(An epigram by Jean-Baptiste Alphonse Karr in the January 1849 issue of his journal Les Guêpes (“The Wasps”).
2012 is 40 years since I first became involved with research in the mental health field as a graduate social science student visiting Henderson Hospital in Surrey as a potential fieldwork site for a study of ‘therapeutic communities’. It is also 40 years since the association of therapeutic communities (ATC) was set up on the initiative of Dr Stuart Whiteley, Medical Director at Henderson. My research question was whether TCs could be better understood as a scientific invention, applying social science as a medical intervention, or as a social movement for change, seeking to influence the balance of power in the mental health field.
That was a period of flux in mental health research. A social understanding of mental health issues was taken seriously by the powerhouse of research and influence in the field – the Institute of Psychiatry. Professors Wing and Brown were looking at social processes in the mental hospital and in the community, with solid research methods and results. But these studies were focussed on the negative effects of the social environment within which patients found themselves. The TC by contrast was promoting the use of social effects as a positive intervention in the pursuit of therapeutic change: characterised by anthropologist Robert Rapoport as the use of ‘democracy, communalism, reality confrontation and permissiveness’.
Such a culture was at odds with a model of specific medical or psychological interventions, not easily reducible to discrete technical processes. Indeed those who used this approach threatened the conventional distribution of power – patients themselves were conceptualised as part of the potential therapeutic armoury, and the personal qualities of staff, especially younger staff with lesser qualifications, were elevated to at least equal if not greater significance than conventionally trained medical and psychological staff. Not surprisingly this approach has never been well tolerated by the dominant players in the mental health field.
TCs have continued to survive as a minor strategy in those areas where they are not a threat – for personality disorder, a condition which has been shunned by a majority of psychiatrists as untreatable; in prisons, and secure facilities, where they have been tolerated as useful in the support of security (relational security); for group psychotherapy, one of a range of non-medical and ‘fringe’ interventions in the field. They have been branded by commentators from the evidence based medicine position as an ‘evidence free zone’ because they have not been seen to produce the right kind of randomised controlled trials (actually they have, but that is another story about the politicisation of evidence).
It is ironic to observe a new effort to harness a social technology, entering the field 40 years later with very similar reactions. ‘Recovery’ has a set of values very similar to the original therapeutic community, and seeks to develop positive social interventions celebrating the mutual support that patients can give to each other, and downgrading the utility and even the focus of conventional medical and psychological interventions. The reactions in the field have been remarkably familiar – those under threat have objected that this raises the spectre of poorly managed risk, and of patients posing a threat in the community. Others (in the Institute of Psychiatry) are trying to reduce it to a conventional medical or psychological intervention, proposing to run randomised controlled trials of factors such as ‘hope’.
36 years ago I published an early paper that forecast the fate of the TC, using two sociological sub-fields focussed on social movements, and on scientific innovation: as a social movement it would follow a pattern identified by Max Weber 50 years before as the ‘routinisation of charisma’ – the slow loss of revolutionary zeal, and the institutionalisation of technique over social values; as a scientific innovation it would be rejected unless it could assemble impeccable evidence of its effectiveness, and force through a ‘paradigm shift’ in the field. This has proved quite accurate. As a sociologist, I would expect recovery to suffer the same fate as the TC: it will lose its impetus for social change, and become routinised, and/or it will fail to lock down a paradigm shift in the mental heath field. If I live to be a hundred, I shall just have another 36 years to find out.
Professor Nick Manning
Director, Institute of Mental Health
University of Nottingham
NottsHC NHS Trust