Psychiatry

Interpersonal and Biological Processes

ISSN: 0033-2747 (Print) 1943-281X (Online) Journal homepage: https://www.tandfonline.com/loi/upsy20

Therapeutic Community Then and Now

Spencer Biel & Eric M. Plakun

To cite this article: Spencer Biel & Eric M. Plakun (2019) Therapeutic Community Then and Now,
Psychiatry, 82:1, 18-23, DOI: 10.1080/00332747.2019.1565561

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Published online: 14 Mar 2019.

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Psychiatry, 82:18–23, 2019 18
Ó Washington School of Psychiatry
ISSN: 0033-2747 print / 1943-281X online
DOI: https://doi.org/10.1080/00332747.2019.1565561

Therapeutic Community Then and Now

Spencer Biel and Eric M. Plakun

Therapeutic community was a central affective experiences, challenges, or difficult

component of long-term inpatient psychiatric
treatment during an era when inpatient stays
were long enough for meaningful immersion
experiences in a community. Inpatient stays are
now much shorter because of their narrow focus
on crisis stabilization followed by prompt dis-
charge. Hence, provision of treatment through
immersion in a therapeutic community (also
known as milieu treatment) has largely shifted
to intermediate levels of care, like residential
treatment that have longer lengths of stay than
acute inpatient settings. At the outset, it is worth
putting the use of therapeutic community with
its immersion in treatment into context.
ADDITIVE VERSUS IMMERSION
TREATMENT FOR MENTAL
HEALTH DISORDERS
Most active treatment occurs in an out-
patient setting, whether this is psychotherapy of
one form or another or general psychiatric
management. For outpatient treatment to be
effective, patients must have two capacities.
First, they need the capacity to use the sessions,
attend them, and do work in them, including
facing and coming to grips with such intense
choices as are aroused in the course of such
work. Second, outpatients need the capacity to
function adequately between sessions in terms
of interpersonal and instrumental (e.g., work or
school) roles (Biel & Plakun, 2015). When one
or both of these capacities required for outpa-
tient treatment are impaired, we initially follow
an additive model of treatment. We add medi-
cations to target disruptive symptoms or under-
lying disorders, add more frequent sessions or
family work, and introduce substance use dis-
order treatment, support groups, skills training,
or other elements to the outpatient treatment.
Nevertheless, some patients continue to strug-
gle to use the sessions and/or function ade-
quately between them despite appropriate
additions to outpatient treatment, often becom-
ing stuck at an impasse or with chronic or
recurrent crises. At this point, active treatment
often shifts to an immersion model of treat-
ment. In such treatment the patient is immersed
in a 24-hour/seven-day-a-week setting for some
period of time with a goal of returning to out-
patient treatment. When such outpatient strug-
gles are associated with acute crises with major
threat of harm or major functional incapacity,
immersion is generally in an acute inpatient
setting, though some “acute residential”

Eric M. Plakun, MD, is Medical Director/CEO of the Austen Riggs Center, which is celebrating its centennial year
in 2019. He is a former Harvard Medical School clinical faculty member, editor of 2 books, author of over fifty
published papers and book chapters, and has presented over a hundred scientific papers. Dr. Plakun is a Distin-
guished Life Fellow of the American Psychiatric Association, a member of its Board of Trustees, and founder of its
Psychotherapy Caucus. Spencer Biel, PsyD, is a psychotherapist and group consultant with Wellington Counseling
Group in Chicago, IL. He is the former Associate Director of the Therapeutic Community Program at Austen
Riggs Center, where he also supervised psychological testing, individual psychotherapy, and group consultation.
Commentary on “Sealing-Over in a Therapeutic Community” by McGlashan and Levy
Address correspondence to Eric M. Plakun, Austen Riggs Center, 25 Main Street, Stockbridge, MA 01262. E-mail:
Eric.Plakun@austenriggs.net
Commentary
settings also exist which offer the same focus on
brief crisis stabilization and discharge as acute
inpatient units.
For other patients unable to use the addi-
tive model of active treatment in an outpatient
setting, immersion in a longer-term residential
treatment setting, including immersion in
a therapeutic community, may be the optimal
intervention. In such residential programs,
treatment is longer term (generally measured
in months) because its goal is not crisis inter-
vention but addressing underlying comorbid-
ity, the recurrent or chronic nature of
disorders, or the impact of early adversity or
trauma that may interfere with developing
a trusting relationship with a treater or with
tolerating intense affects involved in sessions
—or that interfere with adequate functioning
between sessions. This kind of residential treat-
ment includes in its treatment focus identifying
and, over time, addressing issues that interfere
with successful use of outpatient treatment, and
then a return to outpatient treatment after dis-
charge with the patient now better able to use it.
Residential treatment is often the best hope for
disrupting cycles of recurrent crisis admissions
to inpatient units or for motivating patients
stuck in entrenched passivity that immobilizes
them and keeps them from accessing treatment.
Residential settings offer patients a range of
treatment experiences (e.g., therapeutic com-
munity, supported employment, family work,
group and individual psychotherapy) (Shapiro
& Plakun, 2008). Although residential settings
may vary in the precise services offered or in
their intensity, provision of a therapeutic com-
munity experience is ubiquitous.
A CLASH OF MODELS:
BIOMEDICAL OR
BIOPSYCHOSOCIAL?
A biomedical rather than biopsychoso-
cial model for understanding and treating men-
tal disorders has been in ascendancy for the past
several decades. Within a biomedical model
there is emphasis on biological treatments,
19
such as medications, and de-emphasis of the
therapeutic role of such social experiences as
are available in a therapeutic community. How-
ever, emerging research from psychiatric epide-
miology, genomics, and clinical research
suggests that much more than biology is
involved in causing—and is required to treat
—mental disorders (Plakun, 2015). The hope
that we would discover a few genes that cause
mental disorders has morphed into recognition
that it is not genes alone but complex gene-by-
environment interactions that are involved in
the etiology and treatment of mental disorders.
Other research has demonstrated the powerful
impact of early and other adverse experiences
on the presence of mental and medical disor-
ders—and that psychosocial treatments have
a substantial benefit for those facing such
adversity (Plakun, 2015).
McGlashan and Levy’s (1977) inter-
esting paper was published the same year
as George Engel’s (1977) seminal paper
introducing the biopsychosocial model.
Although McGlashan and Levy did not
likely have knowledge of Engel’s integrative
biopsychosocial perspective, their paper
illustrates the profound tension of that era
between psychosocial and biomedical mod-
els of treatment for mental disorders. This
was one of the central debates that was
unfolding in the field at that time. This
explains, in part, their paper’s focus on ten-
sions in staff dynamics, with little to say
about patients’ roles in the work of thera-
peutic communities.
As presented in McGlashan and
Levy’s (1977) paper, the forces of “sealing-
over” privilege symptom resolution and
return to functioning—often a biomedical
focus. The forces favoring “integration” pri-
vilege addressing a person’s underlying psy-
chosocial issues patiently and avoiding
medications—until discharge is approach-
ing, when staff seem to ask the patient to
pull together quickly in order to function
outside of the hospital setting.
It is clear in and between the lines in this
paper that it is the staff who are struggling
20
with this incipient shift in the field, in how to
understand their clinical work and the funda-
mental task of the inpatient unit. The paper
reveals a clash of models organized around
then-timely questions, such as those that fol-
low: “Should hospital treatment be long term,
to allow an immersion in a therapeutic and
treatment rich environment, or short term,
with a focus on crisis intervention and symp-
tom suppression so that a patient can return to
outpatient functioning as soon as possible? Is
optimal treatment psychosocial and interper-
sonal or biological and focused on managing
symptoms?”
The paper reveals an “either/or” ten-
sion in which psychotic patients either have
enough time in an inpatient unit to achieve the
desired goal of fully integrating the meaning of
psychotic experiences in the service of resol-
ving conflicts or of mourning now-accepted
personal deficits, or they settle for the presum-
ably less desirable “sealing-over,” that is, sup-
pression of symptoms without full learning
and integration, but with an eye toward
resuming outpatient functioning.
CONTEMPORARY RESIDENTIAL
TREATMENT AND THERAPEUTIC
COMMUNITY
Currently, psychiatric hospitals are
short term and focused on crisis stabilization;
in the language of McGlashan and Levy’s
paper, this would be symptom remission and
sealing-over. As noted, residential treatment
emerged, in part, in response to the decrease
in acute inpatient length of stay as a way to
provide a longer period of immersion in
a treatment environment to support work on
underlying issues, chronicity, comorbidity,
and the impact of trauma for relevant
patients—psychotic and nonpsychotic—and
intentionally without the restrictions on free-
dom found in locked inpatient units. Freedom
to try and to risk failing in the service of learn-
ing, while balancing freedom against respon-
sibility, is an essential part of most residential
Biel and Plakun
treatment settings. The approach to residential
treatment and therapeutic community cur-
rently in use is “both/and” rather than
“either/or.” We would want to follow the
patient’s lead in teaching us how best he or
she can recover, while facing the losses asso-
ciated with his or her impairment, adapting to
an identity that may now include chronic ill-
ness or otherwise coming to grips with perso-
nal issues. The total community will also
grapple with these issues.
At a place like the Austen Riggs Cen-
ter, with an average length of stay in the
continuum of care of about six months, the
therapeutic community is an active part of
treatment that is highly valued by patients
and staff, along with four-times-a-week indi-
vidual psychodynamic psychotherapy, use of
medications, and other elements of the treat-
ment program. At Riggs we still see evidence
of the either/or tension illustrated by the
paper but in subtly different forms. It is
now manifest more as part of occasional
guild conflict (e.g., psychiatrist versus psy-
chologist or doctor versus nurse), including
conflict about what psychosis is and whether
it is treatable without medications. This
often occurs when psychosis emerges in the
context of clear-cut trauma or as a result of
our learning that psychosis is not just one
thing. It can come up when chronically psy-
chotic patients invite staff and patients alike
to give up on including them in the thera-
peutic community discourse. Treatment staff
can drift toward the grandiose fantasy that
therapy and therapeutic community will
cure psychosis (because every once in
a while it seems like it does) or the devaluing
of therapy and the therapeutic community
except as a way to get patients to “comply”
with the curative powers of medications.
What, if anything, does a therapeutic
community offer to a person suffering with
a psychotic illness? It does not promise cure.
Rather, it offers a rich learning environment
where a premium is placed on membership
and its study. Among other things, member-
ship involves processes of joining, leadership,
Commentary
followership, inclusion, and exclusion. Indivi-
duals approach the therapeutic community, as
people do all communities, with more or less
conscious models for how groups function.
These expectations—for example, that groups
will be welcoming or forbidding, democratic
or tyrannical, alienating, enveloping, or
resource rich and growth promoting—influ-
ence which aspects of themselves they empha-
size. The interplay between expectations,
personality traits, and pressures from the
group helps shape the social position, or role,
individuals come to occupy, such as the
“angry one,” the “caretaker,” the “sage,” or
the “inscrutable witness.”
Therapeutic communities, like indivi-
duals, are always engaged in both sealing-over
and integration. In therapeutic communities,
sealing-over generally means tightening bound-
aries, relying heavily on projection, and making
use of scapegoats. It can also mean crafting
a clear group identity with set traditions, pre-
dictability, and at least the appearance of secur-
ity among seemingly like-minded individuals.
Integration, on the other hand, requires
the depressive position—the developmental
achievement of recognition that the primary
caretaker we need and love is the same person
who fails, frustrates, and angers us (Klein,
1946). Integration entails seeing how what is
painful, distasteful, and discomfiting also
belongs to oneself, while developing the capa-
city to hold a tension between limitations and
possibilities. It also means grappling with
broader definitions of self and other.
A distinguishing feature of psycho-
dynamic/psychoanalytic therapeutic com-
munities is their explicit focus on
reflecting on and learning from individual,
interpersonal, and group processes.
McGlashan and Levy clearly articulate
how staff members pay attention to pecu-
liar features of their engagements with one
another and with their patients in order to
detect enactments that communicate
important aspects of a given patient’s pre-
sentation and struggles. With the treatment
of psychotic illness it is common for
21
treaters to find themselves split along the
lines of grandiose hope, on one hand, and
hopelessness and despair, on the other.
Some staff members may ignore the ser-
ious, enduring, and debilitating troubles
the patient is facing, for instance, becom-
ing sanctimonious when their colleagues
express misgivings about the patient com-
ing off antipsychotic medication or when
trying to live alone despite ongoing pro-
blems with hygiene and budgeting. Other
staff members may assume the stance that
the patient is beyond help, sentenced to
a life of crippling mental illness with no
prospects for meaningful societal adapta-
tion. Customarily, this kind of split
among staff members captures an uninte-
grated aspect of the patient’s internal
experience, as well as often reflecting
a similar split among the patient’s family
members. Integration, where limitations
and possibilities are held together in ten-
sion, is enormously difficult for the
patient, the family, the therapeutic com-
munity, and treaters.
In their focus on staff dynamics,
McGlashan and Levy direct limited atten-
tion to the partnership between patients
and staff in shaping the therapeutic com-
munity culture and its offerings, and on
the myriad ways patients are resources to
one another. Patients assume formal com-
munity roles with genuine responsibilities,
such as working in a greenhouse, chairing
the community meetings, and managing
the funds for social activities within the
patient group. Patients join staff in think-
ing about how important struggles over
authority or complicated gender dynamics
may be embedded in seemingly bland
administrative issues, and help track reso-
nances between the conflicts among
patients and those among staff members.
And in terms of social learning, patients
provide invaluable feedback to one
another, creating opportunities, painful
though they may be, to wrestle with dis-
crepancies between how one views oneself
22
and how one is seen by others. Giving
feedback offers many lessons, too, as
patients encounter loyalty binds and social
repercussions, and can reflect on why and
how they are saying something and on
behalf of whom.
Returning to more specific examples
of group dynamics surrounding psychotic
patients, sometimes, as discussed by
McGlashan and Levy, therapeutic com-
munities invest considerable effort in
ignoring or erasing severe psychopathol-
ogy in a community member because it
feels too frightening to permit its reality
and the possibility that it might live
within all of us. This erasure can take
the form of scapegoating or efforts to
drive the person and the messiness he or
she represents away. Alternatively, the
person is sometimes defined and treated
as a piece of community furniture, barely
noticed, not engaged as fully human, or
removed from the social fabric to an
extent that potential disruptiveness is neu-
tralized. However, there are also times
when people provoke a community mem-
ber who exhibits vulnerability, inducing
craziness in that member in order to
establish a designated home for—in
a sense, to quarantine—the irrational.
These group processes profoundly impact
all involved. The psychotic patient gets
used in ways that further threaten the
patient’s hold on reality, sense of agency,
and sense of eligibility for group member-
ship. Those projecting into this person
lose aspects of themselves, however desta-
bilizing and unnerving these aspects might
be. An illusion gets created about
a rational, stable group, which, of course,
is so reliant on locating madness else-
where that it exists in a state of precar-
ious tension.
Slowing down these processes and
spelling out how they have developed,
including their benefits and costs, gives
everyone a chance to learn something.
How have I contributed to this state of
Biel and Plakun
affairs? What else might I have done?
Which other groups have I been part of
where something like this has happened?
How is this reminiscent of my family and
my role therein? These and other questions
afford people, staff and patients alike,
a unique opportunity to learn about them-
selves as individuals and group members.
Asking and trying to answer such ques-
tions is not a cure, but doing so opens
one’s eyes a bit more and in turn creates
more options, more freedom, and respon-
sibility for how to regard oneself and
relate with others.
Along with providing a laboratory
for studying individuals in context, the
therapeutic community offers numerous
contexts such that patients might be
known, including by themselves, more
complexly. As a given patient moves
between large groups, with intense, mini-
mally organized affects bubbling up and
boiling over, and quieter dyadic conversa-
tions (perhaps contact with a nurse about
a medical issue or while working with
a staff member in the hospital library), dif-
ferent aspects of personality, including
intellectual resources, schemas for relation-
ships, and manners of exercising agency,
are drawn out. This complexity helps inter-
rupt unidimensional characterizations of
a person as either completely sealed-over
or integrated. It helps to show where
patients are wrestling with uneven capaci-
ties and limitations, and where they are
reducing themselves, or are being reduced
by others, to a simpler, less intricate, but
also potentially more stabilizing social
position.
CONCLUSION
Therapeutic community work is
a powerful form of psychosocial learning. It
currently is provided in residential settings
that focus on addressing comorbidity, under-
lying issues, and the impact of adversity and
Commentary
trauma that interfere with a patient’s capa-
city to use outpatient treatment optimally—
which requires the ability to use the sessions
and to function adequately between them.
Immersion in a therapeutic community is an
ideal way to help some people return to out-
patient functioning and be better able to use
the lessons learned to take charge of their
lives. Contemporary therapeutic commu-
nities do not take an “either/or” (either bio-
logical or psychosocial) treatment stance but
instead are based on an integrated “both/
and” biopsychosocial approach to treatment.
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Engel, G. L. (1977). The need for a new medical
model: A challenge for biomedicine. Science, 196
(4286), 129–136.
Klein, M. (1946). Notes on some schizoid
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McGlashan, T. H., & Levy, S. T. (1977). Seal-
ing over in a therapeutic community. Psychia-
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The task of achieving integration of disparate
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the staff who work in such settings. Contem-
porary therapeutic communities balance seal-
ing-over with the integration that comes from
learning to see ourselves as others see us.
DISCLOSURE STATEMENT
No potential conflict of interest was
reported by the authors.
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