Therapeutic Communities: Past, Present, and Future

In an editorial published several years ago, a British psychiatrist, comparing Britain and America, noted that treatment models change much faster in the United States, primarily because Americans strive toward state-of-the-art practices (1). This volume, edited by two psychoanalytic psychiatrists, illustrates the evolution of therapeutic communities in England, where they have been used primarily to treat personality disorders; in the United States, by contrast, they have been used primarily to treat drug abuse.

The book begins by describing England's Northfield experiment, in which soldiers suffering from "psychoneurosis" were treated in group communities between 1942 to 1948. The traumatic costs of World War II gave psychoanalysis the chance to implement a group treatment model designed to reintegrate soldiers into society. Although the experiment's outcomes were never formally measured, it was considered a great success. This is the general theme that reverberates throughout the book.

In the first section, contributors describe the philosophical influence of therapeutic communities on social psychiatry, nursing, and group analysis. The volume continues with sections on therapeutic communities and on "specialist communities," such as prisoners, persons with schizophrenia, and children and adolescents. The chapters that illustrate contributions of therapeutic communities to inpatient treatment will be familiar to many American public-sector practitioners, and the chapters on psychoanalytic models, less so.

One is struck here by the paucity of outcome studies. The chapter on research describes three uncontrolled studies over 50 years, one of which is apparently being used to justify more therapeutic communities to the National Health Service. Cost-effectiveness data are paltry, and outcomes of U.S. therapeutic communities are not sufficiently explicated. Only two meager charts on outcome studies appear. The editors seem to want to believe that therapeutic communities, with lengths of stay of six to 12 months and with dropout rates often exceeding 80 percent, are cost-effective for outpatients. In the United States use of resources in this way has been sharply limited.

Statements of some contributors seem out of step with reality as we know it in the United States. The book decries the use of pharmacology and the trend toward "short-termism." One contributor notes the trend of "resources increasingly concentrated on the chronically mentally ill." The movement toward "community care" is dismissed as controlling and paternalistic. No speculation is offered on whom therapeutic communities should target in today's fiscally conservative climate. Considering the cost and the length of time needed for positive outcomes, use of therapeutic communities in the United States is increasingly being reserved for captive communities, such as prisons.

Perhaps the oddest part of the book is its final chapter. Where one might expect a summary of the book, with speculation on future trends, instead the reader is led through a list of core psychoanalytic principles of therapeutic communities. Although concisely written, the chapter would have been more appropriately placed near the beginning of the volume than at the end.

This book will be useful for persons who want to learn about therapeutic communities in England and, to a lesser extent, how English treatment philosophy and modalities differ from those in the United States. The therapeutic community philosophy has resulted in implementation of humane environments, most notably in inpatient units and in outpatient models such as clubhouses. However, the book describes a treatment model with well-defined structures and elaborate processes, but essentially devoid of outcomes. This "deep in my heart I know it works" approach seems to be dying a slower and more protracted death across the Atlantic.