THERAPEUTIC COMMUNITY:THE organisation of care in a therapeutic community is concerned with recognising the value of a normal domestic environment within

which people with disturbance in mood or behaviour may develop trusting relationship with care workers out of which healthy mental functioning may develop. The therapeutic community can be distinguished in variety of ways. First, the primary therapist and the teacher itself,

BACKGROUND:Two persons, namely T. Main in Bermingham and Max Well Jones of UK during 2nd world war worked simultaneously on this concept with out the knowledge of each other.

CONCEPT:According to Kraft, the therapeutic community is a very special type of milieu therapy in which the total structure of the treatment unit is involved as a part of the helping process. All social and interpersonal interactions in the hospital are the main therapeutic tools used to bring about specific changes in the patient whereas in milieu therapy,, the emphasis is on manipulation of the environment to bring about changes in the patients behaviour. DEFINITION:THERAPEUTIC COMMUNITY IS ONE OF THE PSYCHIATRIC NURSING APPROACHES WHEREIN, THE PATIENTS SOCIAL ENVIRONMENT WOULD BE USED TO PROVIDE A THERAPEUTIC EXPERIENCE FOR HIM BY INVOLVING HIM AS AN ACTIVE PARTICIPANT IN HIS OWN CARE AND THE DAILY PROBLEMS OF HIS COMMUNITY. TYPES OF THERAPEUTIC COMMUNITY:1. GENUINE THERAPEUTIC COMMUNITY OF DEMOCRATIC / ANALYTIC:In these TC, all the material and human resources in the hospital are actively engaged in a therapeutic programme. Usually in residential buildings, the residents collaborate with the staff in a day to day decision making and running of the organisation. 2. THERAPEUTIC MILIEU OF INSTITUTIONAL:These are wards or small units, where, patients and staff have less control over the domestic and administrative decision making of the organisation. 3. SOCIAL THERAPY OR CONCEPT BASED THERAPY:-

Social relations and social environments are the focus of the care. Setting range from voluntarily run hostels. The residents have less control over the values, which permeate the organisation than the previous two. CHARACTERISTICS OF A THERAPEUTIC COMMUNITY:The overall goal of the mental health team is to maintain and create a therapeutic milieu characterised by the following elements:1. 2. 3. 4. 5. 6. 7. 8. Individualised treatment plans Self governance Progressive levels of responsibility Variety of meaningful activities Links with the clients family and significant others Links with the community Effective interaction among mental health team members Humanistic mental health team members

Individualised treatment plans

A therapeutic milieu is tailored to the clients individualised needs as much as possible without infringing on the needs and rights of the other clients and mental health team members. Nevertheless, to provide organisation and predictability within the environment, a definite structure, overall guidelines, and social controls are set forth. Self governance

To assist clients to develop self responsibility and appropriate interdependence with peers, a therapeutic milieu must provide some formal mechanism whereby clients participate in decision making regarding milieu issues. Such a mechanism might include structured community meetings and client team committee meetings held at regularly scheduled intervals. Involving clients in milieu issues enables them to exert a positive therapeutic influence on the environment and on each other. Progressive levels of responsibility

In a therapeutic milieu, clients are expected to assume a responsible role in maintaining the environment. A clients degree of responsibility should be commensurate with his or her capabilities at any point during the treatment process. Matching expected responsibilities with capabilities promotes feeling of self-responsibility in the client. Various approaches can assist a client in becoming self-responsible. One approach is to use a level system designating what the client must do to earn a specific set of privileges. This approach is a form of behaviour modification in that it rewards and reinforces responsible behaviour. Assigning a level to the client is primarily the responsibility of the mental health team; however, comments from clients during community meetings about their peers readiness for a level change are taken into

consideration when making level assignments. Using a level system based on behaviour modification is most appropriate with adolescents and much less so with adults. Variety of meaningful activities

To encourage proactive social behaviour and adaptive coping skills, a therapeutic milieu should provide each client with an individualised activity schedule. Such activities may include structured exercise classes, jogging, weight lifting, interpersonal skills training, (assertiveness training, listening and communication skills), leisure skill classes, and work and occupational therapies. Links with the clients family and significant others

Links with the community Effective interaction among mental health team members Humanistic mental health team members THE THERAPEUTIC COMMUNITY ATTEMPTS TO :-

RESPECT THE INDIVIDUAL CLIENT AS A CITIZEN HAVING CAPACITY FOR AUTONOMOUS ACTION SHARE DECISION MAKING WITH RESIDENTS ABOUT DAY TO DAY LIFE OF THE COMMUNITY USE THE MECHANISM OF MEETINGS AND GROUPS TO DEVELOP OPENNESS OF THE COMMUNICATION ABOUT PROBLEMS, FEELINGS AND CONFLICTS. STRESS AN ORDINARY DOMESTIC ENVIRONMENT, IN WHICH, CLIENTS CAN ENJOY IN MEANINGFUL, PURPOSEFUL ACTIVITY.

PRINCIPLES OF TC:1. RESPONSIBILITY FOR TREATMENT BELONGS TO THE STAFF AND CLIENT 2. ROLES OF STAFF AND CLIENTS ARE EQUALISED MAY DISCUSS EITHER STAFF BEHAVIOUR OR CLIENTS BEHAVIOUR. 3. DEMOCRATIC ENVIRONMENT IS FOSTERED 4. OPEN COMMUNICATION IS ENCOURAGED 5. FOCUS IS ON CLIENT ASSETS 6. PEER PRESSURE IS UTILISED TO REINFORCE RULES AND REGULATIONS 7. INTERPERSONAL INTERACTIONS ARE UTILISED TO IMPROVE COMMUNICATION SKILLS 8. INAPPROPRIATE BEHAVIOUR ARE DEALT WITH AS THEY OCCUR 9. GROUP DISCUSSION AND TEMPORARY SECLUSION ARE FAVOURED APPROACHES FOR ACTING OUT BEHAVIOUR 10. TEAM APPROACH IS USED 11. CLIENTS ARE TREATED AS PART OF TEAM AND SHARE IN THE RESPONSIBILITY AND PROCESS OF MAKING DECISIONS. 12. CLIENTS ARE INVOLVED IN ALL PHASES OF TREATMENT 13. COMMUNITY GOVERNMENT IS SET UP USE MEETINGS TO TEACH STANDARDS, VALUES AND BEHAVIOUR, EXPLORE BEHAVIOUR, MAKE DECISION, USE PROBLEM SOLVING 14. TWO MAIN GOALS FOR CLIENTS LEARN TO SET LIMITS, LEARN PSYCHOSOCIAL SKILLS

Limit setting:Behaviours that requires setting limits: Destructive:- suicide, homicide, harm to person or property Disorganisation:- psychotic behaviour- hallucinations, delusions, disoriented, dissociative episodes of post traumatic stress disorders Deviants:- acting out, breaking rules, illegal activities Dysphoric:- depressed, withdrawn, elated, phobic, obsessive-compulsive Dependent:- avoids responsibility for thoughts and behaviours Psycho social skill development: Leadership:- client government Self assertion:- expressing feelings and attitudes is encouraged, focus is on taking it out. Occupational activities:- basic skills for managing life, activities of daily living, vocational counsellimg, training Recreational activities:- leisure activities, co-operation with others, conversation within social context Independence:- focus on decision making, problem solving, self care Nursing and therapeutic communities:TC emphasizes the importance of nurses developing a relationship with the patient, and through the understanding of this relationship, the patient would gain insight and confidence in his or her capacity to function. Limit setting, social interaction, and maintenance of community structure are the primary role. Personal attributes required by nurses in a TC: SENSITIVE OBSERVATION OF PATIENTS AND SOCIAL RELATIONSHIPS IN ORDER TO FORM CARE PLAN INDIVIDUALISED CARE PLANNING, USING IMAGINATIVE WAYS OF ENHANCING PATIENTS CO-OPERATION AND IMPLEMENTATION ARTICULATE AND CLEAR REPORT WRITING AND STRUCTURING OF CASE NOTES CLARITY OF ORAL REPORTING LISTENING AND COUNSELLING GROUP TECHNIQUES AS LEADER, CO-WORKER AND PARTICIPANTS MANAGERIAL, ADMINISTRATIVE, AND EDUCATIONAL SKILLS APPROPRIATE TO OWN POSITION AND ROLE IN THE COMMUNITY PATIENTS FOR WHOM TC IS USEFUL: SCHIZOPHRENIA SUBSTANCE ABUSE DISORDER ANTISOCIAL DISORDER CHILDREN'S CARE TAKING ENVIRONMENT

The TC approach

TCs are stratified communities composed of peer groups that holds membership in wider aggregate and that are led by individual staff. The preparation of the community itself is the task of the residents, working under staff supervision, work assignments, called job functions, are arranged in hierarchy, according to seniority, individual progress and productivity. The new client enters the setting of upward mobility. Job assignments begins with the most menial tasks and lead vertically to levels of co-ordination and management. Clients come in as patients and leaves as staff. The fundamental aspects of rehabilitative approaches are :Mutual self help( residents conducts self care activities) Work as education and therapy peers as role model staff as rational authorities The induction (60days):- assimilate the individual into the community through full participation and involvement in all of its activities and observation to identify special problems in their adaptation to the TC Primary treatment (2-12 months):- socialization, personal growth, and psychological awareness are followed through all the activities Re- entry (13-24 months) :- client strengthens skills for autonomous decision making and the capacity for self-management with less reliance on rational authorities of a well informed peer network. SALIENT FEATURES OF THERAPEUTIC COMMUNITY ARE:i. ii. iii. iv. v. vi. vii. viii. ix. x. xi. Free communication both within and between staff and patient group Communications are directed towards the modification of patients attitude, behaviour and role performance Atmosphere in the community will be democratic as opposed to hierarchical, rehabilitative rather than custodial, permissive instead of limited and controlled Nurses will be more communal with the patient instead of displaying all the time therapeutic role Environment will be essentially permissive and flexible Patients activities are individualised and the role of patients are unspecified and their participation is completely voluntary Group responsibility is emphasized and oppurtunities for corrective learning experience are deliberatively provided A compulsory daily community meeting that all staff members have to attend and all patients are encouraged to attend The primary role of staff is to help the patients gain new insights and test new behavioural pattern Problems of the patients are discussed and the solutions are sought in the small group therapy sessions following each community meeting Patient government or ward council is to deal with practical unit details such as privilages and house keeping rosters. Staff member is available to the patient government, and all decisions are fed back to the community through the community meetings

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xiv.

Staff meeting or review is essential to on the ward training. It gives oppurtunities for the staff members to examine their own responses, expectations and prejudices Living learning oppurtunities are provided to the patient within the social milieu. Thus the therapeutic community is like a school for living in which the patient learn to meet the demands of everyday life. Feedback is one of the fundamental concepts in therapeutic ccommmunity practice.