A Culture of Enquiry: Research Evidence and the Therapeutic Community

Abstract

This paper presents data from a systematic review and meta-analysis of 29 published studies of therapeutic community effectiveness using controls, including 8 randomised control trials. Metaregressions suggest that the two types of therapeutic community, democratic and concept-based, and the age of the study, are the key sources of heterogeneity in the collection of studies analysed.Otherwise, heterogeneity is low and the meta-analysis confirms the effectiveness of therapeutic community treatment with overall summary log odds ratio for the 29 studies of -0.512 (95% ci -0.598 to -0.426).Keywords systematic review, meta-analysis, therapeutic communities, effectiveness, evidence Historical antecedentsThe literature on therapeutic communities refers mainly to democratic psychiatric settings, originating in Britain during the second world war, or to concept-based houses, originating in the USA in the late 1950s. The early literature on British therapeutic communities was descriptive, usually single case studies, and penned by therapeutic community practitioners themselves, rather than impartial or rigorous evaluations (e.g. Jones 1952;Bion 1960; Foulkes 1948; Main 1946;Harrison 2000); this sort of 'practitioner research' continues today (Black 1999;Coombe 1995).The literature then moved to more sociological, anthropological studies of therapeutic communities, conducted by outsiders (e.g.Rapoport 1960). Although more impartial, these studies were not always well received by practitioners (Jones 1968), a negative reaction itself then studied by sociologists (Rapoport & Manning 1976). However, Rapoport's study of the Henderson Hospital in England became recognised as a seminal text on democratic therapeutic communities, and some of it's classifications, for example the four 'pillars' of democratisation, permissiveness, reality confrontation and communalism were regarded as criteria to be achieved 2 and standards to maintain. These criteria have been reworked recently to fit in with contemporary democratic therapeutic community practice (Haigh 1999). Subsequently, there were some comparative, again sociological, studies (Bloor, McKeganey & Fonkert 1988), but more recently there has been a growing body of evaluative research in the UK on the effectiveness of the democratic therapeutic community, particularly in mental hospitals and prisons (Chiesa & Fonagy 2000; Chiesa, Iacoponi & Morris 1996;Cullen 1994;Marshall 1997;Newton 1997;Shine 2000;Warren & Dolan 2001).In the United States, a different type of therapeutic community -the 'concept house' -emerged, with the founding of Synanon by Charles Dederich, and then Daytop Village, aimed at the treatment of drug addicts. Here again, the early literature was descriptive, but also anthropological and sociological, and mainly written by outsiders to the therapeutic community, more interested in organisational than practice issues (Yablonsky 1965;Sugarman 1974). However, the focus of therapeutic community literature in the USA changed quite quickly, from the early 1970s...

A New Therapeutic Community: Development of a Compassion‐Focussed and Contextual Behavioural Environment

“…From these results, studies having the following characteristics were selected: (i) comprised of a matched-control trial or RCT and (ii) compared TC with a different type of treatment (rather than no treatment or early discharge from the TC). These criteria are more stringent than the ones used by Lees et al (2004) who permitted matchedcontrol trials comparing dropouts and completers from the same TC; thus, we do report below on some such studies that were identified by Lees et al (2004). We did, however, include studies where the control condition was standard incarceration, or treatment that was less frequent than the TC programme; yet such studies also have clear methodological limitations since it is possible that a non-TC treatment of similar frequency could produce equal or better outcomes.…”

“…The vast majority of the identified studies relate to substance misuse and/or forensic services, including six of the eight RCTs identified by Lees et al (2004). There is some (limited) evidence for secure TCs being superior to standard prison services (in terms of reducing risk of future offending behaviour) and very little evidence for TCs being superior to standard treatment for substance abuse.…”

Outcomes of therapeutic community treatment for personality disorder

“…Although DTCs are not included within the National Institute for Clinical Excellence (NICE) guidelines for the treatment of PD (Antisocial PD -NICE, 2010; Borderline PD -NICE, 2009), they continue to be used in community and forensic settings with promising results (Lees et al, 2004;Warren et al, 2003). The limited 'gold standard' evidence base (otherwise known as Randomised Controlled Trials -an experimental design involving random allocation to treatment and control conditions) for this intervention compared to other developing psychotherapy treatments for this client population, such as Cognitive Behaviour Therapy (CBT) and Dialectical Behaviour Therapy (DBT) (NICE, 2009) has prevented its inclusion within treatment recommendations (Pearce & Autrique, 2010).…”

“…This inclusion criterion was used in a previous review (Lees et al, 2004). Studies that focused on different models of TC (e.g.…”

“…TCs have previously been defined in terms of two broad categories -concept and democratic TCs (Lees, Manning & Rawlings, 2004). Concept TCs were specifically designed to treat individuals with addiction difficulties, and are differentiated from DTCs via their use of a social hierarchy, with experienced residents and staff harbouring increased authority (Vandevelde et al, 2004).…”