Rep36 Understanding Personality Disorder

3.2.2c Democratic therapeutic communities
Although there have been several large scale
literature reviews of the effectiveness of
therapeutic community (TC) approaches (Lees,
Manning & Rawlings, 1999; Warren, Preedy 
et al
,
2002), methodological difficulties inherent in
the research have so far prevented the
emergence of clear conclusions. Additionally,
serious ethical concerns have been expressed
about the appropriateness of randomised control
trials for this population (Norton & Warren,
2004; Roth & Parry, 1997; Slade & Priebe, 2001).
Also, the different types of clients, treatment
settings, treatment interventions and research
methods involved make it difficult to compare
the results of different studies. Further problems
arise from the lack of appropriate control groups
and the difficulty of controlling for external
influences, such as the passage of time and other
interventions received during the follow up
periods. 
Despite these difficulties, research reviews
have suggested that the use of TC approaches
with personality disordered patients is promising.
For instance, a five-year follow-up study of the
Henderson Hospital found an absence of
convictions and hospital admissions in 36 per
cent of the treated group versus 19 per cent of
non-admitted controls. The success rate
increased to 65 per cent for those spending nine
months or more in treatment (Copas 
et al
.,
1984). A more recent replication of this study
using as a comparison group those not admitted
due to funding problems achieved similar results
(Dolan, Warren 
et al
., 1995). Similarly, 42.9 per
cent of a treatment group showed significant
clinical improvement on the Borderline
Syndrome Index compared to 17.9 per cent of
non-treated patients (Dolan, Warren & Norton,
1997). Chiesa and Fonagy (2000) have compared
the results of an in-patient only programme (up
to 16 months) with a shorter-term six-month
residential programme combined with 12–18
month group therapy at follow-up and outreach
intervention. The combined treatment was more
successful, emphasising the importance of
continuing support in the community. A control
group receiving Community Mental Health
Team treatment as usual showed little or no
improvement over time (Chiesa, Fonagy, Holmes
et al
., 2002). A more recent 12-month follow-up
study using a similar comparison group found
significant reductions in impulsive urges and
behaviour in those who had received treatment
in a democratic therapeutic community
compared to a non-admitted sample. These
changes were particularly striking in relation to
self-harm (Warren, Evans, Dolan & Norton, 2004).
Research has examined the cost-benefits of
therapeutic community treatment. Dolan 
et al
.,
(1996) identified an average saving of £12,658
per patient in costs of psychiatric and prison care
in the year following treatment compared to the
year before treatment. Other researchers have
reported similar cost-benefits with residential
therapeutic community treatment (Chiesa,
Iccoponi & Morris, 1996; Davies, 1999).