Therapeutic community research: past, present and future

Compassion Focused Group Psychotherapy for attachment and relational trauma: Engaging people with a diagnosis of personality disorder

OBJECTIVES

The research aimed to evaluate an exploratory Compassion Focused Group Psychotherapy Programme and the impact on participants' experiences of self-criticism, usage of services and general wellbeing. Participants included patients with a history of complex attachment and relational trauma (A&RT), who might attract a diagnosis of personality disorder.

DESIGN

This study utilised a quasi-experimental non-randomised within subject controlled design for the evaluation of the efficacy of the programme.

METHODS

Participants were recruited from tertiary care services. The programme consisted of a 12-week Preparation and Engagement intervention (PEG) which was Compassionate Mind Training and Psychoeducation, followed by a 40-week Compassion Focused Trauma Group intervention. The cohort was then followed up after 12 months during which period they received treatment as usual. A comprehensive selection of self-report measures was administered at various points during the therapeutic process and following completion of the group interventions.

RESULTS

The results of the research showed that the provision of a long-term, slow-paced, Compassion Focused Group Psychotherapy intervention, resulted in significant changes across all measures which were maintained at 12-month follow-up. These significant results were maintained following intention to treat and reliable change analyses. These data were supported by a significant reduction in service usage and a significant increase in engagement in employment and education.

CONCLUSIONS

This study has identified that within Compassion Focused Group Psychotherapy, there is a therapeutic process of establishing group-based safeness as a necessary precursor to cultivating compassion and reworking early shame-based trauma memories.

What am I seen – who do I seem? Hidden discursive processes in the large group of a TC

Purpose

The purpose of the paper is to present a possible way of discourse analysis of the meaning giving processes in a therapeutic community (TC).

Design/methodology/approach

Presentation of a research project, which aim is to analyse the attitudes towards the large group within the TC, is based on analysing the conceptual metaphors in semi-structured interviews.

Findings

The findings delineate a possible discourse, namely, the TC’s hidden discourse of working through the mirror-transference at the community level.

Practical implications

The paper proposes a possible content analysis method for better understanding the deep processes of the TC by examining the large group.

Social implications

The paper emphasizes the matrix of a TC as a mentalizing scene.

Originality/value

The use of linguistic methods in understanding the hidden community level mentalizing processes.

The Importance of Nidotherapy and Environmental Change in the Management of People with Complex Mental Disorders

Much has been done in the last 50 years to achieve a better understanding of the psychosocial causes and other factors influencing the manifestation of mental illness, but there has been a conspicuous omission. Although gross environmental deficiencies were exposed in old mental institutions, 70 years ago the more subtle maladaptive settings that reinforce chronicity in mental illness have often been forgotten. In this review, the potential of systematic environmental manipulation as a treatment (nidotherapy) and other similar forms of management, used many times in the past but now mainly in forensic settings, is examined. There is now accumulating evidence, reinforced by controlled trials, that planned environmental change, preferably carried out with the full cooperation of the patient, can be a major contributor to therapeutic benefit. It is also very cost-effective. All forms of the environment, physical, social and personal, can be addressed in making assessments, and once a planned way forward has been chosen, progress can be monitored by personnel with limited mental health experience. These interventions have applications in general mental health and occupational health services and deserve much wider use.

Psychological treatment for personality disorders

There is encouraging evidence that some patients with personality disorder are treatable. Psychotherapeutic interventions show promise, although interpretation of the literature is problematic: the number of patients in most trials is small, outcome measures are questionable, follow-up is limited, and treatments are multifaceted, complex interventions in which the effective components are unclear. The evidence base can be assessed according to efficacy and generalisability, and when both are taken into account the best verification is for psychodynamic therapy. However, there is inadequate evidence to make specific recommendations for any particular therapy.

Group attachment through art practice: a phenomenological analysis of being seen and showing

Purpose

– The purpose of this paper is to explore the role of a social art practice and group attachment in the life of a mental health service user with a diagnosis of borderline personality disorder.

Design/methodology/approach

– Interpretative phenomenological analysis was used as a means by which to explore interview data and bring to bear theories of attachment and psychosocial theories of the creative process.

Findings

– The study found that the process of coming to be seen and showing, relating and narrating, was part of a process enabled by experiences of group attachment within specific groups. These groups appeared to share the core principles of a TC. The artist’s improving reflective capacity and art practice informed and strengthened each other within a context of attachment, containment, communication, inclusion and agency (Haigh, 2013).

Research limitations/implications

– Whilst phenomenological work of this kind is small scale, the nature of the involvement with the participant facilitates a first person narrative which allows unique insight into human meaning making.

Practical implications

– The study offers pointers regarding the role of social art practice and emphasises the importance of developing attachments as part of mental well-being, as well as the potential role and challenge of this for individuals with severe relational problems. The study stresses the importance of groups that nurture particular experiences such as belongingness and sense of agency, and suggests why these experiences may be more effective for some individuals than one-to-one therapy.

Social implications

– The research adds to the debate regarding the benefits of engaging with the arts and the means by which the value of publicly funded community arts projects can be assessed. It also puts forward the case for TCs as potentially offering a substantial springboard not only to recovery but to higher creative functioning.

Originality/value

– The paper attempts to offer a deeper understanding of the combined and interlaced therapeutic power of creative endeavour; narrative identity; group attachment and the role of the fundamental principles of TCs.

Outcomes of therapeutic community treatment for personality disorder

Purpose

– The purpose of this paper is to review quantitative research since 1999 evaluating the effectiveness of democratic therapeutic community (DTC) treatment for individuals with personality disorders (PD) with reference to interpersonal and offending risk outcomes.

Design/methodology/approach

– A systematic search resulted in the review of ten studies. All of the studies investigated DTCs treating PD in community, inpatient residential and forensic settings. Only peer-reviewed, English-language articles employing a quantitative design were included.

Findings

– The majority of studies were conducted poorly and of low methodological quality, with limitations located in the representativeness of participants, limited use of control and comparison groups, follow up periods and controls for confounders. Heterogeneity remained in use of measures and limited consideration was given to the validity of interpersonal measures used. While improved interpersonal outcomes post DTC treatment were noted in forensic and residential settings, results were mixed in day and mini TC settings. Inconsistent findings in offending risk outcomes were also indicated. A study with increased methodological rigour indicated residential treatment had limited effects on interpersonal outcomes, when compared to combination treatment (residential TC and step-down treatment).

Originality/value

– The study provided an evaluation of the limitations of DTC research across a range of settings and highlighted a combination of residential TC and step-down treatment may achieve superior outcomes to residential TC treatment alone in a community inpatient population. Recommendations are made for future research to contribute to the treatment of PD.

Treatment of personality disorder

The evidence base for the effective treatment of personality disorders is insufficient. Most of the existing evidence on personality disorder is for the treatment of borderline personality disorder, but even this is limited by the small sample sizes and short follow-up in clinical trials, the wide range of core outcome measures used by studies, and poor control of coexisting psychopathology. Psychological or psychosocial intervention is recommended as the primary treatment for borderline personality disorder and pharmacotherapy is only advised as an adjunctive treatment. The amount of research about the underlying, abnormal, psychological or biological processes leading to the manifestation of a disordered personality is increasing, which could lead to more effective interventions. The synergistic or antagonistic interaction of psychotherapies and drugs for treating personality disorder should be studied in conjunction with their mechanisms of change throughout the development of each.

Quantitative findings from a mixed methods evaluation of once-weekly therapeutic community day services for people with personality disorder

BACKGROUND

Quantitative findings are presented from a mixed methods study of four one-day-a-week therapeutic communities for people with personality disorder (qualitative findings from the same study are reported in a separate paper). The evaluation assessed both the clinical efficacy of the model and its acceptability to service users, service employees and those who refer clients to the services.

AIMS

The study aimed to clarify whether one-day therapeutic communities can be effective for people with personality disorder.

METHOD

Changes in the functioning of service users who attended the day services were assessed every 12 weeks for up to 1 year.

RESULTS

We found significant improvements in both the mental health and social functioning of service users. Changes in patterns of self-harm and service use were suggestive of possible underlying improvements but failed to reach significance levels. We also found evidence of the possible offset of costs within 16 months of an individual leaving one of the services.

CONCLUSIONS

This study suggests one-day therapeutic communities may be both clinically- and cost-effective for people with personality disorder.