Therapeutic communities enter the world of evidence-based practice

Summary

This editorial provides the modern-day context for a long-established psychiatric treatment, democratic therapeutic communities. As this treatment is now such a small field in psychiatry, readers may not have enough background to be able to place the research in a suitable context. This includes the previous gap in experimental research, the difference between the modern model and the one used in the 20th century and the general field of personality disorder evidence.

Recently in the BJPsych, Steve Pearce and colleagues ¹ demonstrated that it is possible to do an experimental study on a complex treatment modality that has been in use for over 50 years. Theirs is an important study, and is a landmark in being the first ever randomised controlled trial on democratic therapeutic communities for personality disorder. In the seven decades since their role in psychiatric services was established, clinicians in therapeutic communities have generally preferred qualitative approaches to research. ² These were seen to have a more congruent epistemological basis, but were a richer vein for anthropological and sociological enquiry than they were for clinical studies. An extensive systematic review in 1999 found that few studies were suitable for inclusion in the meta-analysis, and those that were included were too heterogeneous and imprecise to give robust results. ³

Modern-day therapeutic communities

For psychiatrists who remember democratic therapeutic communities in their heyday, they were based on Rapoport's four themes (democratisation, permissiveness, reality confrontation and communalism) which he identified at Henderson Hospital in the late 1950s. ⁴ Although the service in Pearce et al's study is based on some of these fundamental principles, they are overlaid with several decades of development and modification. Newer therapeutic communities now bear few superficial resemblances to these residential services, which were formed in the heat of the social psychiatry revolution of the 1950s and 1960s. No wholly group-based residential therapeutic communities now remain in the National Health Service (NHS), and all of those that still function are day units, as in this study. ^5,6 The laissez-faire attitude of ‘leave it to the group’ rarely prevails, there is a high level of structure and order, and there is very little opaque psychoanalytic interpretation delivered by remote therapists. Modern therapeutic communities have a strong emphasis on empowerment, openness and ‘ordinariness’, which soon dispel any notions of therapeutic mysteriousness and charismatic leadership. They are tightly managed services with clear admission, review, progression and discharge protocols. ⁷

In 2002, one of the first quality networks of the Royal College of Psychiatrists' Centre for Quality Improvement (CCQI) was the ‘Community of Communities’. It helped democratic therapeutic communities to agree the nature of best practice and to consistently deliver it. ⁸ Part of this process involved the distillation of ten core values that underlie the measurable standards. These would be entirely familiar to early therapeutic community pioneers: a culture of belongingness, enquiry and empowerment; democratic processes whereby no decisions can be made without due discussion and understanding; and the fundamental importance of establishing and maintaining healthy relationships (which are not always comfortable and are seldom without conflict). This work has also led to the ‘Enabling Environments’ award at the Royal College, and the development of ‘psychologically informed planned environments’ (PIPEs) in criminal justice settings, and ‘psychologically informed environments’ (PIEs) in the homelessness sector. ⁹

Their role in treatment for personality disorder

The publication of outcome studies for personality disorder treatment have had something of the quality of a ‘horse race’ or ‘beauty contest’ in the past decade. New treatments have been constituted from various old psychological theories, which have been branded and packaged, then manualised and researched with much energy and competitiveness. In this way, they have been suitable for ‘selling’ to mental health commissioners as simple value-free ‘commodities’ or ‘products’. ¹⁰ In a way, Pearce et al's study indicates that therapeutic communities have now entered this race. However, it is worth proposing that their study is not of a simple ‘brand’ of treatment, but of a therapeutic philosophy with a long and distinguished heritage, which has now been adapted to fit into the wider ‘whole system’ of a 21st-century mental health service. Therapeutic communities offer a democratic way of conducting therapeutic business, demand specific attention to the coherent and coordinated use of the different therapeutic approaches, and deliberately provide an overall therapeutic environment. ¹¹ These do not often happen in other therapies.

Therapeutic communities also specialise in being able to treat those who have a particularly severe presentation of personality disorder, such as in prisons. This severity can be measured by diagnostic criteria, comorbidity, risk, complexity or unmanageability. ¹² The therapeutic environment, including techniques such as peer mentoring and deliberate informality, facilitates engagement of people who would otherwise be ‘untreatable’. Also, by managing risk primarily through continuing, empathic and intense therapeutic relationships, therapeutic communities can manage levels of risk that would be unacceptable in other services. This study demonstrates that democratic therapeutic communities have now started to accumulate the evidence to earn a place in the therapeutic pantheon for moderate and severe personality disorder.