Setting Up New Services in the NHS: Just Add Water (Community, Culture and Change) - Kingsley Norton, Jessica Kingsley Publishers, 2006, £18.04 pb, 208 pp., ISBN 1-84310-162-9

Therapeutic communities have been a marginal part of the National Health Service (NHS) mental health provision for over 50 years, with the Henderson Hospital being a resilient and enduring example. In the 60s and 70s, perhaps encouraged by a liberal philosophy supported by the antipsychiatry movement, some in-patient wards attempted to emulate therapeutic communities’ principles with such measures as daily ward meetings of patients and staff. Sadly, when community psychiatry was ascendant the culture of in-patient wards was left to become increasingly custodial. However, in the past 15 years interest in therapeutic communities has increased as they embody a number of ways of working in psychiatry that have again come to the fore. These include patient participation and responsibility for their treatment in partnership with staff, as well as a move away from the medical model with a flatter hierarchy in multidisciplinary teams. Perhaps more importantly therapeutic communities have been a model for the treatment of personality disorder that has increasingly been seen as a responsibility of psychiatry after years of neglect as an untreatable condition.

This book gives an account of the attempt to replicate the Henderson Hospital in two locations, Crewe and Birmingham, chosen because of the local NHS managers’ willingness. The Henderson had been at the forefront of studies demonstrating that personality disorder was treatable though had fallen short of the harder evidence of a randomised trial. However, at the time the replication was proposed in the mid-90s randomised trials showing that personality disorder and in particular borderline personality disorder could be treated were just coming out; first with dialectical behaviour therapy, then followed by psychodynamic day-hospital treatment, and more recently schema (cognitive–behavioural therapy) and transference-based therapy. These are all cheaper options to in-patient therapeutic communities and this is perhaps one of the reasons the project fell foul of NHS management and the Crewe therapeutic communities folded.

The account of the project in the book follows the painfully chaotic process of attempting to replicate a culture in another location, though never really addresses a central difficulty. That is, that every therapeutic community is unique and draws its therapeutic power from the creativity inherent in its democratic processes, and this runs counter to the process of replication.