Rep36 Understanding Personality Disorder

2.1.6 Therapeutic communities
Residential Democratic Therapeutic
Communities (TCs) were first developed
during World War II to manage ‘shell-shocked’
war veterans. They reflected a shift in
psychiatric thinking from an authoritarian style
of doctor-patient interaction to a more
democratic style in which the community is the
therapeutic agent. Rapoport (1960) identified
four key principles underlying therapeutic
community treatment: community living,
democratisation, permissiveness, and reality
confrontation. Clients are centrally involved in
the day to day running of the community,
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including making decisions about most aspects
of its functioning. By working collaboratively
with staff, unhelpful ‘them and us’ attitudes are
reduced. Clients are also crucially involved in
supporting each other’s treatment and in
confronting each other’s self-destructive, anti-
social and inappropriate behaviour. Community
discussion and debate aimed at understanding
the causes of destructive behaviour, including
destructive staff/staff and staff/patient
interactions commonly experienced in
treatment with this client group, is a constant
feature. Group processes affecting the
interpersonal and social functioning of the
community, are of key importance.
The term ‘therapeutic community’ therefore
refers to the culture in which treatment is
delivered, and the principles underlying it,
rather than a specific package of treatment.
Therapeutic communities exist in a wide range
of settings, with different client populations and
using various types of therapy. The model has
also been modified for use in both secure and
non-secure settings as well as day programmes
(Kennard, 1998). For instance, the concept-
based therapeutic community model, used for
substance abusers, is based on a much more
hierarchical structure of community living, with
increased responsibility and privileges being
dependent on the individual’s treatment progress.