Psychotherapy for severe personality disorderBMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7211.709a (Published 11 September 1999) Cite this as: BMJ 1999;319:709
Evolution is part of the therapeutic process of therapeutic communities
- Rex Haigh, consultant psychotherapist (firstname.lastname@example.org)
- West Berkshire Psychotherapy Service, Reading RG1 7YL
- St Ann's Hospital, London N15 3TH
- Psychoanalysis Unit, University College London, London WC1E 6BT
- Psychological Therapies Service, Royal South Hants Hospital, Southampton SO14 0YG
- Psychotherapy Section, Institute of Psychiatry, London SE5 8AZ
- University of Sheffield School of Health and Related Research, Sheffield S1 4DA
- Primary Care Mental Health Unit, University of Western Australia, Fremantle, WA 6160, Australia
EDITOR—Kisely bases his ideas of what comprises a therapeutic community on a model that has undergone considerable evolution and development over 50 years.1 The Henderson Hospital and its offshoots are based on a specific type of therapeutic community, which started the social psychiatry movement after the second world war. Although it still provides a robust and effective treatment, several other types of therapeutic community are now used in the treatment of severe personality disorder.
Perhaps the most radical departure is to run the programmes as day services, as occurs in Reading. Francis Dixon Lodge in Leicester does not use small group therapy, and the Cassell Hospital is unusual in incorporating individual psychotherapy in the programme. Research is clearly needed, but the methodological difficulties are formidable. The treatment is complex and volatile and is delivered in very different ways; patient drop out is often part of the clinical process, long term follow up is essential, and measuring robust and useful personality change is difficult.
Randomised controlled trials are being considered, for day units as well as the new Henderson units, but they will not answer the question “Is a different type of therapeutic community better than this one?” or “What is going on here that is important?” As each therapeutic community differs considerably from every other, findings from randomised controlled trials will be difficult to generalise. And as evolution in response to the administrative environment is part of the therapeutic process of these communities, they could not be considered therapeutic communities if they were exactly defined and not allowed to change.
A project funded by the National Lottery and covering 10 centres is under way to isolate the “active ingredients” across a range of therapeutic communities for severe personality disorder. It is being coordinated by the Association of Therapeutic Communities …