The Fusion Model:Its roots in British and American TCs

Rex Haigh and Jan Lees Association of Therapeutic Communities, London

Joint Project Leads, Community of Communities, Royal College of Psychiatrists Research Unit

EFTC Ljubljana, 6 June 2007

Definition: British Model TC

“a consciously designed social environment and programme within a residential or day unit in which the social an group process is harnessed with therapeutic intent. In the therapeutic community the community is the primary therapeutic instrument”

(Roberts 1997, 4)

The Earliest Origins

• 1250: Geel, Flanders - Shrine of St Dymphna

• 1796: Tuke - The Retreat, York

• 1800s: Pinel - Salpêtrière, Paris

• 1817: Pennsylvanian Quakers

• 1862: The Kolonie

• 1920s: Holland - Beilen; Norway -Lier Valley

• 1925: Rudolph Steiner d. - anthroposophy

• 1939: Konig & Camphill Trust - spread over UK

• 1964: Jean Vanier: L’Arche - USA, UK, DK, India

Therapeutic Education

• 1907-1912: Homer Lane - The Boys’ Republic

• 1913-1918: Homer Lane - The Little Commonwealth

• 1924: A S Neill and Summerhill• 1930s: George Lyward and Finchden

Manor• 1934-36: David Wills & Marjorie

Franklin - Q-camps & Hawkspur

• 1970s & 80s Peper Harow & Melvyn Rose

• 1990s Charterhouse Group

Early Origins – learning disability

• 1250: Geel, Flanders - Shrine of St Dymphna

• 1796: Tuke - The Retreat, York

• 1800s: Pinel - Salpêtrière, Paris

• 1862: The Kolonie

• 1920s: Holland - Beilen; Norway -Lier Valley

• 1925: Rudolph Steiner d. - anthroposophy

• 1939: Konig & Camphill Trust - spread over UK

• 1964: Jean Vanier: L’Arche - USA, UK, DK, India

Antipsychiatry

• 1960: Ronnie Laing & David Cooper - Villa 21, Shenley

• 1965-70: Kingsley Hall

• late 1960s - present: Philadelphia Association and Archway Communities

• 1975 - present: Joe Berke - Arbours Association

Social Psychiatry

• 1942: Bion & Rickman - Northfield I• 1942-46: Foulkes, Bridger, Main - Northfield II• 1943: Maxwell Jones - Mill Hill

• 1950s & 60s: David Clark & social psychiatry: a TC in every major hospital; open doors; progressive regimes

• 1972: Institute of Group Analysis founded

• 1998: Reed Report - Henderson replicants approved

• 1999: Systematic review & multicentre research• 2003: “Personality Disorder: No Longer a

Diagnosis of Exclusion”

Therapeutic Housing

• 1959: Elly Jansen - Richmond Fellowship

• 1979: EBC Oxford

• 1984: 45 UK communities, plus overseas

• 1990s: Community Housing and Therapy (SW London), Threshold (Belfast)

“Forgiving Justice”: TCs in prisons

• 1962: HMP Grendon Underwood• 1973-1995: Barlinnie Special Unit,

Scotland• 1975-2002: Max Glatt Centre, HMP

Wormwood Scrubs• 1993: Gartree TC, HMP Gartree• 2000: DSPD proposals• 2001: HMP Dovegate• 2003: Correctional Services Accreditation

Panel -TC Model• 2003: HMP Send (for women) & HMP

Blundesdon

The UK Personality Disorder Programme

• 11 new pilot projects• 2004-2007 • 5 new day-TCs in total• >10 new mini-TCs• Also other approaches:

– 2 ‘managed networks’– 2 DBT-based – Also psychodynamic, CAT, CBT– one early intervention with

adolescents

Rapoport’s “themes”

• Democratisationevery member of the community (all patients & staff) should share equally in the exercise of power in decision making about community affairs

• Permissivenessall members should tolerate from one another a wide degree of behaviour that might be distressing or seem deviant by ordinary standards

• Communalismthere should be tight-knit, intimate sets of relationships, with sharing of amenities (dining room, etc), use of first names and free communication

• Reality confrontationpatients should be continuously presented with interpretations of their behaviour as it is seen by others, in order to counteract their tendency to distort, deny or withdraw from their difficulties in getting on with others.

Developmental experience

• Attachment - belonging– Bowlby, M Main, Trevarthen, Stern, Holmes, AAI work

• Containment - safety– Winnicott, Bion, Meltzer, Bollas, some Kleinians

• Communication - openness– T Main, Whiteley, much dynamic theory

• Inclusion – place amongst others– Elias, Foulkes, Systems, Jones

• Agency – personal effectiveness– Stack-Sullivan, Jung, HIPs

Addiction TCs

• 1958: Chuck Dederich - Synanon, California

• 1960s: Concept Houses

• 1968: Phoenix House, London

• 1975: Synanon declares itself a religion

• 1980 - 90s: development of “hierarchical”, “programmatic”, “concept” or “behavioural” TCs

• 1980s onwards: George deLeon: robust outcome research (USA)

• 2000s: growth across the world of different “flavours” of TC

Key Ideas: Addiction TCs

• ‘the game’ or ‘the stew’

• ‘the roller coaster’

• ‘the onion’• ‘the

community wheel’

• ‘lifestylers’ and ‘squares’

• ‘acting ‘as if’’

• ‘community as method’

• Safety in acceptance

• Verbal reprimands

• Encounter groups

• Family work

•Drug abstinence• Self-help•Hierarchical structure•Social confidence training •Relating

“a concept TC is a drug free environment in which people with addictive (and other) problems live together in an organised and structured way in order to promote change and make possible a drug free life in the outside society”

(Broekaert 2006)

Definition: Addiction TC

Definition: British Model TC

“a consciously designed social environment and programme within a residential or day unit in which the social an group process is harnessed with therapeutic intent. In the therapeutic community the community is the primary therapeutic instrument”

(Roberts 1997, 4)

All TCs: first attempt at a definition

A TC is a consciously designed drug free social environment in which people with various emotional problems live together in an organised and structured way. The social and group processes of the community are the method itself, and through them, change and recovery are promoted. In this way, a new life in outside society is made possible”

All TCs: what is still different?

1. Entry criteria & process2. Range of client groups3. Residential4. ‘Part of the Establishment’5. Global presence

All TCs: what is held in common?

1. Empowerment2. Professionalisatio

n3. Stages of

developmental cycle

4. Progression5. Peer-led6. Various groups &

structures

7. Recovery model8. Survival in a

regulated world9. Need for research &

evidence base10.Funding & short-

termism11.New modifications12.Concepts

Community of Communities: The Annual CycleSixth Year, 2007

Review standards 7 December 2007

Self reviews J une - Oct 2007

TC visits (=peer reviews) September – December 2007

Local report compiled Within 4 weeks of visit

ANNUAL FORUM 23 March 2007

Action planning Until next year’s reviews

TC Journal

Contact Details• JAN LEESjan.lees@nottingham.ac.uk

• REX HAIGHrexhaigh@nhs.net

• COMMUNITY OF COMMUNITIESwww.communityofcommunities.org.uk

• INTERNATIONAL JOURNAL OF THERAPEUTIC COMMUNITIES

tcj@nottshc.nhs.uk