BACKGROUND: The Acorn Programme is an 8–12-month inpatient and day-patient programme for clients who have severe and complex mental-health problems.
AIM: To explore clients’ experiences of joining a therapeutic community.
METHOD: Semi-structured interviews were carried out with six residents, and the data were analysed.
RESULTS AND DISCUSSION: The main themes were divided into two categories: those referring to the assessment process and those referring to starting as a member of the community. The main themes in the assessment period were: fear and anxiety about being judged; things being different; challenges; and making a positive choice. The initial period after joining elicited experiences of: wanting to leave and choosing to stay; being alone in a group; hope; change; the experience being worth the distress; and feeling abandoned.
CONCLUSION: The process of becoming a member of a therapeutic community is difficult and painful, but necessary for therapy and recovery.
Julia Coakes, PhD, BSc, is clinical psychologist; Matthew Miles, DipN, RNMH, is clinical team leader; Katherine Lawson, BSc, is assistant psychologist; all at The Retreat, York.
This research took place within the Acorn Programme at The Retreat in York – a not-for-profit specialist mental health care provider that works with the NHS to provide care for people with complex and difficult needs. The Acorn Programme is an 8–12-month inpatient and day-patient treatment programme for women with self-defeating behaviour. Residents are aged 18 or over, and up to 16 residents undertake the programme at any time.
This group programme uses an integrative model of treatment using a combination of group and individual work, including dialectical behavioural therapy (DBT) and psychoanalytic therapies. Most residents have been diagnosed with borderline personality disorder or complex post-traumatic stress disorder, although this is not a requirement for admission to the programme. The main criteria are:
Existence of self-defeating behaviour;
A commitment to changing this.
The exclusion criterion is an unwillingness to stop self-defeating behaviour.
All clients are assessed individually and within the therapeutic community group for their suitability to join the programme. The individual assessments are carried out by the consultant clinical psychologist or consultant psychiatrist. The person being assessed then joins the community for lunch and attends a structured, DBT-informed community assessment group. Decisions about acceptance are made by the community as a whole and all views are considered.
When a resident joins the programme there is a two-week assessment period, during which both the resident and community are asked to think about whether this programme is suitable treatment for the individual. The community then makes a decision at the end of two weeks about whether this programme is likely to be helpful for the person concerned. If commitment to the programme is questioned, the resident may be asked to complete a third assessment week. The resident is also asked for their decision on whether or not they want to stay.
Within this process, nursing staff provide telephone support two weeks before admission to help the client remain free of self-harming behaviour. On admission, two client buddies – usually senior residents – are allocated to help with orientation to community rules, procedures and expectations during the two-week assessment.
Qualitative research on residents’ experiences of the assessment process and joining the therapeutic community is limited. The most relevant research, by Blount et al (2002), discussed the importance of preparation in reducing the drop-out rate. The overall perception of the assessment process was negative, as residents were not sufficiently prepared to be in a room of up to 10 people who were ready to interview them. The researchers also discussed the use of preparation for admission, including face-to-face contact to answer questions and to ensure the information sent before attending assessment is sufficient.
Rutter and Tyrer (2003) conducted a study on the value of therapeutic communities as a treatment for personality disorder. They subsequently found the experience of the resident interview panel had not prepared clients for the reality of life in the community, with some describing it as intolerable. It should be taken into account that the overall anxiety of attending for assessment may hinder an accurate recollection of the assessment experience.
Foster (1979) described admission and discharge from the therapeutic community as the most significant transition periods, and explained this sociologically as ‘boundary crossing’ from one social system to another. The process places the individual in a ‘crisis’ situation in attempting to learn new social behaviours within the therapeutic community.
We could understand the ‘crisis’ of joining in the theory of attachment. As Humphreys and Bree (2004) argued, joining could tap into fears based on early experiences of attachment. Many residents enter the programme free of self-harm; therefore, the crisis of working on stopping behaviours is substituted with the crisis of joining and gaining a place in the community. Energy is devoted to forming, or avoiding forming, therapeutic alliances and attachments. Once this crisis is over, previous crisis situations re-emerge and so the containment of living within a therapeutic community takes over.
The response to this experience can often lead residents to end therapy early. Chiesa et al (2000) stated that 44–66% of residents leave therapy early within hospital-based treatments for personality disorder. Blount et al (2002) reported 30–75% of patients were likely to stop treatment early.
Linehan (1993) suggested inadequate commitment to therapy is the main reason for early termination, either by therapists or residents. Therefore, commitment in the early stages is vital in ensuring resident retention. Strategies are used to gain and regain commitment; examples of dialectical strategies include the importance of allowing residents to choose. A fundamental component is choosing to enter a therapeutic community – this mirrors the DBT approach of highlighting the ‘freedom to choose’.
Routine data collected from the Acorn Programme showed 10% of residents who accepted a place left within two weeks, 21% within 12 weeks or less and 69% either completed the programme or stayed for over 12 weeks, which is the minimum recommended stay. Reasons for premature discharge included residents:
Being unwilling to commit to change;
Being unable to give up self-defeating behaviours;
Engaging in high-risk behaviour during the assessment period;
Deciding the treatment was not appropriate for them or that it was not the right time for them to participate.
Although our data shows below-average rates of stopping therapy prematurely, it is still an area which could be improved.
Six participants were selected from current residents of the Acorn Programme at The Retreat. One resident dropped out during the interview process. The residents had been on the programme for between three and eight months and were aged 20–55.
We selected the residents in order to provide a breadth of positive and negative experiences and a variety of different lengths of treatment. They were excluded if they were currently in crisis or had only recently joined the programme.
Semi-structured interviews were chosen as the method of data collection because it was felt to be appropriate for qualitative analysis (Smith, 1995). A semi-structured interview schedule was designed specifically for this project. The main areas covered were: experience of the assessment process; experience of joining the community; emotions about joining; and thoughts on leaving. Prompts were included to help elicit thoughts and beliefs that residents may have formed.
We sought ethical approval for this study. The hospital research and audit committee reviewed the application before the study began, and granted approval subject to minor amendments.
A form from the Central Office for Research Ethics Committees (COREC) was submitted to the local committee. At the meeting for COREC approval, we were informed this was not necessary as the research was evaluating current clinical practice and could be seen as a service review.
Other ethical issues involved the issue of informed consent. It is possible that clients may have felt pressured to take part in the research as senior members of the community were carrying it out, who may also have been their individual therapist and, therefore, involved in their clinical care. To limit the impact of this, clients were given information about the project and the assistant psychologist (who was not clients’ individual therapist) obtained consent. To help participants’ data remain anonymous, they were asked to choose a name under which their data could be presented to the team and the wider community.
Potential participants were identified by the clinical team. They were then approached by the assistant psychologist and given a copy of the information sheet. This staff member then approached residents 24 hours later, when they could either decline or complete a consent form.
Interviews took place in an office away from the unit to help residents feel comfortable in talking about both the positive and negative aspects of joining the community. All interviews were carried out by the assistant psychologist, and were recorded and transcribed. They lasted between 20 minutes and one hour.
Interpretative phenomenological analysis (IPA) was used to analyse the data. IPA is a psychological form of analysis concerned with trying to understand lived experiences and how people make sense of their experiences (Smith and Osborn, 2003). It was applied to the five complete transcripts.
The main themes were divided into two groups: those referring to the assessment itself and the following two-week assessment period; and those referring to joining the community.
Themes from the assessment
The themes relating to the assessment included:
Fear and anxiety;
Fear of judgement;
Different from the usual;
Making a positive choice.
This period appeared to be one of intense emotions and had many links to participants’ past experiences of treatment and care.
Fear and anxiety
The initial phase appeared to provoke the most anxiety. Participants expressed fear and anxiety. As people who have often been rejected in their lives, it appeared this first step in joining a community tapped into their most basic fears and beliefs about themselves. One participant talked of feelings of, ‘Terror, absolute terror’ (Charlie B), while another admitted being, ‘Terrified of [the] meeting … because of past experiences …’ (Roo).
Fear of judgement
The fear of rejection and judging themselves as ‘not good enough’ was a common theme:
‘I felt as though I’d said too much…so I was kind of judging myself’ (Pippa)
Given that the women on the programme had often gone through traumatic, abusive experiences – that sometimes involved a family member – it is unsurprising they feared being rejected by a place offering help. As one participant explained: ‘I think I expected people to be negative towards me’ (Whisky).
Many had confused boundaries between care and abuse, so being given power and offered a choice could be wrongly perceived as a chance to be rejected. It was also a real possibility that the community could reject them, but participants’ did appear to exaggerate and over-extended this possibility into a certainty.
Once residents’ anxieties started to diminish, the differences in the Acorn Programme started to become evident. One of the main differences perceived was a sense of acceptance and working together as a community, in contrast to earlier fears of rejection. This difference was both difficult and positive at the same time, and caused some participants to perceive overwhelming challenges and demands. This shows some ambivalence on the part of participants, which was also expressed when they talked about wanting to leave. They noticed a difference but it appeared to frighten them and they were not confident they could manage this new experience, as illustrated below.
Different from the usual
‘Staff are so approachable; it is different to acute units’ (Roo)
‘People accepting you for who you are with all your behaviours and willing to work with you; that’s not something you find in a lot of different hospitals; a lot of hospitals shy away from you or lock you up’ (Molly)
‘It was like a challenge to actually be able to come into a group’ (Pippa)
‘It was just too much. I couldn’t cope with all the emotions: just seemed to come in constant waves that overwhelmed me’ (Charlie B)
Making a positive choice
It appears that the final part of the initial assessment process involved participants having the space and support to make a positive choice. For some, it seemed to be particularly important as they had lacked opportunities to make such choices before:
‘You’ve got choices here which you don’t have at home’ (Roo)
‘It’s really hard; it’s a huge decision to make, but one of the best decisions I’ve made so far’ (Molly)
This choice appears to be based on their optimism and hope about the possibility of the community helping them. The optimism after the initial assessment period changed over time, especially after making the decision to stay. This appeared to lead to more ambivalence, perhaps because residents began to fear change.
Starting as a community member
This section highlights themes relating to participants’ experiences after the initial assessment period. The themes explored are:
Choices: desire to leave and determination to stay;
Being alone in a group;
Worth the distress;
This seems to reflect the process of therapy itself, where first a choice is made about whether to begin and start trusting and building relationships (which is, at times, retracted), and then hope is instilled about change, which allows change to happen. Participants then notice that change does not come without a price and become more realistic about their goals and the work itself. Finally they realise they are alone again.
‘Horrendous, I wanted to pack my bags and go so many times it’s unbelievable’ (Charlie B)
‘You want to leave, get to that stage where you’re about to leave and the change is you don’t leave’ (Whisky)
Being alone in a group
I kind of sit in a corner somewhere, isolate myself not saying anything’ (Pippa)
‘I felt alone, didn’t feel part of the community’ (Whisky)
Hope was a common theme although, at times, it seemed slightly unrealistic. This could reflect ‘black and white’ thinking in this resident group:
‘I was also quite excited about coming…I remember I packed my bags two weeks before my date…it was hard explaining to my family’ (Whisky)
‘I think I was looking forward to coming, to get my life back on track’ (Roo)
After participants allowed themselves to become part of the community, this seemed to facilitate change. They reflected that, during the initial time on the programme, they felt they had learnt new ways of coping but this was not as simple as being taught new skills. This seems to be a more naturalistic process in which new skills are assimilated through the environment and being with others. It was clear that change was not an easy process:
‘It’s really, really hard but if there weren’t groups I wouldn’t have moved on’ (Charlie B)
While participants were mostly positive about making choices, being hopeful, and making changes, they were clear that the initial period in therapy and the assessment process had brought up many distressing issues for them. However, most reflected that these experiences were a necessary part of treatment. These residents had used behaviours for many years to avoid emotions and this might have been the first time they had been guided and strongly encouraged to feel them and not act. This appeared to result in a deluge of emotions in the initial period and an accelerated learning curve that enabled them to cope differently, seen in the examples below.
Worth the distress
‘And I can look back and say “yes that was a good learning curve”. At the time you don’t see it, but when you look back afterwards you see it’ (Charlie B)
‘But in the end it is useful when you get out of it’ (Whisky)
The final part of the process for some participants appeared to be a feeling of being abandoned, usually by their buddy in the community. This appears to be an area that needs improvement in the programme – while reaching a depressive position at the end of therapy would be acceptable, it seems that, for some people, this happens earlier than they are able to cope with. Idealisation in therapy is necessary for change and progress, and this feels like a very early point at which to be disillusioned. One interesting point to note is that participants felt abandoned by community members, rather than staff:
‘…after the first week my buddy seemed to disappear…’ (Charlie B)
‘My buddy seemed to disappear…I didn’t feel I could ask for help’ (Roo)
This research showed that people joining a therapeutic community experienced a wide range of intense, and sometimes painful, emotions.
The limited literature in this area supports the themes in this study. Humphreys and Bree (2004) suggested the ‘crisis’ of joining would tap into early attachment experiences and this was commonly found in our study. Attachment experiences in the residents often included rejection, judgement and abuse. This may relate to their intense fears and the perception of threat to their sense of self and increased risk of self-defeating behaviour, as well as their fears of being overwhelmed. This link to attachment experiences, as suggested by Humphreys and Bree (2004), can also be seen in people’s reactions to the experience. It appears that participants acted out early attachment patterns during the initial period in the community. This was seen in both ambivalent and anxious/avoidant attachment reactions.
The themes found in this study also reflected the research by Foster (1979), which described admission to a therapeutic community as a crisis and sociological boundary crossing. The residents themselves described the experience as different from anything else they had experienced and a crisis.
The main themes found during the initial assessment phase were: anxiety and fear; fear of judgement; different from the usual; being demanding; and making a positive choice. The next phase, in which the client slowly became a member of the community, elicited the following themes: choice regarding leaving and staying; being alone; hope; change and learning new skills; and the process being worth the distress. This was followed by reality hitting hard and, sometimes, going through the experience of being left.
Due to the limited literature in this area, further links could not be explored. It is hoped this research will add to this neglected area of study.
The main limitation is that it may not be possible to generalise the study findings to other services or settings. The Acorn Programme is the only one of its kind and, unusually, mixes DBT-informed therapy, psychotherapy, creative therapies, individual therapy and a group-based therapeutic community programme. However, there are other therapeutic communities throughout the UK that work with similar client groups.
A further limitation is the extreme nature of the residents’ problems when referred to the Acorn Programme. Being outside the NHS, residents need to obtain out-of-area funding to attend. Furthermore, as the therapy is delivered on an inpatient basis for up to one year, this can be an expensive treatment option and only the most severe cases are likely to receive such funding.
A criticism of many qualitative studies is their lack of objectivity and consequent validity of findings. As members of the team, we have never pretended to be totally objective, and the use of IPA allows our subjectivity to be accepted. In future research, the validity of the analysis produced could be enhanced by participants reading and commenting on our interpretations.
Some of the limitations could be overcome through further research in this area. It would be informative and interesting to use the same interview and analysis techniques in other therapeutic communities.
To further develop our understanding of clients’ experiences, it would be helpful to explore other key transitions, such as leaving and becoming a day patient. It may also be useful to explore clients’ experiences after the initial ‘crisis’ of joining and fear of rejection has passed. Clinically we have noticed that self-harm tends to return in this period, therefore it may be important to understand this process in order to aid our clinical effectiveness.
The process of becoming a member of a therapeutic community is difficult and painful, but necessary for therapy and recovery. The residents, community, staff team and the environment can either make this transition successful or overwhelmingly negative. As such, exploring residents’ experiences can be an essential resource in facilitating a successful joining process. It is hoped this work adds to the limited knowledge and research in this area.
This is an adapted article, based on work first published in the International Journal of Therapeutic Communities (Coakes et al, 2007).
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