Life in Therapeutic Communities: The Clinical Context
The context for this research is two therapeutic communities for individuals with a diagnosis of PD and BPD. In the interest of maximising participant anonymity and confidentiality, the names of both communities are given pseudonyms in this research: ‘Powell’ and ‘Hawthorne’. Powell was a residential independent charitable organisation for women only. As a TC, Powell accepted private and National Health Service (NHS)-funded women from the UK. Hawthorne was an NHS day community for both men and women from within that NHS Trust. Both units were registered and accredited TCs with the Royal College of Psychiatrists (Community of Communities 2016). As such, they had to adhere to specific standards of therapeutic work that specifically acknowledged all social encounters as potentially therapeutic and recognised the role of client1 members in their own and others’ therapy.
At both communities, membership fluctuated between 8 and 12 client members, aged between 21 and 60. Powell had 25 members of staff and Hawthorne had 10 members of staff. In addition to a diagnosis of PD/ BPD, many of the clients had co-morbidity, including diagnoses of eating disorders, psychosis and multiple physical health problems. Several clients between the two TCs had spent various amounts of time on acute units under Section 2 or 3 of the Mental Health Act. The majority of clients had made multiple attempts and engaged in different forms of self-harm. The suicide therapeutic programme of both TCs was for 8-12 months, and as
TCs specifically use the terminology of ‘clients’.
client members described it, coming to the TC meant being ‘committed’ to ‘working with the programme’ for the duration of their therapy.
Daily life in both communities was not easy and the choice of a TC was a difficult option for therapy. Powell Graduate member ‘Lori’ remarked that it was as a ‘huge sacrifice’ to join a 12-month programme. Client members explained they had families, some with partners, dependent children or parents, education and jobs outside of the community. All areas of their life were impacted or interrupted during their therapy. Moreover, the clients considered a TC the most intense form of therapy, and several saw their respective TC as a last chance of having a ‘better’ life:
Mary (Hawthorne interview): I think I came to the TC because it was
fulltime treatment and I felt like an hour or two months apart was never going to get anywhere.
Erica (Powell interview): And I kind of just knew I had to do
something to, so I wasn’t going to end up going into hospital for the rest of my life.
Clients were therefore aware they were choosing a tough form of therapy and, once in the communities, reported that the therapy was ‘exhausting’ and harder than having a full-time job. They described life in the community as filled with continuous analysis where anything could be brought to group for discussion and where they had to manage very intense and variable emotions. In addition, the topic of change in the communities was a frequent item of discussion. Clients often feared they were not changing enough or in the areas they had set out to address upon arrival. Despite their fear at their own lack of change, clients regularly highlighted to one another how they were changing and how different they were from when they first arrived. Change, and talk of change, was always a presence within the communities. Their comments, and clients’ own reflections on personal change, often included increased confidence, decreased anxiety, more accepting of themselves and increased feelings of hope. Personal change is therefore subjective and closely linked to emo?tions. Moreover, talk of personal change and practicing changed behaviours occurred in everyday social encounters within the TCs, such as over meal times and during grocery shopping. Understanding the mechanisms of these moments is therefore imperative to understanding how clients experienced therapeutic transformations.