1997) refers to the U.S.A. development of therapeutic community having
similarities to the UK treatment of war neurosis.
During
the same era in the
SOCIAL PSYCHIATRY, SOCIAL THERAPY AND MILIEU THERAPY
This section details some of the terms and processes associated with
therapeutic communities.
Jones defines social psychiatry as:
The preventative and curative measures, which are directed towards the
fitting of the individual for a satisfactory and useful life in terms of his
own environment (1968, p. 29).
Jones further writes on social psychiatry:
Sociocultural process is an integral part of the treatment. The sort of social system
that results is often called a ‘therapeutic
community’, or in terms of social process, milieu therapy.
What distinguishes a therapeutic community from other comparable
treatment centres is the way in which the institutions total resources, staff,
patients, and their relatives, are self consciously pooled in furthering treatment.
This implies above all, a change in the usual status of patients. In
collaboration with staff, they now become active participants in their own
therapy and that of other patients and in many aspects of the unit’s general
activities. This is in marked contrast to their relatively more passive,
recipient role in conventional treatment regimes (1968, p. 85-86).
Kennard describes distinguishing features of therapeutic
communities as:
There is a
‘culture of enquiry’, a phrase that highlights the need not only for efficient structures
but for a basic culture among the staff of ‘honest enquiry into difficulty’,
and a conscious effort to identify and challenge dogmatic assertions or
accepted wisdoms.
The basic mechanism of change can
be described as this: the therapeutic
community provides a wide range of life-like situations in which the
difficulties a member has experienced in their relations with others outside
are re-experienced and re-enacted, with regular opportunities - in groups, community
meetings, everyday
relationships and, in some communities, individual psychotherapy - to examine
and learn from these difficulties. The daily life of the therapeutic community
provides opportunities to try out new learning about ways of dealing with
difficulties (2004, p. 2).
In the context of therapeutic communities, David Clark (1974, p. 14) defines ‘social therapy’ (a term linked to therapeutic communities)
as:
… an attempt to help people to change by
affecting the way in which they live.
This is based on the observation that:
…people are shaped by the way they live, unfortunately often
for the worse (Clark 1974, p. 14).
Carstairs in the
Forward to David Clark’s book quotes another of
…the use of social and organizational means to produce
desired changes in people (Clark 1974, p. 8).
Carstairs also
quotes David Clark’s third definition:
Social therapy is about personal change and growth and
living-learning experience (Clark 1974, p. 8).
David Clark suggested that social therapy could be summarized using
three words – ‘Activity’, ‘Freedom’ and ‘Responsibility’. Jones notes the
‘experience of two centuries’ of the corroding effect of idleness. A central
focus was the potential of a community exploring freedom and responsibility
together (1974, p. 67).
The common theme through the above summary of therapeutic community
experience has been the use of social processes, especially community meetings,
as the change process. Chapters Six to Ten will detail how Neville went way
beyond the above in Fraser House.
The next section explores the intervening forces contributing to a
decline in the use of therapeutic communities within psychiatry.
DECLINE
OF THERAPEUTIC COMMITTEES IN THE UK
David Clark, in Chapter Eight of his book ‘The Story of a Mental
Hospital: Fulbourn, 1858-1983’ (1996), details the reasons for the decline of therapeutic committees in the
UK National Health system.
In 1970, four wards in Fulbourn hospital had been therapeutic communities and a
number of hospitals had therapeutic communities. David Clark writes of the
During the 1960s therapeutic communities had started in many
psychiatric hospitals; Henderson, Claybury, Littlemore, Fulbourn, Dingleton and Ingrebourne became
well known. In the 1980s therapeutic community wards stopped operating, units
were closed, hospitals famous for being committed to therapeutic community
principles, such as Claybury, dwindled in size and
ultimately were being closed down (1996).
The root cause is the incompatibility of an egalitarian, democratic ward
culture with the authoritarian, bureaucratic organisation which the National
Health Service has gradually become.
… the hostility of powerful senior doctors to a system that devalued
their expertise and challenged their power worked against it, and the National
Health Service Bureaucracy of the 1990s, with its emphasis on ‘business management’,
strict economy, and answerability upward could not tolerate a system so
challenging, so revolutionary and so irregular.
Enthusiasm and hope do not appear in accounting systems.
The external response was as suspected; David Clark writes:
A unit where patients make decisions, where disorder is apparent and
from which unacceptable demands may come, perplexes and angers tidy-minded and
harassed managers so that they readily support demands for enquiries,
disciplinary action and closure (1996).
Clark (1996) describes the
British psychiatry has moved away from an interest in social
therapy. With a wider range of new drugs available, many young psychiatrists
concentrate on improving their skill in diagnosing, assessing symptoms,
prescribing drugs and monitoring side effects.
The insecure and inadequate doctor feels far safer in a
white coat examining a half-naked patient with a stethoscope or in a
comfortable armchair out of sight behind the psychoanalytic couch, than working
in an environment where he would be open to scrutiny and criticism by patients
and nursing staff.
Clark (1996) also writes about the Nation Health Service funding in the Seventies
and Eighties:
Most of their time and energy was given to general hospitals which had a
clear traditional social structure of doctors doing their skilled work, nurses
assisting and organizing, and patients lying passively in bed awaiting cure.
The National Health Service, David Clark writes, is now:
…where power and authority is statutorily entrenched with
administrators, consultant doctors and senior nurses and where patients are
usually treated as passive, incompetent, ignorant people whose only task is to
await the attention, skill and compassion of those paid to look after them (1996).
Clark
(1996) details
some of the lasting effects of the therapeutic community movement in the UK:
Quite a few of the practices of the therapeutic community were by now
accepted as normal in Fulbourn - mixed-sex wards, no
staff uniforms, ward meetings, staff discussion groups and open and free
discussion between professions.
Is any of what we learned and taught still relevant? I
believe most of it is. Some of the effects of the social revolution in post-war
British psychiatry remain and will I believe be permanent. Psychiatric nurses
today see their main tasks as listening to patients, counselling them and
understanding them. They know they do this best in a supportive, friendly
humane culture. Most British psychiatric wards and units are now open door. In
many units nurses, patients, and creative therapists meet in groups and in ward
meetings. This is a far cry from the psychiatric nursing culture of the forties
with its emphasis on order, uniforms, discipline and its undertone of brutal
oppression.
DECLINE OF THERAPEUTIC COMMITTEES
IN THE USA
Commencing in 1968, Paul and Lentz (1977) set up the first research in USA on long term chronic mental patients -
comparing two psychosocial change programs with a comparison hospital
treatment. One of their change programs was based on milieu therapy (or
therapeutic community) and the other on social learning (using a token economy).
92% of the patients in the social learning program were released with community
stay without rehospitalisation for the minimum follow
up period of 18 months.
After four and a
half years of results demonstrating that the two psychosocial programs were clearly
superior to the comparison hospital, they were going to move the hospitalised
‘patients’ into the social-learning unit. However, before they could do so,
medico-political forces shut both of the psychosocial change programs down and
ended the research. Shortly afterwards, interests holding to the biopharmacological model linked with forces within the
politico-legal system to get laws passed prohibiting many of the key aspects of
the psychosocial change programs. The effect of these laws and regulations were
that aspects of therapeutic community based programs that Paul and Lentz’s
research had empirically demonstrated as possessing considerable change power
were banned. These changes to the law left the least useful and most
expensive treatment, namely drug-based long-term hospitalisation as the only
option remaining for long term chronic mental patients still in the hospitals.
The ‘patients in and none out’ process would ensure that this pool of patients
would steadily accumulate in the back wards.
Kennard (2004, p. 302), in referring to the success of the Soteria
House Therapeutic Community Experiment, which found the Soteria
program was as effective as neuroleptics in reducing
the acute symptoms of psychosis, writes:
Surprisingly, the success of this experiment has not spawned a host of
replicas, pointing up the conservatism of the professional establishment, the
reluctance to use the natural healing properties of normal relationships, and
the hold that the drug industry still has over treatment models.
WIDER APPLICATIONS OF THERAPEUTIC COMMUNITY
In reviewing the various settings for
therapeutic community Kennard introduces the term ‘therapeutic community
impulse’ as:
….something that flows through many forms of institutional care,
including hospitals, schools, prisons and other settings created by societies
for their ill, disabled or troublesome members (and sometimes for their
brightest too). This impulse comprises a tolerance of the expression of
conflict, a desire to enable people to take responsibility for their lives, a
natural sense of democracy (not necessarily of the one vote per person variety)
where everyone has the right to information and to contribute to decisions that
affect them, and ‘a kind of shirt-sleeves informality about the business of helping
people.’ I believe it is a hardy plant because once experienced, the capacity
to work with people in this way becomes an inner benchmark of the most humane
and effective way of delivering mental health care (1998, p. 27).
Kennard (2004) reviews the application of therapeutic
community as an adaptable treatment modality across different settings in UK,
USA, in Africa and in 11 out of 15 European Union countries – including youth
offenders, drug addicts, and within prisons. Kennard refers to Kasinski’s review of the use of Therapeutic Communities for
Young People as ‘Planned Environment Therapy’ (Kasinski 2003; 2004, p. 297).
In discussing therapeutic communities
in prison, Kennard writes (2004, p. 302):
Prison may seem an
unlikely setting for a treatment model based on democratic decision-making. Yet democratic therapeutic
communities have been run in prisons since the 1960s with positive results, and
today there is an increasing number within the English prison system. The first
and best known of these is Grendon Prison, 30 miles
west of London, which opened in 1962 and takes
long-term male prisoners towards the end of their sentence. Violence, sex
offences and robbery are the most common types of offence.
Once accepted, a prisoner moves to one of five wings of 40
men, each run as a separate therapeutic community, where he may stay for up to
two years.
In Grendon:
…considerable thought is given to how the key therapeutic
principles can be adapted (Cullen 1997; Kennard 2004, p. 303).
Neville spoke to me (Dec 1993, Sept
1998) about Grendon Prison (Association of Therapeutic Communities 1999; Smartt
2001; HM Prison Grendon 2005) in the UK. Grendon has had
excellent recidivism rates (Millard 1993; HM Prison Grendon 2005) - way ahead of traditional maximum security prisons - for
over thirty years. Cullen (1997) reports the overall recidivism rate for men who have served some time
at Grendon being 33%, and for those completing their
program it falls to 16% compared with a 42 to 45% recidivism rate for the
national rate. An article in the
Birmingham Post newspaper states:
Grendon is
the only prison in Britain that operates wholly as a therapeutic community; it
has a waiting list of around 200 prisoners who want to go there and, uniquely,
independent research has just shown that prisoner who complete its therapeutic
regime are significantly less likely to re-offend when released (A Prison to Cure and Not to Punish 1998).
On therapeutic communities applications within the criminal justice
system Kennard concludes:
In the experience
of the author and other experienced practitioners in both the USA (Toch 1980) and Europe (Cullen and Woodward 1997) therapeutic communities in prisons can be surprisingly effective in creating a
culture of openness and exploration of personal issues, in direct contrast to
the conventional prison culture, and also in reducing the incidence of violent
disturbances. Perhaps the major limitation is the acceptability of the model to
prison staff and administrators. For some staff the relaxation of the “them and
us” polarisation of officers and inmates provides a welcome opportunity to do
something worthwhile; for others it is seen as a threat to their authority and
control (2004, p. 303).
Paul Hamilton (1992) describes a therapeutic
community in K Division in Pentridge Prison in
Melbourne, Australia as:
… having a valuable catalytic effect in terms of
education and work practices, as well as providing a relatively normal
environment for HIV seropositive prisoners.
Within
Many therapeutic community
Drug and Alcohol Rehabilitation Centres in
1.
Residents
participate in the management and operation of the community
2.
The
community through self-help and mutual support is the principle means of
promoting behavioural change
3.
There is a
focus on social, psychological and behavioural dimensions of substance abuse (Gowing, Cooke et al. 2005)
The next
section describes ways in which therapeutic community processes were extended
into the wider community.
REHABILITATION SERVICES,
TRANSITIONAL FACILITIES AND THE MOVE TO COMMUNITY BASED CARE
David Clark writes of the setting up at Fulbourn
Hospital of Rehabilitation Services starting in the 1970s and fully developed
during the 1980s, as being another aspect of social therapy. These
Rehabilitation services were precursors to Community Mental Health.
We had moved most of our long-term patients out of hospital into group
homes, halfway houses, sheltered accommodation and so on. We were visiting and
supporting them there. We had developed an effective system of care in the
community - long before it became official government policy.
Many hospitals emptied the wards too quickly, with inadequate support
facilities. We took longer over the process. We set up a wider range of
transitional facilities. We prepared people carefully for discharge. We
supported them in the community. We certainly had remarkably few episodes of
suicide, social breakdown or public disaster over the years while we were
opening the doors.
We developed transitional facilities, halfway houses, group
homes, sheltered accommodation. We set up sheltered workshops and industrial
units and organised supportive rehabilitation using networks of social workers,
community psychiatric nurses and community occupational therapists, and so on (1996).
Kennard writes of the application of
therapeutic community practices to patients in community based transitional
facilities who were no longer ill or could now have
their symptoms controlled by the newer medications, and whose continued
hospitalisation was due at least partly to a loss of the skills and confidence
to manage their own lives.
As these patients
left hospital, those who remained were those whom
today are sometimes referred to as the ‘difficult to place’, whose combination
of treatment resistant symptoms and difficult personalities keep them in need
of 24-hour care. Thus although the crusading aspect of the therapeutic community approach to chronic mental illness is relevant where total institutions
are still found, today there are other important applications in community-based housing
projects for the long term mentally ill, and the work of community mental health
teams. Small domestic households of between 5 and 12 residents live with staff
support (either 24 hour or office hours depending on the level of need). For
people with more integrated or recovered psychoses there are regular community meetings,
service users help to draw up and review their own care plans and those of
their fellow residents, and help in running the household (2004, p. 303).
COMMUNITY
MENTAL HEALTH - THE UK ,
USA
This section outlines the
…an
appropriate perspective for all community-based services. The emphasis
on respect for the individual, the recognition that services users have therapeutic
skills, the importance of a containing environment and awareness of the
potential for splitting within teams and organizations have been noted as some
of the contributions that the therapeutic community approach can make to the
work of community mental health teams (Kennard 2004, p. 300)
United States
Community Mental Health was promoted in the United States as a new wave
of ‘expanded mental health care’ (Citizens Commission on Human Rights 2005).’
Given this aspiration, the organisation LA Voice writes:
There's no question that deinstitutionalising the mentally
ill ended (for the most part) the cuckoo's-nest
horrors of 1950-60s mental hospitals. But it also consigned people with
a horribly difficult-to-manage, stigma-ridden lifetime illness to a ragged net
of jails, outpatient programs and halfway houses from which the Legislature
often enjoys siphoning money. End result? People get dumped back onto the
street.
The Times points out that 34% of the 83,347 homeless in
greater L.A. are severely mentally ill; 47% of the total are chronic substance
abusers and 19% are veterans (though it doesn't say how much those three
numbers intersect) (LA Voice 2005).
Given the concerns, across each
State in the
Mediation has been evolved in some parts of the world as a way of
settling issues in dysfunctional families (Carlson 1971). One such example is the Ontario Family Mediation Centre (2005), which was highly regarded by Neville (July 1998).
Community Mental Health in the UK
Clark (1996) writes that as a
result of the social revolution in post-war psychiatry in the UK, the care of
people with long-term mental disability has been changed utterly:
Very few of them are now in hospital wards. Many live in the community,
with their families or in sheltered accommodation. They attend day centres and
workshops and are supported by teams of social workers and community nurses. We
have created in
The 4 November
1999, BBC program ’Background Briefings’ spoke of care in the community representing ‘the biggest political
change in mental healthcare in the history of the NHS.
It was the result both of social changes and political
expediency and a movement away from the isolation of the mentally ill in old
Victorian asylums towards their integration into the community. The aim was to
‘normalise’ the mentally ill and to remove the stigma of a condition that is
said to afflict one in four of the British population at some time in their
lives.
The main push towards community care as we know it
today came in the 1950s and 1960s, an era which saw a sea change in attitude
towards the treatment of the mentally ill and a rise in the patients' rights
movement, tied to civil rights campaigns.
The 1959 Mental Health Act abolished the distinction
between psychiatric and other hospitals and encouraged the development of
community care (BBC News
2005).
An Internet source document
from the UK NGO ‘Mind’, formerly ‘The National Association for Mental Health’
entitled ‘Key Dates in the History of Mental Health and Community Care states:
From 1955 onwards, psychiatric in-patient numbers
began to slowly decrease due to the introduction of social methods of
rehabilitation and resettlement in the community, and the availability of
welfare benefits, as well as the introduction of antipsychotic medication (Mind 2005).
The same ‘Key Dates’ document identifies 1961 as the year Enoch Powell, as Health Minister,
made his famous ‘Water Tower’ speech to the Annual Conference of the NGO Mind.
He envisaged that psychiatric hospitals would be phased out
and care provided in the community. Powell’s plan was for ‘nothing less than
the elimination of by far the greater part of this country’s mental hospitals
as they stand today’ (2005).
The ‘Key Dates’ document refers to:
The Hospital Plan for
In-patient numbers continued to fall, but many local
services were not yet in place. A new group of ‘long-stay’ patients began to
accumulate in the hospitals. The era of community care had begun and this has
remained official policy ever since (2005).
Sir Roy Griffiths’ 1988 UK report, ‘Community Care: Agenda for Action’
was a precursor to the Community Care Act of 1990, that set up community care
as it has operated through the Nineties (Mind 2005).
In 1998 in the
Care in the community has failed. Discharging people from
institutions has brought benefits to some. But it has left many vulnerable
patients to try and cope on their own. Others have been left to become a danger
to themselves and a nuisance to others. A small but significant minority have
become a danger to the public as well as themselves (Mind 2005).
Burns
and Priebe (1999, p.
191-192)
outline issues in Mental Health Care in the UK:
The past few years have seen
mental health services in
We’re mad to trust shrinks –
Daily Mirror, 9 February 1996.
The
current, pervasive opinion is that English mental health services (especially
in cities) are unacceptably poor (Deahl and Turner 1997).
Burns
and Priebe (1999, p.
191-192)
also refer to comments by Frank Dobson (1990):
The Secretary of State for health, Frank Dobson, has recently
pronounced that ‘community care has failed’, and his predecessors expressed
their lack of confidence by imposing a succession of increasingly restrictive
legislative requirements – the Care Programme Approach.
Burns
and Priebe detail shortcomings:
There are undoubtedly serious short-comings in the
English services. These include the excessive preoccupation with risk, the
limited therapeutic involvement of consultants and the shortage of services for
patients with less severe mental illnesses, to name just a few (1999).
In
the same article Burns and Priebe also comment on
considerations of clinical effectiveness:
Service delivery is generally transparent and subject
to clinical audit and a widespread consideration of clinical effectiveness.
English psychiatrists, correctly preoccupied with the problems generated by the
split between health and social care, seem rarely to reflect on the degree to
which services are fragmented elsewhere. By international standards our
services are extraordinarily straightforward and well co-ordinated (1999).
They
also provide the following contextual information:
Neither one of us doubts the real problems that face
modern mental health services. The rules of the game are changing. Family and
social changes make coping with severe mental illness increasingly problematic.
Public expectations are rising, and in our current, very visible position,
balancing therapy with social control is highly delicate.
There is no shortage of advice about how to reform the
mental health services being proffered by pressure groups and voluntary bodies.
In many cases their conviction may far exceed evidence for the feasibility or
value of their proposals (1999).
Community Mental Health in Australia
Community Mental Health in
As one indicator of the current status of community mental
health care the Weekend Australian newspaper 16 July 2005 ran a headline ‘Time
to Get Mentally Ill Out of Jails’:
Leading psychiatrists have admitted that a
twenty-year policy of treating mentally ill patients in the community has
failed. The psychiatrists are demanding radical review of mental health care
claiming prisons have replaced asylums as holding centres for the mentally ill.
Those calling for a new approach include many of the architects of the current
policy of de-institutionalisation, which lead to the closure of psychiatric
wards and institutions around the country.
A recent study by the Corrections service found
that 74% of prisoners in NSW suffer from a psychiatric disorder with almost 10%
suffering symptoms of psychosis (Kearney and Cresswell 2005).
SELF-HELP AND MUTUAL AID GROUPS
Another
development in the 1960’s was psychosocial self-help/mutual aid groups where
people with mental malfunction provide each other mutual support without the
presence of mental health professionals. Historically, governments and their
agencies, as well as private service providers, have provided care to the
mentally disabled as a funded service. After self-help and mutual aid processes
were evolved in therapeutic communities, ex-patients of these communities began
forming their own self-help groups in civil society. This led to the growth of
voluntary not-for-profit psychosocial self-help group movement in the
Kyrouz, and Humphreys (1997) carried out a review of research carried
out in the 1980s and 1990s on the effectiveness of self-help mutual aid groups.
Their review primarily covered studies that compared self-help participants to
non-participants, and/or gathered information on multiple occasions over time
(that is, “longitudinal” studies).
They summarise findings of five research studies on mental health groups
as well as research on self help groups focusing on suffers of bereavement, diabetes, cancer, chronic illnesses as well
studies on self-help group for caregivers as well as groups for elderly people. Kyrouz, and Humphreys (1997) report:
Most research studies of self-help groups have found
important benefits of participation.
ORGANIZATIONS,
NETWORKS AND MUTUAL HELP PROVIDING SUPPORT AND SUSTENANCE TO MARGINAL PEOPLE
Healthy Living Centres
Influenced by the Peckham
Experiment mentioned previously, the
Its aim is to improve health through community action
and particularly to reduce inequalities in health in deprived areas.
Healthy living centres will take various forms and may
exist as partnerships and networks rather than as new buildings. They are
based on a recognition that determinants of poor health in deprived
areas include economic, social, and environmental factors which are
outside the influence of conventional health services (BMJ
Editorial 1999).
Everyday Life Mutual Help
Rowan
Ireland (1998),
a Melbourne sociologist had been researching an urban renewal social movement
among the extreme poor in São Paulo, Brazil in the
late eighties.
Ireland
refers to Evers' (1985) writings
on new social movements in Latin America. Like
Natural Nurturers in Everyday Life
Resonant
with the São Paulo experience above, a report of a visit
(where I was a member of a international team) to the Southern Philippines war
zone of Pikit, Mindanao identifies ‘natural nurturer
networks’ among the local rice farms living in the war zone as an integral
aspect of ongoing social support among local people:
Given the limitations and the short period allotted,
the team achieved the objectives of the pre-test, especially in drawing out
local contexts, identifying local healing ways, and natural nurturers says
international team member and UP CIDS PST research fellow, Faye Balanon. More importantly, there is the need to help
identify local psychosocial support systems, especially in the areas struck by
calamities, and to identify people in the local cultural context – the natural
nurturers who could support the psychosocial needs of the community after the
team has left (Balanon 2004).
Photo
3 Engaging with Muslim Men’s Group in Pikit Area – used with
permission
Chapters Twelve and Thirteen extend this theme
of natural nurturers.
POSSIBLE
FUTURES
As
in the call to recreate the old asylum
culture in Australia (Kearney and
Cresswell 2005), the same trend is emerging in the UK.
A malignant trend in English society in the 1990s is
the growth in the number of gaols and secure institutions.
Wherever society locks up
people it dislikes and pays other people to keep them in, an oppressive and
cruel culture is likely to develop. If society designates these prisoners ‘insane’ and
hires doctors and nurses as gaolers, they will create the same medicalised, hypocritical gaol culture as in the old
asylums (1996).
SHIFTS IN PSYCHIATRIC MODELS
This section returns to the theme of
psychiatric models and explores forces influencing them in the past few years.
Burns and Priebe (1999, p. 191-192) writing of the UK psychiatric experience point out the
players involved in the underlying economics and review of effectiveness of
mental health service provision:
Mental health care is, with few exceptions, within the
public domain, and service planning is not solely driven by the economic
interests of service providers and insurance companies.
The
powerful forces associated with psychiatric paradigm shift mentioned at the
beginning of this chapter are currently being confronted by Victorian Workcover, a State body in
The five
core principles reflect contemporary practice in injury management and focus
on:
1.
a demonstration of
measurable treatment effectiveness
2.
a biopsychosocial
approach for the management of pain
3.
empowering workers to manage
their injury
4.
treatment goals that focus
on function and return to work and
5.
the
delivery of treatment based on the best available evidence.
With
respect to the ‘psychosocial’ component of biopsychosocial,
the terms ‘functional
overlay’, ‘somatoform reactions’ or ‘psychosomatic reactions’ are used when
people have a psychological overlay suppressing or inhibiting
physiological function. Typically, Workcover
claimants with functional overlay are referred to a psychiatrist or
psychologist. Rather than the previous norm of expert based assessment, the
clinical framework requires the use of standardised outcomes assessment of:
- Physical impairment
- Activity limitations
- Life participation restrictions
‘Life participation restrictions’
asks for considerations on a wellness continuum rather than nosological
diagnoses of discrete or dichotomous conditions.
For psychiatrists and other
caregivers to continue to receive funding for their Workcover
claimants, they need to demonstrate measurable treatment effectiveness resulting in the enhancement of at least two of the above three domains.
Independent standardised outcome assessment has to be used. There is also a
provision that the treatment must focus on empowering the claimants to manage
their own injury. Another provision is that treatment goals must be functional
and focused on a return to work. It is understood that the Transport Accident
Commission is likely to introduce a similar Clinical Framework. This outside intrusion into the power domain of
psychiatrists, psychologists, and other professionals is being strongly
resisted by them (from discussion at an Australian Wellness Association Forum
in
Having
a ‘return to work’ focus is isomorphic with a concern to have people returning
to functional living in society rather than being warehoused in asylum back
wards like soldiers with war neuroses. The Clinical Framework does hold a space
for a psychopharmacological approach; drugs may be an aspect of treatment. The
framework changes the patients’ role from being a passive and dependent upon a
professional expert to having an active self-help role with a functional return
to work focus. The potential role of Neville’s biopsychosocial
processes in the context of the Workcover Clinical
Framework is discussed in Chapter Ten, Eleven and
Thirteen.
THE PSYCHOSOCIAL MODEL, THERAPEUTIC
GOVERNANCE AND
GLOBAL SOCIAL CONTROL
Vanessa Pupavac
(2005) in her paper ‘’Therapeutic Governance:
the Politics of Psychosocial Intervention and Trauma Risk Management’ argues the international psychosocial model and its origins in an
Anglo-American therapeutic ethos is being used for social control via pathologising of Third and Fourth World countries by wide
interests in the First World. Her paper argues
that ‘psychosocial approaches jeopardise local coping strategies’ and
identifies ‘the potential political, social and
psychological consequences of the pathologisation of
war-affected societies’. Her paper concludes ‘that therapeutic
governance represents the reduction of politics to administration’. Pupavac argues that powerful first world entities assume pervasive pathology
exists in third and fourth world societies and take action that strengthens
that assumption, and then uses the claimed pathology to take on a ‘therapeutic
governance’ role on behalf of ‘helpless’ people.
Power is not exercised by the ostensible subjects of rights, but by
international advocates on their behalf.
Effectively, the psychosocial model involves both invalidation of the
population’s psychological responses and their invalidation as political
actors, while validating the role of external actors.
Where populations are experiencing a curtailment of
self-determination and a questioning of their moral capacity, it should be no
surprise if psychosocial professionals find a relatively high instance of
depression - the link between a sense of control and mental health is well
established. However, the presence of depression does not vindicate therapeutic
governance, rather the reverse. It is the functionalism of therapeutic
governance that needs to be examined. Ironically, the unprecedented regulation
of people’s lives and emotions under therapeutic governance risks populations’
mental health. That populations do not succumb to the pathologisation
of their condition under therapeutic governance in greater numbers is testimony
to people’s capacity and resilience.
Chapters Seven and Thirteen
revisit the themes of therapeutic governance and social control where Neville
reverses the above framing – where the locus of governance and control for
re-constituting collapsed society is with the marginalized fringe acting in
mutual help. Neville’s process entailed relational governance.
SUMMARY
This chapter has provided a brief background to my research on
therapeutic communities and community mental health in