ASSOCIATION OF THERAPEUTIC COMMUNITIES

E-List Discussion Thread 1:

Therapeutic Communities, Research, Evaluation, Campaigning

The E-List Discussion pages are taken from the Association of Therapeutic Communities E-Mail Discussion List. You can join the List and the discussion at http://www.psyctc.org/atc .

Unless otherwise stated the opinions expressed in this discussion are those of the authors alone, and not of the ATC or any institution or organization with which they may be associated.

1.

Subject: [ATC] evaluating & campaigning
Date: Tue, 2 Feb 1999
From: Chris Evans
R&D Consultant, Tavistock & Portman NHS Trust

I'm involved in a debate/discussion in ATC on Friday about researching TCs and I thought I'd call on your collective wisdom. Three questions:

a) what, if anything, do you evaluate routinely in your TC? e.g. any assessments etc.

b) what, if any, do you regard as interesting research that has been done on TCs?

c) what, if anything, have you found useful when arguing for the creation and/or continuation of your TC?

I'd really appreciate ANY feedback, flippant, serious, pointers to other things etc. Share it with the list!

Chris

2.

Subject: Re: [ATC] evaluating & campaigning
Date: Wed, 03 Feb 1999
From: David Kennard
Head of Psychology and Psychotherapy, The Retreat, York

Dear Chris, off the top my responses to your three questions are:

a) not strictly applicable as The Retreat does not yet function as a TC, but on the PD unit I think we use measures related to PTSD and Dissociation.

b)The old Attitude to Treatment Q of Caine and Smail; Ward Atmosphere Scale; Woods Community Meeting Rating Scale (TC Jnl); Almond's 1969 Complex stuff on models of change; The old paper by Agnes Miles using sociometric tests with delinquents; The audit papers by Penny Campling and Jane Knowles (TC Jnl)

c) I reckon Bridget's 1996 paper on cost effectiveness is the best, plus Higgins on anyone needing support tonight (if I was arguing for day TC); it would depend a bit on the setting. What's useful is putting the case for a service for a particular client group where there is a known need - e.g. eating disorders - and being responsive to referrers.

Hope this helps
David

3.

Subject: Re: [ATC] evaluating & campaigning
Date: Thu, 4 Feb 1999
From: Chris Evans
R&D Consultant, Tavistock & Portman NHS Trust

Very much so. Come on you others, don't be bashful. I'm sure others have something to say about at least one of a), b) or c)!

Very best all,
Chris

4.

Subject: [ATC] evaluating and campaigning
Date: Sat, 06 Feb 1999
From: Keith Burnett
A worker in a hierarchical TC for recovering drug users

a) what, if anything, do you evaluate routinely in your TC? e.g. any assessments etc.

The progress of residents is routinely recorded in notes in their files, and summarised when requested by care managers (the frequency of which varies from one local authority to another) or for a court report. With some residents progress towards specific goals, e.g. managing anger without resorting to violence, is monitored, but not on a numerical scale.

b) what, if any, do you regard as interesting research that has been done on TCs?

I don't really have time to go through my "reading list" at the moment, but there's some good stuff out there. For me the main difficulty is finding research that is not written from a 'medical model' or purely psychological perspective. I'm doing some research at the moment on client perceptions of a hierarchical TC and have found comparative studies thin on the ground.

c) what, if anything, have you found useful when arguing for the creation and/or continuation of your TC?

This isn't something I've been involved with so far, but I would propose that:

1. ) It helps people who have failed to cease drug use with other treatment models
2. ) The existence of hierarchical TCs is a fundamental part of having a "mixed economy of care" that is not entirely dependent upon care in the community
3. ) The model we use gradually reintroduces people to independent living while working with them to develop the skills to cope with this, thus reducing the risk of relapse.

'Hope this is of some use. The results of various searches on databases for relevant research are available from me for anyone interested.

Keith Burnett

5.

Subject: Re: : [ATC] evaluating & campaigning
Date: Sun, 7 Feb 1999
From: Fiona Warren
Robert Baxter Research Fellow (Henderson Hospital), St. Georges Hospital Medical School

Dear Chris and others who were involved in this debate,

How did it go in the end - I'm sorry I didn't have time to reply to your mail by Friday but I did give Diana Menzies some of my thoughts specifically about RCT designs and their application to TCs. It would be really interesting to hear some feedback about it.

Best wishes,
Fiona

6.

Subject: Re: : [ATC] evaluating & campaigning
Date: Mon, 8 Feb 1999
From: Chris Evans
R&D Consultant, Tavistock & Portman NHS Trust

I think Rex and I were the only two there who are on the list/on Email. It was a good meeting. At one point I thought we were going to be very polarised against John Geddes, the "Evidence Based Mental Health" (EBMH) man from Oxford but that proved unfounded.

We discussed the practicalities and theoretical issues that would bedevil doing a randomised controlled trial of TC intervention and certainly agreed there would be many devils. However, we also all, John G. himself very much included, thought:

a) the time was ripe for doing it

b) the only methodologically justifiable way to do it would be on a large scale with some real potential spin offs for TC development (fantastical to be saying this alongside the news of the closure of Greenwoods [see: Greenwoods - ed.])

c) that there were eminent and very, very able, experienced people in the EBMH ranks who might be very supportive of a large scale exercise and not merely spoiling nor simply "telling us what to do".

We saw this as representing something potentially healthy for the TC movement and for the EBMH movement as, whatever the eventual practicalities. I had the feeling we could move beyond what Diana Menzies very aptly caught about the feeling that in the past methodologists whose work really comes out of pharmacology or out of cognitive/behavioural individual work, come along and say we should do things and seem to assume that money to do them will magically follow too. I felt that John G. would acknowledge to some extent that there's much in this for them and that some of those people have previously gone away learning nothing from us about how their system lacks much that would change it from a hectoring and reductive model to a genuinely therapeutic culture of challenge and real inquiry.

One real question was about international collaboration. Another was about making sure an RCT was only part of the development of enthusiastic, real and self-critical research in the TC world, that it would need to link with naturalistic and qualitative components.

Hm, must take these rosy specs off....

Very best wishes all,
Chris

7.

Subject: [ATC] evaluating and a sad event
Date: Mon, 08 Feb 1999
From: David Kennard
Head of Psychology and Psychotherapy, The Retreat, York

Chris's response to Fiona is certainly encouraging re the discussion with EBP people. I wanted to add a comment to Chris' final point about the apparent contradiction with the closure of Greenwoods. Sad as that is for the staff I think it may be part of a process that has been going on in the movement for the past decade or so which is generally positive. I don't know enough about Greenwoods to be sure if this applies to them, but what I have noticed is that the generalist 'admission unit' type of TC which takes a range of disturbed individuals and offers a general TC environment have gone, (e.g. at Fulbourne, Littlemore) and the surviving TCs are the ones that target a particular disorder with a TC model carefully tailored to their needs by a highly trained staff group (e.g. Winterbourne, Cassel, Henderson, FDL).

So I don't think talk of an RCT evaluation is necessarily at odds with this sad event but may be part of the same process of sharpening the focus of TCs and the skills needed to run them. Anyway, it's a thought.

David

8.

Subject: [ATC] evaluating and a sad event
Date: Mon, 8 Feb 1999
From: Bob Hinshelwood
Chair, ATC

I think it is not true that Greenwoods was a generalist 'admission unit' like Littlemore and Fulbourn used to be. It was the usual mixture of personality disorders merging towards psychotic patients in remission with some evident positive motivation. Perhaps, the level of patient's difficulties was a little higher than the usual TCs always mentioned(Winterbourne, Cassel, Henderson, FDL - are there in fact any others???).

It is a problem of the ATC often to see beyond those four (musketeers) and that the majority of members of the ATC are dealing with the rehabilitation of chronic schizophrenic patients in the wake of large hospital closures (see the new TC Directory at the ATC website). Those PD units amount to less than 100 residents. How many places do the other units comprise?

It would be interesting to know the proportion of places for PD residents compared to rehab places.

Bob Hinshelwood
Chair, ATC

9.

Subject: Re: [ATC] evaluating and a sad event
Date: Mon, 8 Feb 1999
From: Ray

It does sound a little more encouraging than the last few years where TC's have had a rough ride.

In answer to the bit about Greenwoods. I have their brochure and it states the following: Acting in support of mainstream NHS and Social Service resources, Greenwoods, a residential psychotherapeutic community, bridges the gap between the acute ward and the community.

HOW DOES GREENWOODS DO THIS?

Greenwoods uses a psychosocial model to work with people at an individual, interpersonal, group and community level in an environment that stimulates the turning of experience into learning. Each community member, after assessment, will be asked to agree with their keyworker and referring professional a care plan that will include an appropriate mix of:

Individual psychotherapy
Art drama
Small and large group work
Activities
Occupational therapy

The sort of clients who would be suitable:

The functional criteria related to needs assessment rather than clinical diagnosis. Such people may have:
Severe Personality Disorders
Certain Resolving Psychotic Illnesses

Those suffering from:

Depressive States
Obsessive Compulsive Disorder
Anxiety Neuroses
Post Traumatic Stress Disorder

Those recovering from:

The Consequences of Childhood, Emotional, Physical and Sexual Abuse
Eating Disorders
Severe Emotional Problems
Substance Misuse.

They send a lot of info for new potential clients, yet no-where is there any information on success rates.

I have found that the biggest reason why Cornwall Healthcare Trust shun away from TC's is the lack of information on results for poundnotes.

It can be far cheaper to allow a client to carry on the revolving door syndrome. Or treat in County with treatments that may not be totally alright, but have a chance of working.

I sense from local CHT professionals that they are not convinced TC's really achieve anything. It is far cheaper to treat a client with an hour's therapy once a week than to send to a TC. The financial climate is not available to experiment with unproven ways of treatment.

Anyone in Cornwall who does manage to find funding for TC work, are made to realise what a great favour is being done for them. Also how lucky they are be able to attend a placement.

I have spent a lot of time spouting the need of TC's and there are a lot of people who would really be able to re-join life if they had the chance to re-learn, change and know how to BE.

Well! that's off my chest ...... now back to Greenwoods

They don't take all and sundry, they will not admit those with unstabalised acute conditions which require intensive medical attention and those who are actively abusing drugs or alcohol.

I hope that answers your question David.

Ray

10.

Subject: [ATC] Ray's message about Greenwoods
Date: Mon, 8 Feb 1999
From: Rex Haigh
Consultant Psychotherapist, Winterbourne Therapeutic Community

Where are you Ray - it feels different from here.

Have you seen the economic and research evidence in the new Jessica Kingsley book? And the Leicester cost-offset study in this month's Psychiatric Bulletin?

There are also bigger research initiatives planned with bids in, and helpful noises from bodies like HSPSCB and the Royal College.

Our local NHS trust is quite persuaded by the argument that our day-TC brings in nearly twice the contract income that it costs - and caters for an otherwise very troublesome, and bed-blocking, patient group. And I'd want to question exactly when "intensive medical attention" is required: I think it's more usually the iatrogenic cause of escalating disturbance in borderline personality organisation.

I'd like to talk to you about how we as an organisation (ATC) can start to dispel these unhelpful beliefs about TCs. Ideally, we'd feature in the new mental health service frameworks - and we're trying to lobby there - but I doubt that our evidence base is robust enough yet.

Rex

11.

Subject: Re: : [ATC] evaluating and a sad event
Date: Thu, 11 Feb 1999
From: Fiona Warren
Robert Baxter Research Fellow (Henderson Hospital), St. Georges Hospital Medical School

I didn't see many replies to Chris' question about what measures TC's are currently using to describe their client groups or evaluate their outcomes but it worries me that we are discussing conducting large-scale RCT's of outcome before establishing a solid base of descriptive work which addresses precisely the issue illustrated by Bob's reply to David.

RCT's for multiple TCs would surely be rugby tackled by 1) the differences in patient groups currently being treated by different TCs in this(or other) countries and 2) by the differences in treatment being received under the name of "TC".

I think we should know more at least about 1) before we consider comparative outcome work.

I have recently done some work with a Dutch TC (very different in aims, client group and treatment structure to ours) where we found we had used some common instruments. We made some comparisons between patient groups which have produced some very interesting results about differences between these groups (differences which, I might add were not those predicted). We did this by retrospectively pooling data and I have a suspicion that we may be able to do this in this country too. This is a fast way of at least partly answering 1).

I think it would be useful to keep Chris' original question live on this list for a while. What do people think of this idea?

Best wishes,
Fiona

Go to response by Chris Evans, 17]

12.

Subject: Re: : [ATC] evaluating and a sad event
Date: Thu, 11 Feb 1999
From: Bob Hinshelwood
Chair, ATC

I was very pleased to see Fiona's message about the comparison of treatment groups in different TCs (or rather the amazing lack of such research). It was my original hope in supporting the development of a Research group. It seemed essential that there should be a common core of research instruments from which we could find, at the very least, the patient profiles in various communities. I had come to this view when trying to get the Cassel and the Henderson researchers to compare their populations of patients. Not only did they have no single research tool in common, but there was a considerable 'emotional' reluctance to decide to do so.

I am pessimistic about this as, at that time, I was Director at the Cassel and without banging heads together it was impossible to make headway with comparative research - even of a descriptive kind.

It is a pity that the ATC Research group has lost impetus. Multi-mega-buck, Europe-funded research projects are glamorous, and people can make their names at that, but simple things could be achieved if it was agreed that all group members of the ATC would use certain simple and common tools in any research they start. If we could live with the obvious fear and rivalry inherent in our inter-community relations, we could begin to generate useful results in not too long a time.

I hope people will take Fiona's comments seriously and think again.

13.

Subject: Re: : [ATC] evaluating and a sad event
Date: Fri, 12 Feb 1999
From: Chris Evans
R&D Consultant, Tavistock & Portman NHS Trust

I have been involved in the research at the Henderson for nearly ten years and know of the Cassel's work through their papers, presentations at meetings and through the APP initiative. I think the problems of changing data collection in units like that, already committed to particular protocols are huge and have real world determinants in terms of credibility with a wider audience, as well as emotional determinants. The impact of the Henderson and other research on that wider audience has, I'm sure, been helpful to all democratic TCs provided they play those and their own cards right.

However, I fully support the idea of using a common core measure or group of measures, I wouldn't have put a lot of the last four years into developing the freeware CORE "outcome" measure if that weren't the case.

For TCs who don't have the research support resources that places like the HH & Cassel have built up, the CORE with support from Leeds doing the processing and reporting, may be a real step forward. I can say more about the CORE if people want but Bob raises a lot more points and Fiona is also raising one of the crucial ones and I hope others will come in on all this so I'll take a break!

Best wishes all,
Chris

14.

Subject: [ATC] Evaluation instruments
Date: Fri, 12 Feb 1999
From: David Kennard
Head of Psychology and Psychotherapy, The Retreat, York

I take the point about looking beyond the core NHS therapeutic communities to all those working with people suffering from chronic mental illness, as well as with offenders and the ex-addicts. In fact we have been looking at best measures for the rehabilitation unit at The Retreat. It seems hard to imagine one measure that would embrace all these types of dysfunction. One problem seems to me that, when it comes to evaluation, TCs sit between the psychotherapy field which favours self-report measures done by the client, and the psychiatric rehabilitation field which has till recently used measures of other people's views - usually professionals. As mentioned by Chris, the CORE measure is the result of years of work to put together the best yet self-report measure, and the Inventory of Interpersonal Problems, and the Brief Symptom Inventory are also widely used. I also use the old Hostility and Direction of Hostility Questionnaire which Grendon has some interesting data on. There also are now a number of simple, well thought out interview based measures for assessing levels of need from client/staff/carer perspectives, developed very much for use with people with chronic mental disorder, but which make a point of obtaining different views. The emerging front runner seems to be the Camberwell Assessment of Need - CAN. And there is also HONOS - Health of the Nation Outcome Scale - which provides a comprehensive score of severity of mental disorder, from the interviewer's viewpoint.

I think all these offer quite a good menu between them. I'd also be interested to know what measures Fiona used in her Anglo-Dutch comparison. The criteria for choosing any agreed package would have to somehow reconcile the very different levels of functioning of residents at the Cassel, say, and a TC-run hostel for people with chronic psychoses, and it might be useful to go for measures that are widely used so that TC populations can be easily compared with others.

David

15.

Subject: [ATC] TC research
Date: Tue, 23 Feb 1999
From: Rex Haigh
Consultant Psychotherapist, Winterbourne Therapeutic Community

I don't feel as pessimistic about TC research as Bob.

I also take issue with him about the research group losing impetus: it is currently being extremely active in bidding for funding from various sources, and has researchers and contacts who are interested in getting involved. Just wait till we get our hands on some of the money!

It is also very well supported by attendees from most NHS TCs and several others, and has gone a long way to coordinating the use of questionnaires in common. Of course, such instruments are necessarily reductionist and rightly viewed with suspicion: but CORE seems better than most.

We have also had a very energetic and dynamic meeting with several of us and John Geddes, who is a well-established champion of evidence-based mental health in Oxford. We are scheming ambitious multicentre research projects, probably with day TCs, and not unhopeful that they will happen (3-5 years to get started in earnest, 5-10 years to produce definitive results).

There was a real sense of excitement and that the time is ripe - and almost that, at last, TCs have got together and managed to talk to each other (and their superordinate systems) about how to proceed.

And we have a major session at the Society for Psychotherapy Research conference next month on "Assessing Complex Treatments", with Bill Piper from the Edmonton project in Canada.

And there's more in the pipeline....

Of course, there's many a slip twixt cup and lip - but things ARE happening.

Rex

16.

Subject: [ATC] Research: Adaptation
Date: Thu, 25 Feb 1999
From: Craig Fees
Archivist, Planned Environment Therapy Trust Archive and Study Centre

I'd like to pick up on the theme of evolution and adaptation for survival which David Kennard uses in "Therapeutic Communities are back..." (Therapeutic Communities journal 19:4: http://www.therapeuticcommunities.org/journal-kennard.htm).

Research is a tool that therapeutic communities have used to adapt to a radically changing environment, with considerable success. Much of the UK research that we hear about has been generated in relation to the specific environment of the NHS, where a particular culture of business-like financial accounting has held a powerful decision-determining role for some time. It may have gone against the grain for many people who do the work in therapeutic communities, but the Northfield Experiments, among others, showed that these kinds of realities are there to be worked with - not ignored, defied or railed at. Recent targetted research has fortunately engaged with those realities.

Two points:
(1) These key decision-determining environments are themselves changing systems, which have to respond to external as well as to their own internal dynamics; not unlike therapeutic communities themselves; and

(2) The environments in which both of these live and work are changing, deeper, and richer than they themselves.

What follows from this is
a) tremendous gratitude for the kind of research which has proved so successful over recent years; with the caveat that a close eye needs to be kept on trends, for example, within business whence many of the determining winds currently blow. A phrase which leapt out from the most recent issue of "Managing Information" (published by ASLIB, the Association of Information Management; remember, I am an archivist, not a therapist) - "business leaders now believe that IT's intrinsic value should be established by qualitative as well as quantitative methods" - may be irrelevant, or may be a straw.

b) A query about how much therapeutic communities themselves do to make themselves rich sources of different kinds of potential research - how many of them regularly photograph and record aspects of themselves, generate and save internal newsletters, set aside brochures, keep minutes , logbooks, memoes, diaries=and keep them in safe conditions (out of the reach of water, vermin, mould, fire and human interference); much less make them available to researchers;

c) And a feeling, looking at the latest ATC Directory (on the web at http://www.therapeuticcommunities.org/directory.htm) and speakers at the local W.I. and Rotary Clubs, that therapeutic communities themselves are not making themselves as fully known and - in that sense - publically accountable, as one might expect of organisms whose survival depends on being engaged with and adapting to changing and changeable public moods, perceptions, and understandings.

I think what I am trying to say is that therapeutic communities have this extremely useful evolutionary tool available to them: The ongoing research has already proven its value, and must continue to develop and grow. But the most successful organisms in rapidly changing environments are those with the widest range and diversity of tools handy, both for engaging with their environments and for adapting to them. I'm not convinced that therapeutic communities are as rich with these as they can be; or perhaps even realise how rich they already are, which can amount to the same thing in a survival crunch. Only 28 of the 49 organisational members of the ATC even have a listing in the ATC's Directory of Therapeutic Communities, much less pages on the Web.

Changing tack: No one has mentioned the extensive research carried out over a number of years under Loren Mosher on Soteria House in California.

- Craig

17.

Re: : [ATC] evaluating and a sad event
Date: Sat, 27 Feb 1999
From: Chris Evans
R&D Consultant, Tavistock & Portman NHS Trust

This is a very belated response to Fiona's points. I'm sorry, it's long, I can't seem to make this succinct:

On 11 Feb 99, at 12:25, Fiona Warren wrote: "I didn't see many replies to Chris' question about what measures TC's are currently using to describe their client groups or evaluate their outcomes...What do people think of this idea?" [go to original, Response 11, for the complete text Chris quotes]

Whatever they think, they like me, have been sitting on it!

It's a serious issue. A randomised, controlled trial is great for comparing things that are alike in all ways except some way that is crucial to you and which you think you can replicate. The classics are, or course, fertilisers and medications. You can compare them with other variants or with inert substances and you can replicate the winner.

This is clearly not the case for TCs. They are complex human systems that are not replicable in that way and we do not currently know what are their "active ingredients" indeed, many of us think that approach can be oppressive and stupid. Less fundamentally but problematically, as Fiona says, we sometimes think we know that different TCs aim to take in very different people and we sometimes think they take in similar people and we're wrong.

However, as both Bob and Fiona show, having a common core profiling of people entering a good few TCs would be useful and showing that those profiles were not radically dissimilar and that the objectives and espoused methods and resources of some TCs were not radically dissimilar puts you in a position to do a randomised controlled trial (RCT) for those units if you can find something against which to compare residency in those units and find some satisfactory measures of change or outcome. The recent ATC research group meeting was of the opinion that we're nearing the point where refusing to contemplate a RCT and not researching the issues, particularly those of comparability and of a sensible control "treatment" will be conceeding the game rather than being rugby tackled. This is not to say that the final game will be rugby nor that it will be an RCT.

That's one of the issues here and Fiona seems to me to catch it well: you move from some elementary, if offputting to non-statisticians, maths, couched in clear logic and having some considerable utility, even beauty within its true field of application; to something more human, itself a human system, almost a rather deadly "game" which closes units and lays off staff at least temporarily.

For this reason I think Bob is harsh to chastise the research group (let he who is without sin Bob...!) For all I think he is right to advocate much more routine data collection, using comparable measures, and much more open comparison of results between TCs. I think the critical issue is that if we don't continue to move on we are hiding behind TC walls, not moving to the new era that David Kennard (and Bob and Jeff Roberts and many others) have been pronouncing of late. I thought Craig caught something of this in a recent posting and I think the, in 1999 rather odd seeming, counting that was so much a part of the first report by the Tukes, was so important in taking a very early forerunner of the TC style, forward and outward beyond the walls of the Retreat.

More thoughts people?

Reference (!): Tuke, S. (1813<1996>). Description of The Retreat, an institution near York for insane persons of the Society of Friends. Containing an account of its origin and progress, the modes of treatment, and a statement of cases. London, Process Press.

- Chris

18.

19.

This page is hosted and maintained on behalf of the ATC by
The Planned Environment Therapy Trust
"Supporting, promoting, recording and valuing therapeutic work in caring and healing environments/communities/institutions...".