The efficacy of therapeutic communities in the treatment of personality disorders

A therapeutic community (TC) is a complex, psychosocial intervention in which participants come together to explore their emotional, behavioural and psychological functioning in a communal, ordinarily residential setting. Staff provide safe containment and a psychotherapeutic framework. Personal accountability and democratic decision-making are highly valued: the treatment is conceptually 'delivered' by other community members, whose analysis of individual functioning has the legitimacy of peer insight. Proposed changes in DSPD legislation, and recent policy directives from NIMHE promoting treatment for personality-disordered patients, have emphasized the opportunity for TCs to establish themselves as key providers for this difficult group. However, TCs do not traditionally share the diagnostic language of psychiatry, and have so far failed to provide the evidence on which their efficacy might be judged. It remains uncertain who they are treating and what measurable effects treatment may have, as well as how long patients need to stay to benefit. Existing studies are few, often methodologically flawed and use disparate outcome measures. TC champions argue that the 'gold standard' randomized controlled trial is difficult to implement, mainly because patients are unlikely to consent to randomization, and 'control' their own dose by leaving the community at a point of their own choosing, often in the early days of treatment. Variation between TCs and uncertainty about the personality profiles of the clients they accept, reduces the generalizability of the little evidence available. TCs may need to establish credible measures of efficacy, determine which type of patient they can help, and provide greater choice and flexibility to prospective residents if they are to take a greater role in treating personality disorders.