Envisioning a future for psychiatric care

T. F. Main coined the term therapeutic community (TC) [1] as both a manner and method of psychiatric care shortly after World War Two, highlighting institutional deficits of conventional hospitals which may thus be addressed: “The concept of a hospital [means] that patients are robbed of their status as responsible human beings […] making them ‘patients’ […] in a state of retirement from society.” [2] However, it was only under Maxwell Jones’ influence in the 1950s that the TC concept gained support, becoming a replicable method with certain characteristics [3] — small size of no more than 100 persons, daily community meetings, [4] and the psychodynamic hypothesis as an underlying philosophy.

[Editor’s note: many of the concepts only touched upon here are clarified in the accompanying article ‘Demystifying phenomenological and social psychiatry’]

Existing in this day and age, we have the ability to reflect upon past attempts of establishing a therapeutic community, [5] or else a range of other institutions attempting alternative therapeutic milieus — Basaglia’s psychiatric institution in Gorizia; Cooper’s Villa 21 in London; Huber’s Sozialistisches Patientenkollektiv in Heidelberg; Laing’s Kingsley Hall in London; and Mosher’s and later Ciompi’s Soteria in California and Bern, respectively. Historical examples such as these, as well as the accompanying literature, endow us with the privileged position of hindsight: we can learn from prior mistakes and modify a future TC [6] accordingly. Herein, two pillars should be placed at the forefront of any therapeutic concept, namely the impact of both societal and individual determinants on mental illness. [7]

Hence on the one side, a future TC will look to address aspects transcending mere individual suffering, focussing instead on the communal character of such phenomena. The livelihood of the TC as such hereby comes into play, as an actual room, or space, to be inhabited. The use of the term ‘in-habit’ is deliberate: a future TC will be a place where a number of people can indeed live, albeit temporarily, thereby sharing individual life-worlds; the social space thus becoming an intersection between individual habitats. Herein lies not only a social opportunity, but likewise a therapeutic one: ensuring an authentic confrontation with human interaction within a niche of experiential positive resonance [8] for each individual constitutes sustainable and inclusive psychiatric care, for it enables the revaluation of common day-to-day activities — cooking, cleaning and exercising, to name just three. As a result, collective everydayness becomes a powerful manifestation of life, akin to the revaluing of values: [9] negative experiences from the past are replaced, that is re-inhabited by positive experiences in the present. In this manner, societal aspects contributing to the development of mental illness may finally be addressed.

On the other side, psychiatric care must continue to tackle individual elements of mental illness, i.e., personal suffering. Conventional psychiatric and psychological treatment methods remain useful, thus a future TC does not seek to break with certain evidence-based approaches. Rather, a future TC must seek to combine such existing elements, currently implemented separately, with further expertise from a range of professions in an integrated fashion. A holistic approach of this manner will finally cater to the complexity of individuality and differing individual needs. In practise: a multi-professional team of psychologists, housekeepers, social workers, nurses, psychiatrists, neurologists and occupational therapists (which commonly make up psychiatric teams) will be expanded through further professionals: neuroradiologists, general practitioners and other medical specialities; cognitive scientists, biologists and physiologists; physiotherapists; social education workers; anthropologists, philosophers, and sociologists; artists such as filmmakers, painters, musicians, actors, directors, producers and the like; cooks; architects; and many more. Patients seeking help will thus be able to reflect on their needs (with the help of a questionnaire [10] and certain elements of an open dialogue [11] approach) and therapy tailored accordingly. For example, if an individual seeks to understand experienced phenomena on a biochemical, or neuronal basis, then a smaller core team of neuroradiologists, cognitive scientists and biologists could be comprised, subsequently principally responsible for the patient. Other patients may wish to explore their experiences in terms of breaking with social norms, thus a core team of anthropologists, sociologists and philosophers could be comprised. Still others may simply require an antipsychotic drug and the occasional conversation, benefiting primarily through expressive art, thus a core team of psychiatrists, psychologists and a range of artists would be most useful. A multi-professional team within the TC thus reflects this diversity of individual needs, likewise enabling seamless transitions throughout the therapeutic process between smaller core teams in light of any changes.

How does a future TC of the sort depicted here relate to its historical context? The daily community meetings with staff and patients will be adopted, in which decisions are discussed and concerns may be voiced. In accordance with Jones, patients’ status will change: “In collaboration with the staff, they now become active participants in the therapy of other patients, and in others aspects of the overall hospital work […] guided by their intimate knowledge of one another and their intuitive appreciation of one another’s psychological difficulties.” [12] Main’s first demand that treatment be “undertaken within a framework of social reality which can provide […] opportunities for attaining fuller social insight […] according to the demands of real life” [13] will be satisfied. His second demand was: “The daily life of the community must be related to real tasks, truly relevant of the needs and aspirations of the small society of the hospital, and the larger society in which it is set; there must be no barriers between the hospital and the rest of society”. [14] As briefly aforementioned, everyday activities akin to the essentials outside a TC will constitute a central element — including a daily lunch with all members of the TC, during which the reflection and discussion of various points can continue, primarily as an impetus for developing ideas and solving problems. Further, David G. Cooper’s central idea will be respected: “The central idea by which one must assess the worthwhileness of a form of social organisation proclaiming itself to be a therapeutic community is one that defines a certain relation between self and others. This relation […] must be such that in the total structure solitude as enriching inwardness is maintained inviolate, while at the same time there is a community in the sense of a contact between the inner worlds as well as the outer worlds of persons.” [15] Consequently, a future TC will reflect a key insight from a report published by the World Health Organisation on the state of mental health in 1953: “the creation of the atmosphere of a therapeutic community is in itself one of the most important types of treatment which the psychiatric hospital can provide.” [16]

In contrast to some of the aforementioned alternate therapeutic milieus, a future TC will seek to avoid a cult ‘figurehead’. Instead, a largely democratic equalitarian structure [17] will be adopted to ensure transparency and promote self-efficacy by distributing responsibility. [18] It will require caution to ensure this approach does not lead to failure, or worse a radicalisation of ideas as has been witnessed elsewhere. [19] A trialogical framework between patients, family or friends, and staff will be adopted — likewise inherent to a future TC, resting upon the belief in the universality of mental illness, and thus a continual rotation between the roles of a trialogue for each member of the TC, indeed society.

To conclude a few remarks on potential political work, broadly speaking, seem justified. Psychiatric care desperately needs to overcome the inner boundaries of hospital walls. Care must focus, instead, on engaging with the society breeding mental illnesses. Over recent years there have been many efforts to advance these demands both theoretically and institutionally. However, a major shortcoming of many projects is their necessary anchoring within the hermetic field of psychiatry itself, thus separated from the social domain and subsequent confrontation with the public. A future TC of the form depicted here would have endless opportunities of overcoming this: [20] a theatre, various sports teams, chess games, reading groups, jazz bands, poetry events, a restaurant, a cafe, concerts, snooker tables, etc. These cultural, culinary, and philosophical ‘offers’, for lack of a better word, will not exist isolated within the TC, but be open for the public, ensuring an authentic and unclouded confrontation with differing life-worlds. This will also enable a long-term relationship between the individual and the TC, surpassing initial habitation and thereby facilitating a sustainable therapy of psychiatric problems with a door that is always open.

 

Footnotes

[1] An in-depth description of the history of TCs, including the distinction between the ‘TC proper’ (equated to the shortened form TC for the purposes of this essay) and ‘alternative asylum TC’, is given by Kylie Innocente: “A historical and phenomenological study of Bradley Gardens therapeutic community (1980-1984).” As it is not possible to find this in the internet, please contact us if you wish to receive a copy
[2] Main, T. F. (1946). “The hospital as a therapeutic institution.” Bulletin of the Menninger Clinic, 10, 66-70
[3] Clark, D. H. (1964). “The Therapeutic Community — Concept, Practice and Future.” British Journal of Psychiatry, 111, pp. 947-954
[4] Jones, M. (1959). “Towards a clarification of the ‘therapeutic community’ concept.” British Journal of Medical Psychology, 32 (3), 200-205
[5] Such as Bion, Rickman and later Foulkes’ ‘Northfield Experiments’ at Northfield Hospital and in the Social Rehabilitation Unit under Maxwell Jones at Mill Hill Hospital
[6] The following depiction of a future TC is in no way complete, nor is this an attempt at being so. Rather, these initial thoughts are meant to guide further considerations in the years to come, enabling a thorough historical reappraisal and thereafter a thoughtful conceptualisation, avoiding any hasty practical implementation
[7] Such a complementary view of therapeutic subjects of the individual as well as the community in which the individual lives is likewise found elsewhere, e.g. a slightly differing version in Thoma, S. (2018). “Common Sense und Verrücktheit im sozialen Raum”. Köln: Psychiatrie Verlag, p. 244: “Die Formulierung ‘Therapie des sozialen Raums’ verstehe ich dabei im doppelten Sinn des Genitivs sowohl als eine Therapie des Individuums durch den sozialen Raum wie auch als eine Therapie, die diesen sozialen Raum selbst transformiert” (Note: there is not yet an english translation of this book)
[8] Thoma, S. (2018). “Common Sense und Verrücktheit im sozialen Raum”. Köln: Psychiatrie Verlag, pp. 220-222 (Note: there is not yet an english translation of this book)
[9] Nietzsche, F. (1887). “Zur Genealogie der Moral”. Goldman Verlag. See the discussion on the conflict between what Nietzsche calls ‘noble morality’ and ‘slave morality’, resulting in the inversion of values
[10] A suitable questionnaire would need to be developed. The intuitive idea would be to include a range of items covering various key topics, approaches, schools of thought etc. Hereby it would be possible to distinguish the type of therapeutic situation which would be most useful for the individual
[11] This approach, now widely implemented, was founded in Finland. See for example open-dialogue.net
[12] Jones, M. (1959). “Towards a clarification of the ‘therapeutic community’ concept.” British Journal of Medical Psychology, 32 (3), 200-205
[13] Main, T. F. (1946). “The hospital as a therapeutic institution.” Bulletin of the Menninger Clinic, 10, 66-70
[14] Ibid.
[15] Cooper, D. G. (1967). “Psychiatry and Anti-Psychiatry”. Tavistock Publications, p. 74
[16] Clark, D. H. (1964). “The Therapeutic Community — Concept, Practice and Future.” British Journal of Psychiatry, 111, pp. 947-954
[17] Jones, M. (1959). “Towards a clarification of the ‘therapeutic community’ concept.” British Journal of Medical Psychology, 32 (3), 200-205
[18] There is an important discussion on the effective power relations within a TC so as to avoid a disorganisation of the community which can only be hinted at here. See for example Basaglia, F. (Hrsg., 1968). “Die negierte Institution oder Die Gemeinschaft der Ausgeschlossenen. Ein Experiment der psychiatrischen Klinik in Görz”. Suhrkamp Verlag, pp. 168-175
[19] See, for example, the radicalisation and subsequent RAF-association (German: Rote Armee Fraktion) of members of the Sozialistisches Patientenkollektiv in Heidelberg from 1970-71
[20] This has been previously described by Maxwell Jones as ‘social learning’. See Basaglia, F. (Hrsg., 1968). “Die negierte Institution oder Die Gemeinschaft der Ausgeschlossenen. Ein Experiment der psychiatrischen Klinik in Görz”. Suhrkamp Verlag, p. 167

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