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.
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. 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. 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.
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.
Their role in treatment for personality disorder
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. 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. 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.
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.
References
Pearce S, Scott L, Attwood G, Saunders K, Dean M, De Ridder R, et al. Democratic therapeutic community treatment for personality disorder: randomised controlled trial. Br J Psychiatry 2017; 210: 149–56.
Lees J, Manning N, Menzies D, Morant N. A Culture of Enquiry: Research Evidence and the Therapeutic Community. JKP, 2004.
Lees J, Manning N, Rawlings B. Therapeutic Community Effectiveness: A Systematic International Review of Therapeutic Community Treatment for People with Personality Disorders and Mentally Disordered Offenders. University of York Centre for Reviews and Dissemination, 1999.
Rapoport R. Community as Doctor. Tavistock, 1960.
Haigh R. The new day TCs: five radical features. Ther Communities 2007; 28: 111–26.
Pearce S, Haigh R. Mini therapeutic communities: a new development in the United Kingdom. Ther Communities 2008; 29: 111–24.
Pearce S, Haigh R. A Handbook of Democratic Therapeutic Community Theory and Practice. JKP, 2017.
Haigh R, Tucker S. Democratic development of standards: the Community of Communities – a quality network of therapeutic communities. Psychiatr Q 2004; 75: 263–77.
Haigh R, Harrison T, Johnson R, Paget S, Williams S. Psychologically informed environments and the ‘‘Enabling Environments’’ initiative. Hous Care Support 2012; 15: 34–42.
Haigh R. Industrialisation of therapy and the threat to our ethical integrity. Personal Ment Health 2014; 8: 251–3.
Haigh R. The quintessence of a therapeutic environment. Ther Communities 2013; 34: 6–15.
Department of Health. Recognising Complexity: Commissioning Guidance for Personality Disorder Services. Department of Health, 2009.