Therapeutic Community Treatment

Bateman & Tyrer (2002) define a therapeutic community as 'an intensive form of treatment in which the environmental setting becomes the core therapy in which behaviour can be challenged and modified, essentially through peer pressure'. Dolan, Warren & Norton (1997) compared 70 patients admitted to the Henderson Hospital, a national specialist inpatient unit for severe personality disorder, with 67 non-admitted patients at assessment and then 12 months later. On average subjects met criteria for seven of the eleven DSM-III-R personality disorder categories, with borderline and paranoid types being most common (80 %). The admitted sample showed significantly greater reduction on the Borderline Syndrome Index (Conte et al., 1980); baseline BSI scores correlated positively and significantly with initial severity of personality disorder as assessed by the Personality Diagnostic Questionnaire (PDQ-R) (Hyler & Reider, 1987).

A New Zealand study reports on 31 patients (81 % with Cluster C and 19 % with Cluster B personality disorders) who were treated in a day and semi-residential psychotherapy setting informed by feminist values (Krawitz, 1997). Patients were offered 'psychodynamically informed' therapy in group and individual sessions combined with cognitive-behavioural skills training. Therapy also included gender role analysis and exploration of social factors contributing to individuals' distress. Mean duration of treatment was four months. The authors report significant gains on the SCL90, the Global Assessment Scale and the Goal Attainment Scale lasting up to two years post-treatment. The study is notable for its emphasis on social factors influencing patient's difficulties, its unusual structure and its minimal resources. One full-time psychotherapist and one half-time psychiatrist treated up to eight patients at a time in an open group that accepted new members as vacancies arose. Individuals attended as day patients or lived in for half a week at a time - returning home in the interim to maintain community links and assist generalisation of skills.

Lees, Manning & Rawlings (1999) published a systematic review of the studies that have attempted to evaluate the effectiveness of therapeutic communities. They identified 29 studies for analysis, of which 22 were conducted in secure settings. The authors concluded that existing evidence does support the effectiveness of therapeutic community treatment in both secure and non-secure settings, with the strongest evidence for programmes aimed at substance misuse in secure settings.

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