What is a Therapeutic Community?

A Therapeutic Community (TC) is a place whose primary aim is to help people with their emotional and interpersonal problems. The way this help is structured is guided by a set of values and beliefs about the way people should treat each other and be treated, based on self-awareness, interdependence, deep mutual respect and assumption of personal responsibility. These shape the principles which underpin TC practice. TCs differ in the details of their approach, depending on the client group.

What are the values of TCs?

Central to all TCs is the belief that people can change, and that in order to realize their potential as individuals and active citizens, they require an environment that fosters personal growth. They need to form relationships with others in an atmosphere of trust and security, they need to be valued, accepted and supported by those around them and they need to take real responsibility for themselves, others and their environment. A strong sense of community membership and belonging are critical to the process; in order to benefit from participation in a TC the member must be positively motivated to change, and to accept the TC’s rules. These rules uphold the values and norms of the community, which are a reflection of those held by society.

What do TCs do?

A TC is an informal, casual environment. Members and staff are not immediately distinguishable from each other and there is a distinct communal atmosphere. The TC offers a safe environment with a clear structure of boundaries and expectations.

TCs have a daily structure that incorporates all practical arrangements for maintaining and developing the community, as well as a varied programme of formal and informal therapeutic activity, These may include group or individual therapy, creative therapies, social or cultural activities, and educational or work placements. All members of the TC are involved in the daily programme that contributes to both the individual’s needs as well as those of the community as a whole.

Everyone is expected to contribute to the life of the TC according to his or her ability. Members are expected to take responsibility for themselves (for example, in terms of personal cleanliness, tidiness and appropriateness of behaviour) and to participate in the running of the TC. This includes duties such as cleaning, gardening and administrative tasks, which are assigned by the whole community. Members and staff meet together regularly to discuss the management and activities of the community and to make decisions affecting them, for example members’ joining or leaving are particularly important. Members take on increasing responsibilities as their confidence and abilities develop during their time in the community.

Members tend to learn much through the routine interactions of daily life, and the experience of being therapeutic for each other. The goal is to improve members’ interpersonal functioning; first within the therapeutic community, and ultimately in the wider community. Feedback from peers enable members to reflect on the way their conduct affects others, and members may practice new behaviours and ways of relating and begin to gain increased self-esteem and knowledge of themselves.

Who can TCs help?

TC principles can be applied to the therapeutic care of a wide range of people in different settings. TCs can be residential or day facilities. They can be located across all sectors in Health and Social Care, including the Prison Service. They help some of society’s most vulnerable and socially excluded adults, children and young people. Problems include mental illness, learning difficulties, substance misuse, severe emotional and behavioural difficulties and offending behaviour.

There is considerable research evidence for the effectiveness of TCs for those people with personality disorder, offending behaviour and substance misuse. Evidence for TCs working with adults with severe and enduring mental health problems, learning difficulties and children and young people can be extrapolated from broader relevant research and from feedback from clients, their family and friends and relevant professionals. In addition, the durability and the demand for places in these TCs highlights the important role they play within the health and social care system. Expanding and improving the research evidence for the effectiveness of the service is high priority for all TCs, and the organisations supporting them.

What are the “types” of TC?

Broadly speaking there are three main types of TC: (i) Democratic, (ii) Drug-free and (iii) Therapeutic living. All TCs can be recognised as described above with a few important differences.

Democratic TCs

These communities cater for those with mental health problems and offenders, and include some of the childrens’ TCs. They are structured with a flattened hierarchy where all members and staff have equal voting rights on all decisions relevant to the community. Permissiveness is a fundamental principle that ensures that behaviour that is otherwise not tolerated in society can be expressed, then engaged and worked with therapeutically. They are most commonly run using psychodynamic principles, and are staffed by professionals who use formal therapy and informal time as the basis for helping clients to develop healthy relationships, by using the past to inform the members’ experiences and behaviour in the present. They generally work with time-limited placements.

In many ways, these are similar to democratic TCs, and there is considerable overlap. TCs for learning difficulties tend to be based on a spiritual model providing members who are often rejected with a valid place within society and a “family-like” environment where they can experience being equal citizens with others who are not disabled. Members will often make a home for life within these communities, and they are staffed by volunteers who will most often live within the communities. They are less “professionalised”, with the emphasis on living together in a safe and supportive, and spiritually aware, way, There is much less formal therapy, and most of the activities involve ordinary day-to-day tasks, undertaken in their deliberately constructed therapeutic environments. Non-verbal work is often very important; the level of democracy and permissiveness possible necessarily varies with the client group.

Drug-Free TCs

These communities cater for those with substance misuse problems. They are typically highly structured environments with a distinct hierarchy, which includes novice and senior members. Senior members have equal responsibility with staff. These TCs base the therapeutic programme on a self-help model. Placements are time limited and staff are a mix of professionals and members who have been through the programme. Members must behave in ways that are acceptable to the community: maladaptive behaviours are explicitly not tolerated, and members are expected to live “as if” they are fully functioning, healthy citizens.

UK Organisations: contact details

The Association of Therapeutic Community (ATC) grew up in the 1960s and 1970s as a supportive organisation for professionals who worked in therapeutic communities, who visited each other’s units and shared ideas. It acts as a focus for information, debate, training and support - for anybody who wants their milieu to have a therapeutic effect on the residents, patients or clients; or for anyone who works in a therapeutic community.

The Charterhouse Group (ChG) of Therapeutic Communities is a charitable organisation speaking and working on behalf of its members who provide specialist treatment, through therapeutic care and education, to severely emotionally deprived and damaged children, young people and their carers. Charterhouse Group highlights the needs of these often forgotten and poorly understood children through promoting, supporting and informing the development of specialist care, treatment and education provision at national and international levels.

The Planned Environment Therapy Trust (PETT) is a small charitable trust founded in 1966 to promote research and discussion furthering the support and use of approaches to living and working with unhappy, disturbed, delinquent or disturbing individuals, in which all the resources of a thoughtfully created environment, the shared living experience, and above all the enormous healing potential of relationships, are brought together for therapeutic ends.

The Community of Communities is a network of communities managed by the Royal College of Psychiatrists. It works on an annual cycle where communities draw up standards, review themselves, then visit, support and audit each other, then have a annual congregation (normally in London in February). There are several dozen members, mostly from UK but also Europe, India and New Zealand.