Steve Pearce

How therapeutic communities work: Specific factors related to positive outcome

Background: Therapeutic communities (TCs) are becoming increasingly widespread as a form of treatment for entrenched mental health problems, particularly addictions and personality disorders, and are equally used in educational, prison and learning disability settings. Despite growing evidence for their effectiveness, little research has been conducted to establish how TCs work to produce positive outcomes. We hypothesize that there are two specific factors that in combination contribute to TC effectiveness: the promotion of a sense of belongingness and the capacity for responsible agency. Although both factors are found in other therapeutic approaches and are important to the psychosocial aspects of psychiatric care more generally, we argue that their combination, extent and emphasis are unique to TCs. Material: Drawing on social and experimental psychology, we: (1) review research on a sense of belongingness and the capacity for responsible agency; (2) establish the mechanisms by which TCs appear to promote them; (3) draw lessons for TC practice; and (4) suggest why they may contribute to positive outcome. Discussion: A sense of belongingness is correlated with improved self-esteem and overall well-being. The capacity for responsible agency is central to behavioural change. TCs are typically used in fields where positive outcome requires both personal growth and behavioural change. We suggest that TCs are uniquely placed to demand such growth and change of their members because the sense of belongingness engendered by TC methods protects against the risks engendered by this demand. Conclusion: Empirically informed, evidence-driven research is necessary to understand how TCs work and how TC practice can be improved. This understanding may offer lessons for the improvement of psychosocial aspects of psychiatric care more generally.

Finding the will to recover: philosophical perspectives on agency and the sick role

Recovery from a range of common medical conditions requires patients to have the will to change their behaviour. The authors argue that the proper recognition of the role of willpower in recovery is necessary for effective treatment.

The moral content of psychiatric treatment

Psychiatric treatment can enhance human morality. It can promote the emergence of moral motives and intentions, aid in the acquisition of skills essential to moral action, and help to develop the ability to apply moral understanding and skills in particular circumstances. Good psychiatric practice demands an honest appraisal of its moral dimension.

Democratic therapeutic community treatment for personality disorder: randomised controlled trial

BACKGROUND Democratic therapeutic community (DTC) treatment has been used for many years in an effort to help people with personality disorder. High-quality evidence from randomised controlled trials (RCTs) is absent. AIMS To test whether DTC treatment reduces use of in-patient services and improves the mental health of people with personality disorder. METHOD An RCT of 70 people meeting DSM-IV criteria for personality disorder (trial registration: ISRCTN57363317). The intervention was DTC and the control condition was crisis planning plus treatment as usual (TAU). The primary outcome was days of in-patient psychiatric treatment. Secondary outcomes were social function, mental health status, self-harm and aggression, attendance at emergency departments and primary care, and satisfaction with care. All outcomes were measured at 12 and 24 months after randomisation. RESULTS Number of in-patient days at follow-up was low among all participants and there was no difference between groups. At 24 months, self- and other directed aggression and satisfaction with care were significantly improved in the DTC compared with the TAU group. CONCLUSIONS DTC is more effective than TAU in improving outcomes in personality disorder. Further studies are required to confirm this conclusion.

DSM-5 and the rise of the diagnostic checklist

The development and publication of Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) produced a peak in mainstream media interest in psychiatry, and a large and generally critical set of scientific commentaries. The coverage has focused mainly on the expansion of some categories, and loosening of some criteria, which together may lead to more people receiving diagnoses, and accompanying accusations of the medicalisation of normal living. Instructions given to members of DSM-5 work groups appear to have encouraged this.1 This has not been the only source of disquiet. The influence of the pharmaceutical industry on the members of the appointees to DSM diagnostic work groups, which constructed the new rubrics, has caused concern,2 as remuneration and insurance coverage in the USA depends partly on DSM diagnosis, and the pharmaceutical industry has been accused of encouraging the development of new diagnoses as a way to increase profitability.3 Societal impact has been an explicit part of the development of DSM-5, as outlined in the article in this issue.4 Reasons for decisions by DSM-5 workgroups have included enabling sufferers to receive treatment which would not be available without a DSM diagnosis (a local US concern), or …

Milieu approaches and other adaptations of therapeutic community method: past and future

Purpose The purpose of this paper is to provide an overview of the application of therapeutic community (TC) method in non-TC environments. Design/methodology/approach Milieu treatment is defined and differentiated from TC “proper”. Literature is reviewed covering attempts to use TC methods in inpatient wards, across hospitals, and more recently in the criminal justice system and more widely through the enabling environments initiative. Findings It is unclear whether TC milieu treatments proved helpful in acute ward environments in their heyday in the 1950s, 1960s and 1970s, in particular those involving people suffering from acute psychosis, and the changing landscape of psychiatric provision may make further investigation difficult. The reasons for this, and for the difficulties reaching a firm conclusion, are outlined. In contrast, TC milieu interventions appear to be demonstrating usefulness more recently in less mixed populations without the implementation of full TC “proper”. Research limitations/implications Much of the research is old and the methodology poor, which limits the conclusions that can be drawn. Practical implications Recent innovations pick up in a more accessible way principles of therapeutic communities that can inform and improve care in a variety of contexts. They are sufficiently well defined to lend themselves to research, which should now be a priority. Originality/value After a gap in developments in the field, recent innovations are reintroducing elements of TC functioning to new contexts including criminal justice settings, inpatient wards, homeless shelters and city communities.

“I know you think I think – therefore I am”. Mentalisation based therapeutic community: a description

Purpose The mentalisation based therapeutic community (MBTC) is a group experience which promotes the acquisition of the capacity to mentalise. Members of the community gain greater emotional stability and psychological robustness. The paper aims to discuss these issues. Design/methodology/approach MBTC works with three theoretical principles: the intrapsychic, interpersonal and social. It is a slow open group where each member completes a ten-week course. The approach is deliberately non-interpretive with an emphasis on personal responsibility and accountability in order to promote clarity of mind. Findings The authors’ experience is that the model engages group members with few drop outs. Originality/value The combination of mentalising and the use of therapeutic community principles within in MBTC has enhanced outcomes for group members.

Balancing costs and benefits: a clinical perspective does not support a harm minimisation approach for self-injury outside of community settings

Patrick Sullivans emphasis on the importance of supporting autonomy and independence among vulnerable people who self-injure is fundamental to good clinical practice. Although people who self-injure typically experience overwhelming emotions and may be prone to impulsive behaviour, self-injury is nonetheless a choice and must accordingly be treated as such.1 In addition, patients who self-injure when not acutely mentally ill typically retain decision-making capacity in relation to self-injury.2 This is why some forms of harm minimisation, such as encouraging reflection, responsibility, safe cutting and where appropriate self-aftercare, are uncontroversial and already widely practised within community settings. The situation is different, however, with respect to both secure and non-secure inpatient settings. It is also different when we consider some of the other forms of harm minimisation that Sullivan advocates, namely the provision of self-harming instruments alongside education about anatomy and physiology. Sullivan does not distinguish secure and non-secure settings, but it is crucial to do so. In secure (forensic) inpatient settings, it is neither practical nor ethical to provide implements that can be used as weapons to any patient, for any reason. This would be to severely compromise staff and patient safety. In non-secure inpatient settings, patients are likely to be detained under the Mental Health Act. This raises the question of the grounds of detention. Typically, patients who self-injure are detained because they are judged to be currently at risk of life-endangering or life-changing injury. As Sullivan notes, it is not clinically or ethically appropriate to provide patients with the means to self-injure when they are in this state of mind. This means that the relevant inpatient population for which a harm minimisation approach could even be considered is relatively small: those who have a standing pattern of self-injury and who are detained on non-secure units for reasons other …

Invited commentary on … When unbearable suffering incites psychiatric patients to request euthanasia: a qualitative study

Although the paper in this issue by Verhofstadt et al sheds some light on the features of unbearable suffering stemming from psychiatric disorder leading to a request for euthanasia, this is limited. The bulk of the paper illustrates the particular ethical challenges posed by the policy of making euthanasia available in these circumstances.

Trials of therapeutic communities in personality disorder are under way

Gask and colleagues state that there is no evidence for the effectiveness of therapeutic communities in the treatment of personality disorder.1 This is misleading. As the authors note, therapeutic communities have been …