Advances in therapeutic communities. Reflections on British and Italian experiences

9th May 2015, Anna Freud Centre, London

Abstract for morning session: Barone & Bruschetta

The therapeutic community in the local community: the limits, resources of

partnership and democracy

Raffaele Barone*, Simone Bruschetta**

Prof. Psychiatrist* and PsychologistPhD**

University of Palermo and Messina* and University of Catania**, Sicil y.

Associazione Laboratorio di Gruppoanalisi di Catania - Italy.

Associazione Italiana Residenze/Risorse per la Salute Mentale – AIRSaM, Italy.

Confederazione delle Organizzazioni Italiane per la Ricerca Analitica sui Gruppi – COIRAG, Italy.

Associazione per la Ricerca sulle Comunità Terapeutiche e le Residenze Italiane – Mito & Realtà, Italy.

Advisory Panel, International Network of Democratic Therapeutic Communities – INDTC, London, UK.

Abstract

Since the pioneering work of Basaglia in the ‘60s, TC programmes, aimed to a residential care for people

with severe mental illness (SMI), were considered hallmarks of good practice in the Italian Psychiatry. In

Italy, with Basaglia’s Law 180/78, the psychiatric hospitals were closed and mental health services became

territorially organized and community based. Users with SMI are cared for and rehabilitated through

various forms of local care and therapeutic communities. These TCs provide integration with social services

and network of stakeholders, from the phase of “post-acute care”.

Now, only for one or two weeks, patients may be hospitalized in public general hospital wards (an

average of 12 users) to treat phases of “crisis” (onset or relapse). The care is administered in health care

services integrated in the local community social services, and offers support to housing and recovery from

illness. Public services, both medical and social, are regionally administered, and in each regional

government, the majority of economic resources, is directed to the treatment of serious and persistent

mental illness. In 2015 also the judiciary psychiatric hospitals will be definitively closed and communitarian

treatment of these users will be totally in charge of territorial mental health services and of TCs.

Finally in Italy we have an economic crisis which also affects territorial services and so the

organizational structure of the community treatment has been changed, in a different way, territory by

territory. Local services for mental health have organizational policies so much different from each other,

reflecting different local policies for social development. Especially in a time of economic crisis, public

investments in the MHS are considered necessary resources needed by the regional and local governments

to support the most marginalized parts of the population. Every territorial MHS is inserted in a “Local

Community” made up of people who belong to social contexts in which user and staff share a partnership

that is productive, economic, organizational, institutional, civil, cultural and political.

The TCs for users with SMI are characterized by the strong partnership with the local service network

offered by the MHS and by other social organizations, both governmental and no-governmental, the user’s

family and the economic context. So, TCs can be defined as the Communal Living Environment of a median

residential group of users in a wider democratic Local Community. Recovery from SMI becomes a

fundamental social process based on supportive relationships, and that allows indiv iduals to become

interdependent in what we use to define the “Local Community”. One of the risks of TC is: “Does it favour

social inclusion, or not?”

One of the main therapeutic factors of TCs is the creation of partnerships between users, clinicians,

families, mental health services and the other local community stakeholders.

The relationship between the TC and the territory is relevant. The permeabil ity and the

“impermeability” of the local community depends on the social context, on its resources, formal and

informal, public and private, and on the promotional capacity of the empowerment of the users and on the

fight against the stigma. The meaning of the rehabilitative activities in the TC depends on the support to

recovery route, on the autonomy development and on the participation to the democratic life in the local

community. In this sense are decisive the promotional capacities of the local social and working inclusion

projects, as for example:

- IPS-SE (Individual Placement and Support – Supported Employment)

- Social farms

- Social firms “Type B”

- Vocational Training

- Job Bursary

- Microcredit Programmes

In general, a national framework of different types of TCs for SMI, identifies the different levels of

intensity of health treatment and social support that takes form in these four models.

1. TCs with intensive (18 months) and extensive (24 months) temporal health treatment for maximum

20 users. These communities also accept users coming from judiciary psychiatric hospitals, which are

closing, or sent by the judge as controlled freedom users. In each TC there are about 20-30-40% of these

users. The main part of TCs are managed by private enterprises.

2. TCs with low intensity of health treatment and high social treatment for maximum 10 users. These

communities also can become “Housing Community” for those users who have a long term disease and

require a high level of social protection. These are funded by the local government for the social treatment

and receive health care services by the staff of the public territorial services of mental health. These are

managed by social firms.

3. The “Group Apartments” is another supported Housing programme. The objective target of

programme is the social, work and human inclusion. In this housing programme there are only 4 people.

The operators are there two to four hours a day. It’s self managed as a cooperative apartment.

4. “Enabling Environments”. Social farms and green care are beginning to spread in rural territories.

This is a new experience and combines the work inclusion and the development of the agriculture

cooperatives. It supports the domestic life through the building of a social net of social relationships. This

programme finishes when the patient decides to live in a flat in total autonomy.

If the context is rich in democracy and in opportunities or participation the growth is obviously better.

The Mental Health Services can’t and hasn’t to represent an “isolated” circle of the public Health System

and in general of the society, but it has to be adapted to a social context in continuous change. The context

analysis and the psychosocial rehabilitative intervention is important but it’s not enough to face the

difficulties that you meet in the care, in comparison and in the relationship with people with severe mental

illness.

For this reason the mental health care passes always more through the development of relationship

capacities and individual interior resources, promoting the improvement of his mental functioning in

relation to both social belonging and participation contexts and to the interiorized and interpersonal

relationships which pass through him forming his “internal groups”(Napolitani, 1987).

So we think that therapeutic devices, which are community based are also supporting economic-social-

psychological devices, worked out by the clinical group-analytical practice, to intervene on the territory

level in which they are articulated with some fundamental groupal belonging of the individuals. In Italy the

TC experiences have developed the culture and the praxis of the psychotherapy of the severe psychosis and

of the severe psychopathological symptoms. Our challenge is to pass through these experiences o f social

and democratic psychoanalysis of the therapeutic work in the territory and in the local community. We

have defined this idea “psychotherapy community focused”.

A new care context for severe psychiatric patients are the Multi -Familiar Psychoanalysis Groups. These

are groups in which meet, in a dynamic matrix founded on the exchange, on the mirroring and on the

resonance, couples or families with users and operators (Foulkes, 1975; Garcia Badaracco, 2000). These

groups are usually intermediate dimensions, and are articulated along the themes of the typical family

conflicts. The Multi Familiar Group-Psychoanalysis helps the patients and the families either in the

discharge phase from the TC or in the prevention of the use of Housing Community. This sort of group has a

psychotherapeutic care function for the members of a family and the patients and it is very effective as

formative function for the operators.

In the Italian TC and in the public Mental Health Services oriented to the Community Mental Health

practice they begin to spread the Multi Familiar Group-Psychoanalysis. This experience, besides to be an

effective care of the severe psychosis, encourages the protagonism and the associationism of the members

of the family and of the users.

One of the critical points of the therapeutic practice in Italy, either in the TCs or in the public Mental

Health Services is the difficulty to be able to conjugate and to integrate in the care the community based

psychotherapy and the social promotion as rehabilitative practice. The TCs are permeated by this problem

either inside or outside them.

The challenge is how the TCs, in its various articulations and models, can help users to support their

autonomy and their right to citizenship and in the same time promoting the democratization of local

development.

Forword

The TCs problems in Italy have been strongly influenced by the closure of the Psychiatric Hospitals through

the strong influence of the law 180. New problems come out with the definitive closure of the Judiciary

Psychiatric Hospitals. The opening of the Protection Territorial Services of the mental health, has put at the

core of the intervention the local community.

Who has worked to affirm the practice of the TC in Italy has always argued with a lot of existing technical

and political contraddictions. 1) The not always coherent allocation of the economical and human resources

oriented to the real needs of the patients with SMI. The difficult relationship between the community and

the territory. 2) The permeability/impermeability of the social environment and the relationship with the

life projects of people discharged by the residential communities, among rehabilitation, empowerment and

recovery towards the autonomy. 3) The complex involvement of TCs in the development of the local

community and of the patient’s family context. 4) The users and operators’ democratic and participant

practise inside the TC, in the local community and in the decision sites of the mental health programme s.

The first reflection we do is starting from Franco Basaglia’s thought that with regard to the TC wrote:

“The subversive action of the TC which would unmask the castle of scientific prejudices on which the

traditional psychiatry is based, loses all its meaning in the moment in which it is absorbed as model of a

new institutional reality, inside the same structure. In this way, the new contraddictions which come out

could only be covered and strangled through the communitary ideology which explains, disso lves and

resolves them. The essential is what comes after the recovery: which is a technically unsolvable problem

because it is essentially a political and social question. Unless, in our position of technicians, we continue to

accept the political use generally done of science, going on to sanction scientifically the diversity of the

expelled and confirming the necessity of their exclusion, only to defend ourselves.

If you want to act inside these institutions, you couldn’t consider the double level on whi ch the problems move. The care of a mentally ill always presents two faces: the fight against the disease as a specific fact; and the fight against the disease as a social fact, that is, that the role of the sick person, in the society, comes up ambiguously confused with the weak one to put offside, to exclude, to cut out of the social life … But if the action on the sick person as a specific fact is a technical question, the action on its social aspect can only be political, if it’s true that the technician – even if he can affect on the creation of a new culture which considers the mental ill recoverable –he can’t create for him (we add “with him”) neither a satisfying social role, nor a human liveable reality. The technicians’ task inside this system is using the technical proposals as means to stress the contraddictions in which you live. Without this unmasking, which has an essentially political meaning, every technical solution is reduced to act as a cover of problems, which have nothing to do with the disease and with the science” ( Basaglia 1968).

The second consideration concerns the difficult social and economic crisis which we are living in Italy . Today

it’s more complicated represent the current scenery, our mental health’s operator world, because of a

crisis arrived suddenly, which even announced, we hoped could be of less entity and easier to overcome .

We are actually living an extraordinary phase of uncertainty where almost all seems to be called into

question, which tells about a welfare in progressive retreat or worse of decay, which produces new and

growing exclusion from the workmarket and an increasing discomfort of the “social coexistence”.

The increase of mental health departments, on which they discuss for a long time, is worsen by cuts of

resources and not correct reorganizations to answer to the new complex questions of mental health, while

the social cooperation seems to have finished that innovative motivation which has accompanied its strong

growth in these years and that today is further affected by the economic and financial difficulties of the

public authority. On the other side we assist to the emerging of mental health users’ ripener protagonism

who claim the will to count in the defnition of thei r life project and to be released from the traditional

control power of psychiatry. In this crisis phase, in many realities in which we operate, we are starting a

series of innovations full of new positive perspectives for our users: health budget for an independent life,

group apartments, social farms, protagonism of users and families’ associations.

Therapeutic Communities as enabling environment

Let’s define “therapeutic community”, the life and work context which create “enabling environment”,

inhabited by persons’ groups (patients, operators, relatives, managers, costumers) which share the

ownership and the responsibility of the Personalized Therapeutic Planning for each user, starting from his

health needs and from the economic budget that the “local community” addresses to them.

These “enabling environments” work like “Communitary therapeuthic devices” when the following six

therapeuthic community-focused factors” (Barone,Bruschetta &Bellia, 2010) are present:

1. a theoretical understanding and shared language among clinicians, other staff, users, relatives and purchasers;

2. a practical organization of the clinical work that gives space to understand the collective narrative of the clinical-social history of the patient, and to the reflection on the relationships among all the involved subjects;

3. an authorized methodology to allow the democratic sharing of decisional power (about specific projects and daily activities) as part of the treatment;

4. to be based on inter-cultural, multi-institutional and multi-modal therapeutic plans, customized for each user, in the position to contemporarily affect the family nucleus and the user’s community context;

5. the clinical intention to build a ‘community mental field’ that works as a ‘group field’, to act in a therapeutic sense rather than to cause iatrogenic harm;

6. a treatment programme based on the psychodynamics of the transference between mental fields and of the mentalization of interior states, and a political programme based on the construction of places of personal recovery and social experimentation: both programmes led by an authentic culture of enquiry.

The psycotherapeutic practice which supports the work in these devices today has taken the name of

“Community-Focused Psychotherapy” (Barone, Bellia & Bruschetta, 2009; 2010) and is a clinical practice,

methodologically, philosophically and historically based on the device of the “groupanalythical

psychodynamic group” (Foulkes, 1975), intended to the care of the SMI in the contemporary urban

communities.

The TC for the SMI is first of all an “enabling environment”which interconnects the functions of the ps ychic care and the support to the living for users, also carrying out a fundamental inclusion function of the same user in the social community. Through the participation to the TC life the users partecipate better to the life in the social community, supporting so the processes of democratic political living together (Barone,

Bruschetta, Frasca, 2014).

The idea of the Analythic Group Psychotherapy applied in the Social Community and that of Health Residence for the Mental Health understood as Resources for the Local Community , meet in a Democratic Therapeuthic Community model, which starts therapeuthic, evolutionary and transforming processes for all that group of people, “interest bearers” in the users’ Personalized Therapeuthic Projects, which we define

“Local Community” (Barone, Bruschetta & Giunta, 2010).

In the TC for the SMI it is fundamental that the whole life and the work which occur through the groups, which animate it, permits the passing of time in spaces, either physical than mental in which the patient

can creatively recognise next to him, inside and around himself the presence of the Other.

With the term Other we mean not only the symbolic alterity or the unconscious structure (Lacan, 1986), but

also the real persons who share the presence in the enabling environments, and which can be distinguished

depending on the position they occupy regarding to the therapeutic function, in four typologies (each of

them with its own truth):

1. the community users;

2. operators in a wide sense (staff, equipe, voluntary workers, trainees, etc.);

3. the community strangers, but who can be: “relatives” and members of social groups belonging to the

patient, who are interested in the therapeutic project;

4. “citizens” who go through the communitary places, met casually in and outside from the domestic

places.

The Communitary Milieu so becomes a place in which:

The four functions of coexistence in the therapeutic community could mirror to each other for a better

comparison with the reality of the social life;

The absolute distinction between professional activity and private life is diminished because of the

sharing of the vital spaces;

It is possible to recover the physicality and the body of the Other, even before its social and/or

professional role;

The emotional experience of meeting the Other can also be conceived thanks to a representation on a

groupal transferal scene;

Acting replaces saying and the first communication vehicle in the daily taking care become the

“speaking acts” (Racamier, 1992).

In this perspective the Therapeutic Community starts a “therapeuticcommunalenvironment” only if in the

meanwhile it supports a “localdemocraticpolitic”; and that is if it respects the following “short checklist of

democratic process standards”:

1. Does the TC support users’ participation and personal responsibility?

2. Does the TC promote users’ Empowerment and Recovery?

3. Is the TC open to users’ and their relatives’ evaluation?

4. Is the TC sharing the development dynamics of the local community?

5. Is the TC a social-working inclusion tool?

6. Does the TC promote and bear witness of people’s human rights?

7. Is the TC also an anthropological and groupanalitical reading system of the society?

8. Does the TC support and promote the empiric free and laic research?

TC as Group Psychotherapy

Inside the communitary analytical therapeutic setting it is possible starting the following groups, of

different shapes and various therapeutic and analytical values, each of them with its own specific setting

and each of them with a specific social net from which it emerges in figure (Bruschetta, Barone, Frasca,

2014).

1. GROUP THERAPEUTIC TREATMENTS

Activity groups

Organizational and management groups Relational-expressive workshop groups

2. LITTLE PSYCHOTHERAPEUTIC GROUPS

Little psiychodynamic groups o with expressive finality o with analythic finality

Big psychodynamic groups o with intramural communitary finality o with multifamiliar communitary finality

3. OPERATIVE AND VITAL GROUPS

Operative groups o oriented to the Personalized Therapeutic Planning o oriented to the coordination of specific services

vital groups of family therapy

little groups of family therapy

social-working inclusion groups 4. SUPERIVISION/COVISION GROUPS

Clinical supervision/covision groups

Supervision groups and institutional analysis

Covision groups centred on the vital groups

In fact we consider each therapeutic or working group in the TC, a technical figure which emerges from the

background of a specific social net which goes through it, and whose knots represent the members, who

belong to it. The social epidemiology (Berkman, Kawachi, 2000), through the social nets, has demonstrated

for a long time the connexion between the involvement in social -working nets and the maintenance and

recovery of health, also mental, in the professional contexts.

The social nets, like all natural systems, are not static and crystallized in an always equal form to itself, but

passed through, rather composed by psychological-group dynamics, which constantly modify the identity of

the knots and the quality of the relationships. The richness and the fecondity of a net is based on the

interchangeability of the knots and on the insaturability of the bonds..

Technically the nets based on the personal relationships of each individual are made, as the most general

personal social nets, by strong bonds, weak bonds, intermediate bonds (called bonds with explicitly

therapeutic function).

The Primary Social Net is characterized by “the intimacy of the exchange” which happens in it, and is

composed by Strong Bonds, that is on sentimental relationships (positive or negative) and by reciprocity

(immediate or delayed).

The Secondary Social Net is characterized by the “sociality of the Exchange”which happens in it, and is

based on Weak Bonds, that is in Right and Money (Formal Secondary Net), Solidarity and Civil Ethics

(Informal Secondary Net), Right and Solidarity (Net of the Third Sector), Money and Profit (Market Net).

The intermediate Social Net is characterized by an Exchange in the same time intimate but social, and is

based on links in transition from one of their strong position to a weak one and vice versa. It is the net of

the therapeutic relationships par excellence because it represents the ideal meeting point (to which tend in

the communitary work without never reaching it definitively), between the social reference to the

professionalism and the familiar reference to the gratuitousness.

Without gift there isn’t community. The latin etimo of community is actually cum-munus (common gift).

But it’s a gift which obliges who receives it to Exchange , and so to start the social rule of exchange.

The democratic participation supports the development of the sentiment of citizenship, which is based on

the multibelonging experience made through a net of social bonds which is as extended as elastic and

unsaturated; in absence of which it would be the sense of emptiness and of confusion to characterise the

life and work contexts.

Caring the social bonds means to work on the specific connective element for the social nets , represented

by the “social participation” to the cultural, political and economic life contexts , developing that sentiment

of belonging and social identity, called indeed «citizenship».

Therapeutic Community as Social Inclusion

A therapeutic community, which cares the social bonds, works to the social-working inclusion of the users,

starting intervention devices able to permit the participation of the patients to secondary belonging groups,

supporting them in a process of autonomy from attachment, often saturated, to the familiar primary group,

but above all connecting them to the structured mental fields by the Social Institutions which organise the

participation to the secondary belonging groups.

The work groups which support the social working inclusion devices carry out a Collective Auxiliary function

(Hinshelwood, 2004) which permits the users with SMI to:

accessing to a self awareness as active, expert and effective subjects;

evaluating the resources and the limits of self representation and their change possibilities ;

developing new aspects of itself and starting them, integrating them with the old representations,

using the outcomes of these new activations as real capacity indicators;

finally using the improved image of himself as refuge of the pathologic simptomatology and from the

damaging elements of the social stigma, but above all as recovery of the mental illness and from the

suffering that it involves.

The recovery (Davidson, et al. 2009) concerns the construction of a satisfying life and fitted out by sense so

defined by the persons themselves, inspite of the presence or less of symptoms or recurrying problems.

The recovery represents a progressive distancing of the pathology and of the disease towards the health

and the wellness. It answers to the evolutionary need to affirm himself as subject in the position to take

decisions for himself, but it is above all a new social way to intend today the “healing“, developed thanks

to the statements and to the politics continued directly by the mental health users’ movements, often self

identified as “survivors to the psychiatry”.

In this other perspective, exactly specular to the one of the communitary democratic vision, the TC, starts

a “localdemocraticpolitic” only if in the meantime it supports a “therapeuticcommunalenvironment”; and

i.e. if it respects the following “short checklist of the subjective factors of the recovery”:

1. Do users renew every day the hope and the engagement?

2. Are users supported by the other members of the community?

3. Do users redefine themselves through their path of recovery in the community

4. Can users manage symptoms?

5. Do users take control on their lives?

6. Do users fight against the stigma?

7. Do users mature empowerment?

8. Do users find their place in the social community?

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