clinical innovations in the therapeutic community and community care

CLINICAL INNOVATIONS IN THE THERAPEUTICCOMMUNITY AND COMMUNITY CAREbjp_1201 419..425

Angela Foster

abstract My contribution to the development of theory and practice has taken theform of writing and teaching based on clinical experience, and for this celebration ofthe work of Robert (Bob) Hinshelwood I have selected four examples of innovation– the first two in the boundaried setting of a therapeutic community, the third in atemporary organization representing care in the community and the fourth in acommunity service that requested consultancy following the tragic death of a child.

Key words: therapeutic community, community care, psychodrama, child pro-tection

I have known Bob since 1974 when I joined the staff of the MarlboroughDay Hospital working alongside him in the therapeutic community (TC),and this paper is testament to the fact that Bob and I found ways of workingcreatively together which, I suggest, are rooted in his ability to hold onto afierce belief in psychoanalytic theory and practice while pursuing innovativeapplication of these. The aim is always to enable deeper understanding ofpatients and of the organizational defensive dynamics that hinder clinicalwork.

In clinical settings, whether involving direct contact with the patients orsupervision and consultancy to staff, this is done through reflective explora-tion of the complex web of dynamics woven through unconscious processesof splitting and projection in intrapersonal, interpersonal, group, intergroupand organizational dynamics. Bob (Hinshelwood, 1998) writes that: ‘Thepatient arrives in the service but, more than this, his or her disturbance tooenters the organization’ (p. 17). It is the anxiety-producing and consequentmind-deadening effects of this that make reflective supervision so essentialin order that workers can regain their capacity to think and manage the painand despair inherent in the work. A prerequisite for successful reflectiveexploration therefore is the presence of a container capable of managing theanxiety unleashed, when the mind-deadening defences that are put in placeto avoid this are either dropped or cease to be effective.

angela foster is a social worker and psychoanalytic psychotherapist. She has manyyears’ experience of teaching in higher education and is director of FRC Consultantsproviding organizational consultancy and professional development services to indi-viduals and clinical teams in the public and voluntary sectors. She has known BobHinshelwood since 1974 when they worked together in the Marlborough Day Hos-pital and benefited from his support and encouragement on subsequent projects andpublications. Address for correspondence: [[email protected]]

© The authorBritish Journal of Psychotherapy © 2010 BAP and Blackwell Publishing Ltd, 9600Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. 419

The following four examples aim to illustrate this method of work. (Forfurther illustration and examples, see the contributions of Gordon andKirtchuk, and Skogstad).

Innovations in the Marlborough TC

1. A Psychodrama Exercise

We were aware that the daily large group morning meeting had becomeunusually lifeless while the range of small group activities was increasingbut, before we could understand this, we were subjected to a number ofarson attacks in the Occupational Therapy (OT) Department always on aTuesday at the time all staff were gathered for the Reflective Practice group!In spite of much speculation no-one – staff or patient – could or wouldidentify the culprit. So, assuming that the community’s collective ignorancewas the result of the increasing fragmentation we had noted leading to thesplitting off of knowledge and experience, we decided to bring everyonetogether for a large psychodrama exercise.

We mapped out the geography of the Day Hospital in the large grouproom and everyone, staff and patients, was asked in turn to walk through thisas if they were walking to the OT department with the intention of settingfire to it. At the point of arrival each person was asked to use their imagina-tion and speak of any reason they might have for wanting to do such a thing.After a good while there was a collective realization that each one of us hadsome grievance that might potentially lead us to carry out a destructiveattack on the community; and at this intense emotional point the fire-raiserowned up.

A psychotic young woman was enabled by this exercise to re-integrateinto her consciousness her previously split-off rage and knowledge of heractions. It was the containing nature of the carefully constructed psycho-drama event which enabled us all to take back our projections – recognizingand owning our rage – that made this possible.

We understood from this event that we had unwittingly allowed the com-munity structure to become psychotic, i.e. disconnected, so that, instead ofbeing a therapeutic environment, it had been supporting psychotic processesin the vulnerable patients in our care; and following this we were able torestructure the community to facilitate greater integration and containment.This is something, I believe, that any community treatment setting has to dofrom time to time as there will always be the pull towards deintegration, oreven disintegration, and I am saddened to think of current situations incommunal community care (CC) settings where, once someone responsiblefor destructive acting out is identified, they are summarily discharged.This isto their detriment and that of the organization. The most likely outcome isthat all feel confirmed in their cynicism and despair.

420 BRITISH JOURNAL OF PSYCHOTHERAPY (2010) 26(4)

2. The Student Summer Scheme

This is something Bob and I devised which ran for three years from 1975 to1977. The TC was closed in 1978.

We had become increasingly involved in working with student break-downs and decided to work more closely with colleagues in student healthservices to devise a way of bringing vulnerable students into the Day Hos-pital therapeutic community for the three month period of their summervacation. We noted that breakdowns often occurred in the summer termaround exam time and during the unstructured summer break. We alsoinvolved our community of patients – a group varied in background, educa-tion, age and disturbance who expressed mixed feelings about this proposedshort-term fostering plan.

Over the three years we took in 18 students who joined in all the TCactivities alongside the other patients but had their own three-times-weeklysmall group.The dynamics between the full-time patients and the privileged,special, temporary additions were complex and valuable. As individuals ineach group began to drop the distinctions of identity as either student orpatient, the regular patients could begin to let go of their envy recognizinginstead their potential to be students, and the students were free to own andaddress their patient parts, some recognizing that they needed to take abreak from their studies and spend a longer time in treatment.

It may well be that something like this scheme is needed now. Universities,under pressure to fill all their places in order to secure funding, are taking onpeople who are not able to study at this level and are then very reluctant tolet them go. This combined with the Disability Act, which entitles studentswith histories of mental illness to receive extra support, means that thedemands on the student health services are greatly increased.

Also, contrary to our expectations, when we ran the scheme, nearly aquarter of the students referred to us had already obtained their degrees andwe noted that: ‘The crisis point in their lives was not the summer break, butthe move from college on to other things’ (Foster & Hinshelwood, 1978, p.95; see also Foster, 1976, pp. 22–3). Currently we are even more aware of thisphenomenon because the personal anxieties of young people making thetransition from education to work are exacerbated by the economic situa-tion, and what might have previously been thought of as an individualconcern is rapidly becoming a social problem.

3. Innovation in a Temporary Organization

With the advent of Community Care and the internal market in 1990 Iworked with two colleagues in the Adult Department of the Tavistock Clinicdevising a CC workshop for research and training purposes. Our aim was tocreate a setting which could contain the new anxieties arising from thislegislation – the anxiety of caring for seriously disturbed people in the

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unboundaried community and the anxiety generated by the new businesstasks of managing budgets, marketing resources and securing the financialsurvival of one’s agency. To do this we created a structure using TC methodsof large and small groups, added a communal market place and ‘marketed’this to people working in both statutory and voluntary community services.29 people were recruited – 20 women and nine men.

The workshop took place one morning a week for ten weeks. Eachmeeting began with three small groups – representing newly formed multi-disciplinary teams with the twofold task of working on case material whichwas to be provided by the members (this could include presentations of anydifficulties within particular systems of care), and of developing multi-disciplinary teamwork skills by reflecting together upon policies and prac-tices from the perspectives of the different participants.

This was followed by the ‘market place’ – an informal gathering in adesignated room where refreshments were available – representing the openand fluid space of the community in which we all live and need to survive aswhole people in a variety of roles. It also represented the market of com-munity care in which people are expected to buy and sell their services aswell as make collaborative contracts with each other. Each morning endedwith a large group and here we had an external facilitator to help us with thetask of examining the dynamics in this new system.

Evaluation took the form of a follow-up session and written feedbackfrom members. From this it was clear that the small groups did representmulti-disciplinary teams and were valued by the membership, someparticipants setting up work consultation groups within their own multi-disciplinary teams.The market place gradually acquired layers of meaning asa place which represented the community at large, where personal andprofessional boundaries are crossed, at the same time as simulating thebusiness of a community in which useful contacts can be made and thepotential of a community to provide containment for mental disturbance.There was an increased awareness of the need for each person to own theirpersonal authority and behave less dependently. The carer in the group –who could be thought of as the person living in closest contact with mentalillness – had initially sat alone in the market place, feeling marginalized.Over time, she began to feel much more at ease in this setting and this wasdue to more than simple familiarity.The market place of the community wasbeginning to work, and, as communication of differences between membersincreased, changes took place in the large group. A form of creative inter-course emerged and members began to think that, if they could manage thissort of communication, they could manage community care (Foster, 1994;Foster & Grespi, 1998).

What this and other CC research led us to was an increased awareness ofwhat I termed ‘the difficulty in finding the third position’ – the depressiveposition. I identified three structural ways in which splitting took place


leading to paranoid/schizoid dynamics. The first, a splitting off and denial ofillness – as if no one need be a patient, all are now clients, users or consumersand therefore deemed capable of recovery, the second, the splitting off ofcommunity which occurs when a client remains as isolated and cut off intheir own home as if they were in lonely institutional care, and the third isthe splitting off of professional carers as if relatively unskilled family andsocial care is an adequate replacement for skilled psychological care.

This triangular model – with mental illness, carers and the communitylocated at the corners – provides us with a basic framework for thinkingabout what needs to be kept in mind. Of course we cannot do this all thetime but what matters is that we are intellectually and emotionally ableto identify with each position within this triangular system which offersthe possibility of being engaged in different dyadic relationships, and ofstanding back to observe and reflect on the nature of these and on one’spart in them, within the total system of care. Essentially what workers haveto do is to place disorder clearly within systems of care and keep thecommunity and themselves in touch both with it and with each other(Foster, 1998).

This challenge, embedded in the Duty to Care, and elaborated in my finalchild care example, gives rise to considerable anxiety and some form ofsplitting may well be inevitable, even necessary for self-preservation (we allneed our emotional time out). But here I will identify just two areas in whichproblematic splitting occurs – firstly, as a result of powerful unconsciousprojective identification from clients who wish us to remain ignorant of thatwhich they wish not to acknowledge and, secondly, from the demands of ourorganizations. We have all witnessed the introduction of a whole series ofbureaucratic policies and audit procedures that often give rise to considerablepersecutory anxiety in workers who fear for their futures should they fail tocomply. The demand to eliminate rather than think about the unavoidableand inevitable element of risk in the work diverts time and attention awayfrom the clients and invades any reflective spaces in a team’s week. We haveto find ways of being alive to and emotionally in touch with what the publicand the client wish to remain ignorant of, and the task of the organizationalconsultant is to challenge the splitting where it is deemed to be out of touchwith reality and therefore increasing rather than eliminating the risks toclients, workers, the agency and the general public (Foster, 2001[2002]).

4. Innovation in Consultation: An Inquiry into the Death of a Child

I was contracted to work with a team that had been subject to a formalinquiry following the death of a young child through parental neglect. Whenworkers are called to make individual, confidential statements about theirwork and that of their colleagues, it becomes almost impossible for teams tohave open discussions and learn from past mistakes. Instead there is an

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increase in the range of socially defensive monitoring routines as a way ofcovering the organizational back.

In such circumstances the external consultant’s job is to re-establish thecontainer for reflective work and, when this is successful, people regain theirability to hold onto painful, ambivalent feelings and become better con-nected with themselves and their clients.

The death of a child is always particularly painful and, through providingconsultation, the agency was offering this team some help with managingtheir feelings and an opportunity to learn from their experience. I was askedto make times available, at my place of work, not theirs, for anyone whowished to take up the offer of individual sessions. However, I spoke of theimportance of meeting as a team and included group meetings in myproposal.

Sessions away from the workplace guaranteed confidentiality and thisappeared to provide a strong enough container for individual workers toaddress personal issues in relation to the events that had led to this child’sdeath. However, as the work progressed, I began to feel increasingly over-looked and neglected: my invoices were not paid and I was unsuccessful inmy efforts to contact the organization. One way of thinking about this is tohypothesize that what could be contained and addressed individually, inprivate and away from the workplace, could not be owned or acknowledgedcollectively within the organization.

In a misguided attempt to protect the organizational container, the linkbetween it and the work – taking place elsewhere – was attacked. This couldalso be viewed as a desire to locate the pain of being in touch personallywithin the individual workers whilst protecting the organization from a moreappropriate but feared collective ‘in-touchness’. I felt that, having become arepository for the awful, personal and often sordid details of the case, I wasbeing cut adrift from the organizational lifeline for fear of contamination. Ibelieve that these dynamics mirrored the dynamics between the infant andits parents – all the disgusting and shameful feelings of this very dysfunc-tional and disturbed family were projected into this child who was then shutaway and left to die. Similarly, one can speculate that the agency with theduty of care found excuses to keep their distance from this unpleasant,demanding and disturbing family.

At this point I had to demonstrate that the consultancy could survivethese unconscious attacks and hold the group meetings I had proposed as away of indicating that it was possible to integrate this work back into theteam and into the organization. In other words my unstated but clearlyassigned task was to reassure those involved that there was a way of collec-tively examining the details of the case, learning from the process andsurviving the experience. This was extremely painful yet it succeeded infostering a greater awareness and understanding between team members;and I was eventually paid for my work.


However, shortly afterwards the department was re-organized and theteam dispersed. I would suggest that this, like many other re-organizations,was re-organization as a psychic retreat (Steiner, 1993) – an organizationaldefence against living with persecutory and depressive anxiety – the latterconnected with the pain of the experience and the knowledge of what hadgone wrong. Instead of being clearly cited and sighted within the midst ofthe organization, this awareness was pushed to the back of people’s mindsas they busied themselves adjusting and adapting to their new circum-stances. Recent disasters in childcare leading to scapegoating of individualworkers and organizational restructuring provide further evidence of thesedynamics.

In contrast to this I am encouraged by recent movements to place greateremphasis on reflective supervision and will end now with a quote from Bion(1970) in which his advice is to ‘be aware of those aspects of the materialthat, however familiar they may seem to be, relate to what is unknown’ (p.124). This is achieved by locating a state of mind he calls patience in whichone has to suffer frustration ‘without irritable reaching after fact and reasonuntil a {new} pattern evolves’ (Bion, 1970, p. 124).

References

Bion, W.R. (1970) Attention and Interpretation. London: Tavistock; London: Karnac,1984.

Foster, A. (1976) Helping students through the vac. Community Care, 22 Sept., pp.22–3.

Foster, A. (1994) Managing care in the community: Analysis of a training workshop.Journal of Social Work Practice 8(2): 169–83.

Foster, A. (1998) Psychotic processes and community care: the difficulty in findingthe third position. In: Foster, A. and Roberts, V. (eds), Managing Mental Health inthe Community: Chaos and Containment, pp. 61–70. London, New York, NY:Routledge.

Foster, A. (2001) The duty to care and the need to split. Journal of Social WorkPractice 15(1): 81–90. Reprinted in: Bishop, B., Foster, A., Klein, J. and O’Connell,V. (eds), The Practice of Psychotherapy Series: Book One. Challenges to Practice,pp. 85–101. London, New York, NY: Karnac, 2002.

Foster, A. & Grespi, L. (1998) Learning to keep one’s head: Analysis of a trainingworkshop. In: Foster, A. and Roberts, V. (eds), Managing Mental Health in theCommunity: Chaos and Containment, pp. 188–202. London, New York, NY:Routledge.

Foster, A. & Hinshelwood, R.D. (1978) The Marlborough Experiment: A summervacation scheme for students with personality problems. Students in Need: Essaysin Memory of Nicholas Malleson, pp. 91–7. London, New York, NY: SRHE.

Hinshelwood, R.D. (1998) Creatures of each other: Some historical considerations ofresponsibility and care and some present undercurrents. In: Foster, A. andRoberts, V. (eds), Managing Mental Health in the Community: Chaos and Contain-ment, pp. 15–25. London, New York, NY: Routledge.

Steiner, J. (1993) Psychic Retreats: Pathological Organizations in Psychotic, Neuroticand Borderline Patients. New Library of Psychoanalysis, vol. 19. London:Routledge.

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clinical innovations in the therapeutic community and community care

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