Tag: Therapeutic Community

An Overview of Claybury Hospital

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Introduction

Claybury Hospital was a psychiatric hospital in Woodford Bridge, London. It was built to a design by the English architect George Thomas Hine who was a prolific Victorian architect of hospital buildings. It was opened in 1893 making it the Fifth Middlesex County Asylum. Historic England identified the hospital as being “the most important asylum built in England after 1875”.

Since the closure of the hospital, the site was redeveloped as housing and a gymnasium under the name Repton Park. The hospital block, tower, and chapel, which is now a swimming complex, were designated as a Grade II listed building in 1990.

Brief History

The Project

The building of Claybury Hospital was commissioned by the Middlesex Court of Magistrates in 1887 and would eventually become the fifth Middlesex County Asylum. It was built to a design by the English architect George Thomas Hine who was a prolific, late-Victorian architect of mainly hospital buildings and asylums for the mentally insane. It was the first asylum to successfully use the echelon plan upon which all later asylums were based.

The site was situated on the brow of a hill and was surrounded by 50 acres (200,000 m2) of ancient woodland and 95 acres (380,000 m2) of open parkland, ponds, pasture and historic gardens. These had been designed in 1789 by the landscape architect Humphry Repton.

Early Years

In 1889 the uncompleted building passed to the newly created London County Council which opened it in 1893 as the Claybury Lunatic Asylum.

By 1896, the hospital had 2,500 patients. The first Medical Superintendent and directing genius was Robert Armstrong-Jones. By the first decade of the twentieth century, Claybury had become a major centre of psychiatric learning. It was internationally admired for its research, its pioneering work in introducing new forms of treatment and the high standard of care provided for the mentally ill. Armstrong-Jones was knighted in 1917 for his exceptional work at Claybury and his general service to psychiatry.

Armstrong-Jones held progressive views on community care, advocating in 1906 that city hospitals should have out-patient departments where patients could seek help for mental symptoms without loss of liberty. Each asylum should be a centre for clinical instruction where all medical practitioners could refresh their understanding of insanity. People showing early signs of insanity should be free to seek advice and if necessary be admitted on a voluntary basis and not have to wait until they became certifiable. The first voluntary patients could not admitted until 1930 when the Mental Treatment Act was passed.

In 1895, the London County Council appointed Frederick Mott as director for their new research laboratory at Claybury. Over the next 19 years he carried out vast research, documented in his Archives of Neurology and Psychiatry published between 1903 and 1922. He was knighted in 1919 and is particularly remembered for helping to establish that ‘general paralysis of the insane (GPI) was due to syphilis.

Helen Boyle was appointed as an Assistant Medical Officer in 1895, one of the first women to be employed as a doctor in an asylum. She became a pioneer of early treatment for the mentally ill and went on to found the Lady Chichester Hospital. In 1939 she became the first female president of the Royal Medico-Psychological Association (now the Royal College of Psychiatrists). In Pryor’s words: “The work of this ‘lady doctor’ formed part of the pale new dawn of community care for the mentally ill.”

The asylum was renamed Claybury Mental Hospital in 1930 and simplified to Claybury Hospital in 1959

A Patient Experience in the 1930s

The English artist, Thomas Hennell, published an account of his personal experience of schizophrenia in his book, The Witnesses, in 1938. Sectioned and detained at St John’s Hospital, Stone, Buckinghamshire in 1935, he was then moved to the Maudsley Hospital in London, and finally, to Claybury. He disliked his treatment at the first two, and satirised the Maudsley psychiatrists, but he enjoyed the humane therapy at Claybury (though there is a signed drawing by him in the Tate of staff stealing from a patient in Claybury). In the course of his illness he produced several pictures that depicted his mental state. Before leaving Claybury in 1938, the medical superintendent, Guy Barham, agreed to him painting a large mural covering three walls of the canteen. A photograph of this painting was rediscovered circa 2015. He became an official war artist during World War II.

Post-War Years

Claybury became part of the National Health Service in 1948. The introduction of new drugs, the phenothiazines in 1955 and 1956, and the anti-depressant drugs in 1959, dramatically altered the treatment of the major psychoses, reducing the severity and duration of many conditions and creating a setting where normalisation could flourish.

From the mid-1950s Claybury again attracted widespread attention as, led by consultants Denis Martin and John Pippard, it pioneered a controversial therapeutic community approach to an entire institution of over 2,700 people. In 1968, Martin described the development of Claybury’s therapeutic community in Adventure in Psychiatry. In 1972 a collection of essays by staff members and edited by Elizabeth Shoenberg were published under the title, A Hospital Looks at Itself:

The three pronged attack of therapeutic community techniques, use of new drugs and minimal use of the physical treatments, led to a reduction of the patient population from 2,332 in 1950 to 1,537 in 1970. However, lack of community care resulted in the ‘revolving door syndrome’ with over half admissions being re-admissions.

From the late 1940s it became increasingly difficult to recruit student nurses and other support staff from the UK. Many, with little English, were recruited from Europe and given English language tuition. In 1962, Enoch Powell, then Minister of Health, proposed that hospitals should seek recruits from the West Indies and Pakistan. By 1968 there were 47 nationalities represented at Claybury with different ethnic, religious and linguistic backgrounds, all part of the therapeutic community diversity.

Developments in Community Care

Enoch Powell had predicted in 1961 that all psychiatric hospitals would be closed within 15 years. In reality, the first, Banstead, closed in 1986. In 1983 the North East Thames Regional Health Authority (NETRHA) committed itself to a 10-year plan for the re-provision of care currently provided by Friern and Claybury hospitals. The number of patients on Claybury’s statuary books at the year end in 1980 was 1,057 and in 1990 was 429.

For some long-stay patients, thoroughly institutionalised, Claybury had been both home and local village for decades, in some cases for over 40 years. The challenge to manage their rehabilitation in a new environment, that they had never experienced and might well treat them with suspicion, was immense. In 1988 the Health and Social Services Research Unit at South Bank Polytechnic published a research paper detailing the post-discharge experience of a group of former long-stay Claybury patients.

Closure

To mark its centenary in 1993, the Forest Healthcare Trust published a comprehensive and well documented history of the hospital entitled, Claybury, A Century of Caring, written by Eric Pryor who had been a member of the nursing staff since 1948.

With the Care in the Community Programme and the planned decline in patient numbers, the Claybury site faced a difficult future. The NHS pressed for extensive demolition and maximum new build, whereas the Local Planning Authority and English Heritage argued for maximum retention of the historic buildings and restriction of new build to the existing footprint, in accordance with the Green Belt allocation in the Unitary Development Plan. The hospital was closed in 1997.

Historic England identified the hospital as being “the most important asylum built in England after 1875… [it was] the first asylum to successfully use the echelon plan, upon which all later asylums were based.” The hospital block was designated as a Grade II listed building in 1990, as was the stable block, which is located to the north west of the main building.

Repton Park

After the hospital was shut down in 1997 it was converted into gated housing by Crest Nicholson (working closely with English Heritage and the London Wildlife Trust) and renamed Repton Park.

The hospital chapel was converted into a swimming pool and health centre for the use of Repton Park residents. Former residents of Repton Park include singers V V Brown and Simon Webbe and actress Patsy Palmer. Properties have also attracted professional footballers from Arsenal and Spurs.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Claybury_Hospital >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

An Overview of Cassel Hospital

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Introduction

The Cassel Hospital is a psychiatric facility in a Grade II listed building at 1 Ham Common, Richmond, Ham in the London Borough of Richmond upon Thames. It is run by the West London NHS Trust.

Brief History

The Hospital

The hospital was founded and endowed by Ernest Cassel in England in 1919. It was initially for the treatment of “shell shock” victims (aka combat stress reaction). Originally at Swaylands in Penshurst, Kent, it moved to Stoke-on-Trent during the Second World War. In 1948 it relocated to its present site at No. 1 Ham Common, Ham.

The Building

The present hospital was originally a late 18th-century house known as Morgan House after its owner, philanthropist and writer, John Minter Morgan. Morgan died in 1854 and is buried in nearby St Andrew’s Church, Ham. In 1863 it became home to the newly married Duc de Chartres. In 1879 it became West Heath Girls’ School. The school moved to its present site in Sevenoaks, Kent in the 1930s, and the building became the Lawrence Hall Hotel until its purchase by the Cassel Foundation in 1947. The building was Grade II listed in 1950.

Facilities

The hospital developed approaches informed by psychoanalytic thinking alongside medicinal interventions, techniques of group and individual psychotherapy. It was here that Tom Main along with Doreen Wedell pioneered the concept of a therapeutic community in the late 1940s. Together they pioneered & developed the concept of psychosocial nursing. By promoting and being proud of the role of the nurse – rather than try to imitate therapists; working alongside the patient in everyday activities, Weddell & Main developed a whole new way of working that reduced dependence upon services and fostered patient’s working collaboratively. Nurses were supported and taught to understand their reparative need, to challenge their sense of omnipotence and to rely on the patient group as the most useful resource. In 1948 Eileen Skellern came for her training and joined the staff in 1949.

The hospital formally established a research department in 1995 and has collaborative relationships with University College London, Imperial College and the Centre for the Economics of Mental Health at the Institute of Psychiatry, London. It is now a psychotherapeutic community which provides day, residential, and outreach services for young people and adults with severe and enduring personality disorders.

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What is Milieu Therapy?

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Introduction

Milieu therapy is a form of psychotherapy that involves the use of therapeutic communities.

Outline

Patients join a group of around 30, for between 9 and 18 months. During their stay, patients are encouraged to take responsibility for themselves and the others within the unit, based upon a hierarchy of collective consequences. Patients are expected to hold one another to following rules, with more senior patients expected to model appropriate behavior for newer patients. If one patient violates the rules, others who were aware of the violation but did not intervene may also be punished to varying extents based upon their involvement.

Milieu therapy is thought to be of value in treating personality disorders and behavioural problems, and can also be used with a goal of stimulating the patient’s remaining cognitive-communicative abilities.

Organisations known to use milieu therapy include:

  • Cassel Hospital, in London, UK.
  • Forest Heights Lodge in Evergreen, Colorado, US.
  • The United States Veteran’s Administration, US.
  • The Kansas Industrial School for Girls in Beloit, Kansas, US.

This page is based on the copyrighted Wikipedia article < https://en.wikipedia.org/wiki/Milieu_therapy >; it is used under the Creative Commons Attribution-ShareAlike 3.0 Unported License (CC-BY-SA). You may redistribute it, verbatim or modified, providing that you comply with the terms of the CC-BY-SA.

What is a Therapeutic Community?

Published on by Andrew Marshall1 Comment

Introduction

Therapeutic community is a participative, group-based approach to long-term mental illness, personality disorders and drug addiction. The approach was usually residential, with the clients and therapists living together, but increasingly residential units have been superseded by day units. It is based on milieu therapy principles, and includes group psychotherapy as well as practical activities.

Therapeutic communities have gained some reputation for success in rehabilitation and patient satisfaction in the UK and abroad. In the UK, ‘democratic analytic’ therapeutic communities have tended to specialise in the treatment of moderate to severe personality disorders and complex emotional and interpersonal problems. The evolution of therapeutic communities in the US has followed a different path with hierarchically arranged communities (or concept houses) specialising in the treatment of drug and alcohol dependence.

Brief History

Antecedents

There are several antecedents to the therapeutic community movement. One of the earliest is the change in treatment of institutionalised patients in the late 18th century, continuing throughout the 19th century. A major contributor to this change is Philippe Pinel, a French physician who advocated for a more humane treatment of psychiatric patients. In the UK William Tuke founded the Retreat where patients were treated according to humanitarian principles, called moral treatment. Tuke based the treatment of mentally ill people partly on the Quaker ideology. The influence of Quaker principles continues through out the development of the therapeutic community.

Moral treatment focused on a more humane treatment of patients and a stimulating environment that engages them in healthy behaviour. An important distinction between the later therapeutic community is the strong hierarchy in moral treatment facilities. The superintendent had authority over and responsibility of the patients. The patients followed a strict schedule to promote obedience and self-control.

After the First World War, multiple varieties of living-and-learning communities for young adults were established. Examples are the Little Commonwealth school run by Homer Lane and the Q camps initiated by Marjorie Franklin. The Q camps were based on Planned Environmental Therapy, which focused on normally functioning parts of a patient’s personality and use them to deal with difficult social situations. These projects all emphasized shared responsibility and decision-making and participation in the community. What influenced the establishment of these projects were, among others, the developments in psychoanalytic theory in the UK.

United Kingdom

The work conducted by pioneering NZ plastic surgeon Archibald McIndoe at Queen Victoria Hospital and others at Northfield Military Hospital during World War II is considered by many psychiatrists to have been the first example of an intentional therapeutic community. But this story is prone to adopt a origin myth approach. The principles developed at Northfield were also developed and adapted at Civil Resettlement Units established at the end of the war to help returning prisoners of war to adapt back to civilian society and for civilians to adapt to having these men back amongst them.

The term was coined by Thomas Main in his 1946 paper, “The hospital as a therapeutic institution”, and subsequently developed by others including Maxwell Jones, R.D. Laing at the Philadelphia Association, David Cooper at Villa 21, and Joshua Bierer.

Under the influence of Maxwell Jones, Main, Wilmer and others (Caudill 1958; Rapoport 1960), combined with the publications of critiques of the existing mental health system (Greenblatt et al. 1957, Stanton and Schwartz 1954) and the sociopolitical influences that permeated the psychiatric world towards the end of and following the Second World War, the concept of the therapeutic community and its attenuated form – the therapeutic milieu – caught on and dominated the field of inpatient psychiatry throughout the 1960s.

The first development of therapeutic community in a large institution took place at Claybury Hospital under the guidance of Denis Martin and John Pippard. Beginning in 1955 it involved over 2,000 patients and hundreds of staff. The aim of therapeutic communities was a more democratic, user-led form of therapeutic environment, avoiding the authoritarian and demeaning practices of many psychiatric establishments of the time. The central philosophy is that clients are active participants in their own and each other’s mental health treatment and that responsibility for the daily running of the community is shared among the clients and the staff. One phrase commonly used to summarise this treatment philosophy is ‘the Community as Doctor’. ‘TC’s have sometimes eschewed or limited medication in favour of group-based therapies.

The Henderson Hospital first established in 1947 by Maxwell Jones and named after David Henderson evolved the specific concept of Democratic Therapeutic Community (DTC). Admission to and early discharge from the one year of residential treatment was by majority vote and residents of the DTC always held the majority in these votes. No psychotropic medication or one to one therapy sessions were available and so all the work of the DTC was pursued, on the one hand, in small or larger therapy groups or work groups and community meetings, which could be called (by the residents) day or night; and on the other hand, in the unstructured time in between these more formal spaces, in which belonging in and membership of a living community could become in itself a healing experience. The Henderson Hospital DTC became an international centre of excellence for the care of survivors of severe trauma who did not fall under conventional psychiatric classifications and towards the end of the twentieth century it was funded to replicate the treatment model in two other DTCs: Main House in Birmingham and Webb House in Crewe.

The availability of the treatment on the National Health Service in the UK came under threat because of changes in funding systems. Researchers at the University of Oxford and King’s College London studied one of these national Democratic Therapeutic Community services over four years and found external policy ‘steering’ by officials eroded the community’s democratic model of care, which in turn destabilised its well established approach to clinical risk management (this had been jointly developed by clients and staff). Fischer (2012), who studied this community’s development at first hand, described how an ‘intractable conflict’ between embedded and externally imposed management models led to escalating organisational ‘turbulence’, producing an interorganisational crisis which led to the unit’s forced closure. The three ‘Henderson’ DTCs had all closed their doors by 2008.

However, development of ‘mini’ therapeutic communities, meeting for three or fewer days each week and supported out of hours by various forms of ‘service user led informal networks of care’ (for example telephone, texting and physical support), now offers a more resource and cost effective alternative to traditional inpatient therapeutic communities. The most recent exponent, the North Cumbria model, uses a dedicated out of hours website moderated by service users according to therapeutic community principles. This extends the community beyond the face to face ‘therapeutic days’. The website guarantees a safe group-based response not always possible with other systems. The use of ‘starter’ groups as a preparation for entry into therapeutic communities has lowered attrition rates and they now represent a cost-effective model still aimed at producing durable personal and intergenerational effects; this is at odds with the current trend towards the defensive needs of service providers, rather than service users, for less intensive treatments and management of pathways to control risk.

United States

In the late 1960s within the US correctional system, the Asklepion Foundation initiated therapeutic communities in the Marion Federal Penitentiary and other institutions that included clinical intervention based upon Transactional Analysis, the Synanon Game, internal twelve-step programmes and other therapeutic modalities. Some of these programmes lasted into the mid-1980s, such as the House of Thought in the Virginia Correctional system, and were able to demonstrate a reduction of 17% in recidivism in a matched-pair study of drug-abusing felons and sex offenders who participated in the program for one year or more.

Modified therapeutic communities are currently used for substance abuse treatment in correctional facilities of several US states including Pennsylvania, Washington, Colorado, Texas, Delaware, and New York. In New York City, a programme for men is located in the Arthur Kill Correctional Facility on Staten Island and the women’s programme is part of the Bayview Correctional Facility in Manhattan.

Main Ideas

The therapeutic community approach aims to help patients deal with social situations and to change perceptions they have about themselves. Difficult situations are re-enacted and experienced and patients are encouraged to examine and try to learn from them with the help of group and individual therapy. The communities function as a living-and-learning situations, where every interaction can serve as a learning moment.

There is no encompassing definition of what a therapeutic community should be. Some have therefore also argued that it follows a family resemblance. A common conception of therapeutic community is a group of people living together in a non-hierarchical, democratic way that brings psychological awareness of individual as well as group processes. Furthermore, the community has clear boundaries of place, time and roles of the participants. They are democratic because the patients are involved in decision-making to encourage a sense of responsibility. This is fostered by the non-hierarchical structure that tries to minimise dependency on the staff.

A key principle is the creation of a culture of enquiry. Everyone within the community is encouraged to reflect and ask question about themselves and others. In this way the participants are supported by continuous feedback to create better self-awareness.

The therapeutic community approach is informed by systems theory, organisation theory and psychoanalytic practice.

Effectiveness

As an intervention model for drug-using offenders with co-occurring mental health disorders, therapeutic communities may help people reduce drug use and subsequent criminal activity. Research evidence for the effectiveness of therapeutic community treatment is substantial and a demonstration of the cost efficacy of a year of residential therapeutic community treatment was instrumental in funding being granted in the late 1990s for the replication of the Henderson Hospital DTC.

In Popular Culture

  • The Alfred Hitchcock film Spellbound takes place within a therapeutic community called Green Manors.
  • Leonard Cohen and his touring band The Army gave an impromptu concert at the Henderson Hospital DTC in August 1970, just before the Isle of Wight Festival, after being invited by one of the residents.

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Who was Thomas Forrest Main?

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Introduction

Thomas Forrest Main (1911-1990) was a psychiatrist and psychoanalyst who coined the term ‘therapeutic community’. He is particularly remembered for his often cited paper, The Ailment (1957).

Refer to British Journal of Medical Psychology for The Ailment.

Life

Thomas Main was born on 25 February 1911 in Johannesburg, where his father was a mine manager who had emigrated there from England. At the start of World War I his mother returned to England with Thomas and his two sisters Isabella and Mary, while his father joined the South African Army. Main was educated at the Royal Grammar School, Newcastle-upon-Tyne before studying medicine at Durham University, graduating in 1933 and becoming a doctor in 1938. Specialising in psychiatry, he gained a Diploma in Psychological Medicine from Dublin in 1936. In 1937 he married Agnes Mary (Molly) McHaffie who also graduated in medicine at Durham University and who also became a psychoanalyst. They had three daughters and a son, Jennifer (Johns), Deborah (Hutchinson), Ursula (Kretzschmar) and Andrew.

Main worked as superintendent at Gateshead Mental Hospital. During the Second World War he joined the Royal Army Medical Corps as an adviser in psychiatry, attaining the rank of lieutenant colonel and working at the Northfield Army Hospital (aka Hollymoor Hospital) for the treatment of war neuroses. The work conducted at Northfield is considered by many psychiatrists to have been the first example of an intentional therapeutic community. The principles developed at Northfield were also developed and adapted at Civil Resettlement Units established at the end of the war to help returning prisoners of war to adapt back to civilian society and for civilians to adapt to having these men back amongst them.

The term “therapeutic community” was coined by Main in his 1946 paper, “The hospital as a therapeutic institution”, and subsequently developed by others including Maxwell Jones, R.D. Laing at the Philadelphia Association, David Cooper, and by Joshua Bierer.

After the war Main joined the Cassel Hospital, as medical director in 1946 and continued working there for the next thirty years.

Training as a psychoanalyst under Michael Balint, he was supervised by Anna Freud, Melanie Klein and Paula Heimann. In 1974 he co-founded with Michael Balint the charitable Institute of Psychosexual Medicine in London. He served as its Life President. He also served as vice-president of the Royal College of Psychiatrists, and was a co-editor of the British Journal of Medical Psychology. He died in Barnes, London on 29 May 1990, aged 79.

His papers are held in the Archive of the British Psychoanalytic Society, whose member he was for many years.

Works

  • The hospital as a therapeutic institution.
  • The Ailment and other Psycho-Analytical Essays, ed. Jennifer Johns, London: Free Association Books, 1989. ISBN 1-85343-105-2. The noted essay, The Ailment, is a report of Main’s detailed study of the feelings aroused in a team of nurses caring for a group of psychiatric patients with low potential for recovery. He found that a sedative would be used in the management of a patient “only at the moment when the nurse had reached the limit of her human resources and was no longer able to stand the patient’s problems without anxiety, impatience, guilt, anger or despair”.
  • Mothers with children on a psychiatric unit.
  • A fragment on mothering.
  • Meanings of madness: psychiatry comes of age.

Reference

Main, T.F. (1957) The Ailment. British Journal of Medical Psychology. 30(3), pp.129-145. https://bpspsychub.onlinelibrary.wiley.com/doi/10.1111/j.2044-8341.1957.tb01193.x.

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