The notion of the therapeutic community emerged in the 1940s and was developed in the UK throughout the subsequent decades. Therapeutic communities developed participative approaches to working with people with long term mental illness. Usually residential, they offered a complete therapeutic milieu with therapists and patients living in the same environment and within the same ‘rules’, with patients being seen as active participants in their own and each other’s treatment.
The researchers in this study were interested to apply the ideas behind the therapeutic community to a secure setting for men with mild learning disabilities and personality disorder.
They worked with an intervention group of over 11 men and compared this group on a number of measures with a pragmatic control group of 10 men, who were receiving treatment as usual. They did the work over a period of twelve months and collected information on violent incidents, seclusion hours, and informant and self-report clinical outcome measures at three time points – six months before, at six and 12 months after the start of the intervention.
What they found was that there were clinical changes in the therapeutic community group which showed comparatively less pathology over time and in relation to the comparison group.
They found though that change was more likely for scales that measured internalising problems rather than in those that measured externalising problems. They also found that the mean number of violent incidents did not reduce over time.
There was a strong trend towards reduction in seclusion hours in the treatment group over time and there were significant differences between groups found at the six and twelve month stages.
The authors point out that there is little literature on this approach in people with learning disabilities and that the sample size was very small. Literature in the mental health field has suggested a need for a minimum of 18 months in therapeutic community treatment to bring about treatment effects. At this point therefore, the findings are interim and they plan to complete a further evaluation after two years.
They conclude that their findings suggest that therapeutic community treatment as outlined in their study is consistent with involvement and choice and that the preliminary findings from this initial evaluation are promising, suggesting the theraprutic community approach may be a
potential mode of treatment suitable for a proportion of patients with learning disability in secure conditions.
Evaluation of a therapeutic community intervention for men with intellectual disability and personality disorder, Morrissey C et al., in Journal of Learning Disabilities and Offending Behaviour, 3 1,.52 – 60
The results of this study reates more discussion around use of therapeutic community (TC) for people LD and personality disorder with offending behaviour. My criticism of comparing patients in a therapeutic community with a control group is that therapeutic community patients are a highly selected group of individuals. For an example, patients who have been in seclusions are not eligible for TCs. There are various other crietrias used when selecting patients for TCs. This itself makes the results questionable especially if outcomes are measured based on number of seclusions. We need to think of different methodologies and outcome measures when evaluating therapeutic communities.
Thanks for your comment and adding your concerns about this study. I think the authors do have a non intervention group who are also in the forensic setting and this is an intitial evaluation. There will be more from this study in the coming months,
While TC’s are generally selective (as are most interventions) this paper indicates that the men were placed on the TC pragmatically as part of a wider reconfiguration of services. Seclusion use was not used as a criteria for excluding people from the TC. Furthermore, the profile of the men placed on the TC appears to have been comparable to the profile of the men who were transferred to the TAU. I think this suggests that they are comparable?
Also, its apparent that the data collected reveals changes in the TC group over time – the seclusion hours reported at 12 months post are less than the seclusion hours for the same group of men before they went into a TC. So while additional methodologies may be useful lets not throw the baby out with the bathwater – reduced seclusion, reduced impression management and reduced anxiety are surely positive outcomes for this group of men?
Thanks for your comment Steve,
as I pointed out to Bhathika, it is also the cse that this is an initial evaluation, so we are expecting some more details of the outcomes over a longer period. If you have access to the journal, there is a longer description of the development of this approach in the journal of learning disabilities and offending behaviour http://www.emeraldinsight.com/journals.htm?issn=2042-0927&volume=3&issue=1&articleid=17032352&show=abstract&PHPSESSID=19bekmir4jt455r2et7jrp5rk0 ehich you might find interesting,