CYC-Online 128 OCTOBER 2009
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The therapeutic community at work

Alwyn W. Bloomfield

There can be many approaches to the problems raised by the delinquent personality, but a positive and successful solution can only result from a sympathetic relationship between individuals. In this article Mr. Bloomfield describes a vital therapeutic community in a hospital environment and shows how individuals and groups react together, their reaction often eliciting favourable responses for future rehabilitation into the wider community.

Delinquency, as we all know, is a growing problem and more and more children coming into care already have several convictions and court appearances behind them. They will probably have many more in front if nothing is done to adjust them to the demands of society.

The methods one may use in treating the young offender are many, and vary from strictly disciplined establishments to experimental self-governing communities. Within these two extremes there can be found as many methods of approach to the problem as the number of units that exist. This is because, in the last resort, treatment is and must be a personal thing, tailored to the individual by another individual. No matter what the lesson is to be learned, or the problem to be solved, a human agent is responsible for either the awakening of knowledge from within (which is the aim of a self-governing or psychotherapeutic group-oriented community) or the inculcation of certain attitudes of behaviour from without (which is the approach of the stricter disciplined institutions).

In this article I shall describe a unit run within the Hospital Service which was set up to deal with behaviour problems of boys of from 10 to 18 years in a self-governing environment with regular sessions of group therapy. The aim of this group therapy was to enable the young delinquent patient to come to terms with his own problems and increase his ability to deal with these, thus forming a basis for a more adaptable attitude to the demands of society. The Unit was under the direction of Dr. M. J. Craft, 1 and the work of the unit formed the basis for a research project for the Home Office. A description has already been published of this experiment and a follow-up is due to be published shortly.2,3 I worked under Dr. Craft within the general set-up of the
unit and hope that this description will prove interesting to residential child care workers.

My thanks are due to Dr. Craft for the opportunity to work with him in this project and for his help, encouragement, and permission to describe the project and use his material.

The therapeutic community
The basic element throughout the stay of an individual in the community unit was the group discussion held twice weekly, in which not only were routine matters of unit activities discussed but also the personal behaviour of the members if they had caused some disturbance or broken the rules. The group as a whole gave sanctions to its members for bad behaviour although no actual court of peers was set up.

Many of you may well have read of Homer Lane and the “Little Commonwealth–4 or David Wills and “Bodenham Manor–5 and I feel that it is true to say that within the framework of the hospital organization some attempt was made to come as near as possible to a situation in which the unit members felt they had some direct control over their environment. An incident which describes this attempt rather well is when a very reserved hospital chef was asked to attend a group meeting to discuss possible variations in the menu!

The principle here in the day-to-day running of the unit was that an involvement in these routine matters or organizing, would make for a more natural understanding and acceptance of society’s standards. The drawing up of rules for the unit sub-committees formed for the organizing of activities, were all useful in helping the boys to a fuller understanding of how society’s laws had evolved for their protection, rather than just some faceless lawmakers being difficult.

Apart from this twice weekly meeting which everyone, including all the staff, attended, other counselling groups were held for boys with special problems, such as the petty pilferers and the sexual offenders.

In these sessions, led by Dr. Craft and only attended by the members of the group, an attempt was made to bring the individual to a knowledge of where his own problems lay and to a rehabilitation of his social attitudes along more conventional lines.

One other agent was used to help attain our goal with these boys and this was a “points system”. This was found to be quite effective in helping to improve attitudes and work output. Pocket money was paid daily against the points system on two scales, one for work and one for attitudes. The points gained were added up by the senior nurse on duty and then paid out and charted on a board. The boys also kept a chart of what they felt they were due and thus they were able to compare their own estimation against that of the staff. Teachers and instructors phoned through to the ward the marks gained by boys working with them.

The staff were able in this way to influence behaviour by loss of points, but other possible sanctions had to be discussed at group meetings.

The treatment centre
I shall now try and give a picture of the position of the unit in the Hospital and its day-to-day running.

The ward set aside for the unit contained 36 beds divided into two small dormitories of six beds and one of twenty-four beds. There were also two single rooms which could be used either for isolation during difficult episodes or as an incentive to boys holding the highest points for a certain period.

The downstairs rooms included a meal room, two sitting rooms, one intended as a quiet room and one for television viewing. The office was next to a small kitchen, although all the meals came over from the main kitchens.

The staffing was on a two-shift system with the nights being covered by the normal hospital duty rota, although it was usually possible to maintain some kind of continuity. The day staff consisted of a Charge Nurse, a Staff Nurse, two student nurses and a female domestic on each shift.

When a boy was admitted to the unit he was introduced to the group whenever practical and stayed on the ward for the first week or so. Later came the opportunity to work within the hospital and later still to take a job in the town, returning to the Hospital in the evening.

The work within the Hospital was quite varied. A school teacher was employed to continue school where required. The occupational workshops as well as catering for the needs of a high percentage of subnormal patients were able to offer work in a carpentry shop and, under a building foreman, boys on the building group made strides in converting an old army hut into a good games room suitable for five a-side football and barbecues. The maintenance staff also helped by having one of the boys act as an assistant. Places were always available in the kitchens, still room, dining room and laundry. The supervisor of the occupational therapy attended group meetings and acted as a counsellor to many of the boys, being able to gain confidences, being not so closely related to the system as the nurses on the ward. The Occupational Therapy Department also provided a useful base from which to organize such spare-time activities as stage shows and a regular dancing lesson and hobbies club. On the ward, of course, there was available the usual table tennis, darts and billiards. Camping and “outward bound” activities also played a role in the treatment programme.

The therapeutic chain of reaction and response
But to return now to a fuller description of the group discussions. The aim of the group discussions or group therapy, as I have already said, is to help a patient recognize some truth about themselves as individuals in relation to society. This is achieved in the discussion, by the group leader who was usually the Doctor in charge of the unit.

It may not be any actual explanation or interpretation by the Doctor that achieved this result. The therapeutic action can stem from any member of the group or even an incident within the meeting. It is this very action and inter-action of group forces that acts as the therapeutic agent.

The effect of what is said can be seen to produce a reaction and the witness of this reaction can trigger off responses which in their turn produce more responses. The leader of the group watching these responses can lead the discussion to the best advantage of one or more members of the group. Sometimes certain points were continued in smaller groups at the conclusion of the main meeting. It is often quite amazing how much insight is shown by members of the group about each other’s difficulties and outbursts.

The awakening of self knowledge and the tensions it provoked were helped by individual counselling, often carried out through the medium of the spare time activities and in the office of the Occupational Therapist where boys often went to blow off steam in a neutral atmosphere; within any community attempting to rehabilitate its members such safety valves are needed, and the knowledge gained from such sources can be very enlightening about the progress being made.

You are probably thinking that this is all very well but theory does not always work out in practice, but here in the hospital setting a definite attempt was made to weld the two together, at every turn theory had to relate to the practical problem in hand. Theory alone would not have helped these young men to understand their problems. Helping them to understand their immediate motivations and also helping to get a tent up in half a gale after a long hike all worked together in achieving some measure of success in the work of the unit.

I do not feel this article would be complete without suggesting that in any residential establishment group discussions could be used to advantage in helping behaviour problems to recognize where they fail in relating to society’s demands. The only experiment that I know of where group counselling was attempted in a family-group Home took place about three years ago. In practice, however, individual psychotherapy took the place of group work. Although circumstances beyond the control of the organizers were responsible for the early closing of the experiment, there were clear indications that counselling of this nature in this setting was not only possible, but could and did have the desired therapeutic effect.

1. Dr. M. J. Craft, Medical Superintendent of Oakwood Park Hospital, Conway, N. Wales.
2. Michael Craft. (1965). Ten Studies into Psychopathic Personality. Bristol, John Wright.
3. Michael Craft. (Editor) (1966). Psychopathic Disorder. Oxford, Pergamon Press.
4. E. T. Bazeley. (1928). Homer Lane and the Little Commonwealth. George Allen & Unwin.
5. David Wills. (1960). Throw away thy rod. Gollancz.

This feature: Bloomfield, A.W. (1966). The therapeutic community at work. The Anti-social Child in Care: Annual Review of the Residential Child Care Association, 14. pp. 79-82.

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