<br><h3> Chapter One </h3> <b>Introducing Forensic Democratic Therapeutic Communities</b> <p> <i>Alisa Stevens</i> <p> <p> <b>Introduction</b> <p> Of the 140 prisons in England and Wales, just five currently offer a vision of 'offender management' based upon the principles and aims of the democratic therapeutic community (TC). Grendon - a category B (medium secure) establishment for up to 235 men - is the first, largest, and still the only dedicated TC prison, but has been joined in its penologically distinctive quest by TC units within the 'mainstream' men's prisons of Gartree, Dovegate (both category B) and Blundeston (category C), and at Send, a closed women's prison. <p> Democratic therapeutic communities, whether located in their traditional mental health, or more recently developed custodial, settings, offer a consciously designed, predominantly residential social environment and programme of treatment intended to help their members understand and, as far as possible, lessen or overcome their social, psychological, and emotional problems. It is the community as a collective and collaborative entity that is the primary therapeutic instrument (Roberts, 1997a), within which psychodynamic therapy - which emphasises the processes of change and personal development - is employed to unearth and 'work through' the (often unconscious) motivations and learned maladaptive protective behaviours that result from formative experiences, particularly those acquired during a traumatic or abusive childhood (Malan, 1979). This potent combination of dynamic interaction between the individual, his peer community, and psychodynamic therapy encourages gradual accumulation of self-knowledge and insight which ultimately allows for profound and permanent personal change. Within prisons, this means that the community - the residents (the preferred TC term for inmates) <i>and</i> prison staff - work together to move from historical exploration and understanding towards a reduction in problematic behaviours and attitudes and hence ultimately, a non-offending future. <p> <p> <b>Psychiatric Origins</b> <p> The origins of the TC treatment modality are generally attributed to the creation of specialist units - at Mill Hill, and more particularly, Northfield psychiatric military hospital - to treat traumatised World War II combat veterans presenting with acute dissociative and hysterical disorders. Keenly aware of the punitive and disabling mistreatment of Great War shell-shocked soldiers, and inspired by an emerging body of social scientific literature on small group processes and interpersonal relations (notably, Adler, 1924; Freud, 1922; and Mead, 1934), a handful of psychoanalytically-orientated psychiatrists considered the contemporary hegemonic 'medical model', as practised in secure psychiatric hospitals, to be systemically incapable of treating traumatised military personnel either effectively or humanely (Whiteley, 2004). In these 'total institutions', authoritarian, paternalistic professionals preoccupied themselves with the maintenance of control, hierarchy, and routine and slavish adherence to a myriad of, often bizarre, bureaucratic rules (Belknap, 1956; Caudill, 1958; Goffman, 1961; Stanton & Schwartz, 1954); whilst their deferential patients internalised an apathetic and pliant 'sick role' (Parsons, 1951) devoid of autonomy and individuality. By contrast, these TC pioneers hypothesised that this damaging and dependency-prone social environment only exacerbated in traumatised persons their tendency towards neurosis and personality disorder and that a more tolerant and empowering milieu might therefore relieve their symptoms of distress. Accordingly, they incrementally engineered a genuine revolution in psychiatric social relations by renouncing both the oppressive culture of the secure hospital and the traditional psychoanalytic dyad of 'expert' therapist and 'grateful' patient, in favour of a flexible, egalitarian organisational structure and collaborative, group-based interaction (Manning, 1976). <p> The initial, modest attempt at establishing a democratic TC occurred in the unlikely setting of a temporarily converted public school at Mill Hill, north London, to which psychiatric patients from the Maudsley Hospital were evacuated in 1940. In charge of a psychosomatic unit conducting physiological research into the aetiology of effort syndrome (or neurocirculatory asthenia, characterised by breathlessness, chest pain, giddiness, and persistent fatigue), the psychiatrist Maxwell Jones decided to share the research findings with his patients through regular didactic lectures. He soon realised, however, that the patients understood more, and their morale and self-esteem consequently improved, if he involved them in interactive group discussion by which each member contributed to the 'social learning' of the community. These small discussion groups began to affect the social structure of the ward, encouraging a flattened hierarchy and, in turn, greater sociological contextualising of the challenges treatment posed for both patients and staff (Jones, 1952, 1968; Whiteley, 2004). <p> Wilfred Bion, meanwhile, was appointed director of the Training Wing of Birmingham's Northfield military psychiatric hospital and charged with rehabilitating men who, although psychologically disturbed, were considered capable of returning to military service (Whiteley, 2004). Together with his colleague John Rickman, Bion decided to confront the patients' unruly and disruptive behaviour by re-defining disciplinary problems, in suitably combative terms, as the 'common enemy'. For six weeks in 1943, they introduced discussion groups and communal activities, designed to replace the fractured social bonds of war with the mutual support of a peer community and hence, 'to treat socially the social elements of the patients' neuroses' (Roberts, 1997b). The insubordination and subversion of military discipline this represented, however, proved intolerable to their superiors and Bion and Rickman were dismissed from their posts. Undeterred, over the next three years Siegmund Foulkes and Harold Bridger, amongst others, implemented gradually (what has been retrospectively called) 'the second Northfield experiment' in creating an avowedly democratic and therapeutic milieu - but this time with the approval of senior personnel - which again advocated the use of group analysis, regular meetings, and social activities involving the whole community (Kennard & Roberts, 1983; Whiteley, 2004). <p> In 1945, Northfield acquired a new hospital director, Tom Main, who sought to incorporate techniques from both psychiatry and psychoanalysis to construct a psychodynamic and interpretative exploration of his patients' objective difficulties through their subjectively experienced interpersonal frustrations and conflicts. In May 1946, Main published an article in which he argued that a neurotic, attachment disordered individual needed 'a framework of social reality which can provide him with opportunities for attaining fuller social insight and for expressing and modifying his emotional drives according to the demands of real life' (Main, 1946). He rallied his colleagues to replace the hospital as 'social refuge' with an internal community, and the role of the 'superintendent' psychiatrist with a humble 'technician', whose daily task was to study and facilitate 'the social pull and push' of the community in order to mobilise its therapeutic potential (Main, 1946). Several commentators have since timed the appearance of this 'stirring and inspirational' paper as the 'date of birth' of the democratic therapeutic community (Kennard, 1996). <p> It was, however, the prolific stream of publications which emanated from Maxwell Jones (inter alia 1942, 1946, 1952, 1953, 1956, 1959, 1968); his 12-year leadership from 1947 of a social rehabilitation unit for the treatment of personality and psychopathic disorders; and his international evangelising of social psychiatry, which were to secure for him the reputation of the father of the TC movement (Manning, 1976). Thus, although Main and his Northfield colleagues can claim the creation of the <i>TC philosophy,</i> it was Jones at Mill Hill who devised the <i>method</i> (Whiteley, 2004). <p> <p> <b>A 'Living-Learning' 'Culture of Enquiry'</b> <p> Endorsement of Jones's distinct vision was consolidated by three years of independent research at the Henderson Hospital, conducted (at Jones's astute request) by a team of seven social anthropologists, led by Robert Rapoport. The resulting publication, <i>Community as Doctor</i> (Rapoport, 1960), identified four complementary and interdependent therapeutic community principles. These guiding tenets apply equally to staff and to residents, are intended to realise the inherent therapeutic and rehabilitative potential residing within the community, and are still widely used to define the TC 'proper' (Clark, 1965) - the ideal, power-sharing, therapeutic community whose social environment is the main therapeutic instrument. <p> The principle of 'democratization' exists to ensure that each member of the community can participate equally in therapeutic and administrative decision-making, with unfettered access to vertical and horizontal communication channels. This is achieved through regular whole community meetings, in which all matters relating to the running of the community - both the mundane and the substantial - are openly discussed and debated (Rapoport, 1960). Jones (1976) was acutely aware, however, that shared decision-making could encompass a wide variety of practices, ranging from the full involvement of every community member, to resigned acquiescence, managerial manipulation, or the most cursory show of hands. This principle therefore further requires residents to develop an internal commitment to, and interconnectivity with, their community, in order that they experience a high degree of ownership of the democratic process and become willing to assume responsibility for its implementation and implications, regardless of whether this coincides with their personal preference. <p> The most straightforward principle, <i>communalism,</i> requires that facilities and domestic arrangements are shared. Involvement in communal tasks - and the helpful realisation this frequently entails that one's seemingly unique problems are, in fact, shared by fellow residents - is intended to increase a fragile member's self-esteem and lessen his isolation and helplessness, whilst simultaneously reinforcing the community's espoused moral values of social responsibility and altruism and promoting the development of trusting, reciprocal relationships (Rapoport, 1960; Yalom, 1980). The simplicity of communalism, however, conceals the complexity of its application: people may be united in their problems but have no propensity to co-exist harmoniously, and to do so without adopting a nave conception of community as 'phoney sharing' (Morrice, 1979) often requires a substantial and sustained effort. <p> Although now possessed of rather unfortunate pejorative connotations, in Rapoport's (1960) original designation <i>permissiveness</i> simply meant that residents tolerate in each other behaviours and speech that might normatively be perceived as deviant. Within the psychodynamic tradition all behaviour is meaningful, so all the individual's conscious and unconscious cognitions, emotions, motivations, and interpersonal dynamics are considered diagnostically and therapeutically informative (Yalom, 1980). This behaviour, however, will not be available for analysis if, in order to gain approval or avoid censure, one feels compelled to modify or disguise one's behaviour provisionally and instrumentally. The permissiveness principle therefore allows a TC resident to behave as he typically would - expressing and enacting habitual difficulties, secure in the knowledge of his continuing membership of an accepting environment - and this in turn facilitates the provision of plentiful 'living-learning' opportunities (Jones, 1968). <p> Crucially, however, this empathetic analysis is balanced by <i>reality confrontation</i> - the principle that although problematic behaviour is tolerated, it does not pass unnoticed or without criticism. Predominantly through the intimate forum of small therapy groups (typically of up to eight residents), members - as auxiliary therapists and role models - relate the effects such behaviour has upon them. This circumvents the universal tendency to deny, minimise, or rationalise one's less admirable characteristics and their objectionable consequences (Rapoport, 1960) - or, in the criminologists Sykes and Matza's (1957) memorable phrase, the deployment of 'techniques of neutralisation'. Even seemingly trivial incidents and interactions are therefore analysed within this 'culture of enquiry' (Main, 1946) in order to excavate their 'true' meaning and purpose, and to encourage members to offer support, advice, and feedback in a collaborative and pro-social manner. <p> This dialectical relationship between the individual and the 'miniature social universe' (Yalom, 1980) of the group additionally expedites the ability of the TC member to confront the discordance between self-image and the figurative mirror presented by one's peers, and so incrementally to acquire insight into the pervasiveness of maladaptive beliefs and behaviours. Indeed, Jones, who came to prefer the terms 'social learning' and 'facilitator' to 'treatment' and 'therapist' (1976), described social learning simply as 'two way communication of content and feeling, listening, interaction, and problem solving, leading to learning' (1980), and ultimately, personal change. (However, Jones did not explicitly accord social learning the status of an underpinning theory of TC treatment, nor does his use of the term properly correspond with social learning theory, as familiar to criminologists and psychologists.) Accordingly, the reality confrontation principle best embodies Main's (1946) exhortation that a genuine therapeutic milieu must prepare the resident for a return to 'a real role in the real world'. <p> Forty years after Rapoport, and as befits TCs' continually evolving and dynamic nature, Haigh (1999) updated and adapted the original principles as 'five universal qualities' of therapeutic environments, presenting them as a developmental sequence which reflects the therapeutic journey of the TC resident. The first quality, <i>attachment,</i> utilises attachment theory (Ainsworth, 1967; Bowlby, 1969, 1973, 1980) to show the importance of sensitive joining (and leaving) procedures, so that residents develop a sense of belonging to, and of valuing and being valued by, their community (Haigh, 1999). The resident then learns that the TC's culture of safety and <i>containment</i> (extending permissiveness) sets, and holds, appropriate boundaries within which they can experience their emotions; of necessity because 'it is more fundamental for a place to feel safe than for anything to be allowed' (Haigh, 1999). Only once these two elements are in place can residents confidently commit to clear, open, and honest <i>communication</i> (communalism) between and amongst staff and residents, and with the external world (Haigh, 1999). Greater <i>involvement</i> with, participation in, and responsibility for the community (reality confrontation) can then occur, so that residents become not only mindful of each other's needs and problems and how to negotiate their place within the community, but of the ultimate interdependence of all members of society (Haigh, 1999). Finally, 'a deep recognition of the power of each individual' (Haigh, 1999) (extending democracy) promotes residents' sense of agency, empowerment and self-efficacy. <p> <i>(Continues...)</i> <p> <!-- copyright notice --> <br></pre> <blockquote><hr noshade size='1'><font size='-2'> Excerpted from <b>Grendon and the Emergence of Forensic Therapeutic Communities</b> Copyright © 2009 by John Wiley & Sons, Ltd. Excerpted by permission.<br> All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.<br>Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.