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Volume 31, Issue 4 (winter 2010)

EDITORIAL: Evidence of Evidence

Rex Haigh, Steve Pearce and John Diamond

ABSTRACT: No abstract.

Death, Taxes, Certainties, Groups and Communities Or NICE and the Deathly Hallows

Chris Evans

ABSTRACT: This paper argues that the laudable wish to fund health and social care through taxes makes governments desperate for rigorous probabilities to contain these costs. Statistical analysis of double-blind randomised controlled trials (DBRCTs) is beautifully adapted to this task for drug interventions. However, statistical analyses of experiments have been worshipped as if they were not just excellent methods to describe uncertainty but elevated as they provided certainties. Interestingly, the statistical logic that enables the randomised controlled trial (RCT) to test differences between two drugs does not work for therapeutic communities (TCs), nor for interactive therapy groups nor a number of other psychosocial interventions. This paper sketches out why the statistical logic for cannot distil certainties from RCTs of TCs. However, it argues that this a point of contact enabling us to work with governmental evaluators to help them retain the strengths of their own methods and community processes while perhaps gaining from some of ours.

Manual or Matrix
How Can We Know Our Outcomes?

R.D. Hinshelwood

ABSTRACT: The assumption that all forms of medical and psychological therapy should conform to the production of evidence advocated by NICE (The National Institute of Clinical Excellence) appears to evade the question whether they all can. In certain kinds of therapies within the mental health field, from psychoanalysis to the therapeutic community, there are significant issues about the applicability of these standard scientific methods. In this paper, I highlight some of the issues.

On the Need for Randomised Trials of Therapeutic Community Approaches

Steve Pearce and Mieke Autrique

ABSTRACT: A number of objections have been raised in response to calls to carry out randomised experimental studies in therapeutic community (TC) settings. In the context of an increasing emphasis on particular kinds of evidence to demonstrate the usefulness of health care interventions, a meeting of experts was convened in Oxford, UK, in 2008 to examine the question of whether such studies were desirable and possible. Taking these discussions as its starting point, this paper examines the objections to carrying out a randomised trial of TC treatment, and describes how a randomised controlled trial of health TCs for personality disorder currently underway in Oxford has addressed them.

A Synthesis of Outcome Research at Grendon Therapeutic Community Prison

Michelle Newberry

ABSTRACT: This paper summarises outcome research conducted at Grendon therapeutic community prison. Research into the quality of prison life has shown that, overall, prisoners perceive their quality of life at Grendon more positively than offenders in other prisons of the same category, particularly with regard to dignity, personal development, and relationships between prisoners and staff. In addition, prisoners and staff at Grendon tend to perceive the social climate to be more positive than that of other secure settings in the UK. Studies which have evaluated changes in the psychological wellbeing and attitudes of prisoners have found that, following treatment at Grendon, offenders experience less anxiety and depression, are less hostile, tough-minded and impulsive, and have fewer negative relating tendencies. Furthermore, Grendon residents are less likely to be reconvicted than prisoners selected for Grendon but who do not come to Grendon, and those who remain in treatment for at least 18 months demonstrate a reduction in reconviction rate of between one-fifth and one-quarter.

An Achievable Standard for In-house TC Evaluation?
Service, Individual and Group-level Outcome Data for CHT Therapeutic Communities

Mark Freestone, Beatriz Sánchez España, Nesha Kelly and John Gale

ABSTRACT: This paper presents the results of a naturalistic evaluation of the therapeutic community (TC) projects comprising Community Housing and Therapy (CHT), a network of TCs in the South East of the UK. A panel sample design was used and data were collected at set periods by in-house research assistants working at the TCs, which were then gathered and analysed centrally, with reference to previous studies performed by the Association of Therapeutic Communities and others. The project was conducted without significant external funding and was intended to demonstrate what could be achieved by a motivated in-house research team.
The study had a high initial take-up from clients, and regular recruitment, but experienced a high dropout rate over its 12-month duration. The results suggested the heterogeneous nature of presenting difficulties residents experienced with mental health and social functioning when entering CHT, which were equivalent in many respects to those individuals admitted to NHS psychotherapy services and in some cases more severe than those in all but prison TCs. They also indicated that those admitted to CHT during the study showed statistically significant overall improvement on most psychometric measures, with 31% reporting reliable and clinically significant positive change and 11% a reliable deterioration.

Evaluating the Effectiveness of Treatment in the Therapeutic Community: CORE Outcomes and Health Care Contacts

David Rawlinson and Chloe Bennett

ABSTRACT: This study took place within the Complex Needs Service at the Winterbourne House Therapeutic Community in Reading.
The aim of this investigation was to evaluate the effectiveness of the therapeutic community (TC) for individuals with complex needs (Personality Disorder), with regards to health care service usage pre- and post-treatment. The average number of health care contacts made by patients in the two years before they entered the TC was significantly higher than the number of contacts made in the two years following discharge from the TC. In the 2-8 years after TC treatment, the number of health care contacts slowly increased, and more steeply so for those who had left the TC in an unplanned manner compared to those who left the TC in a planned manner.
Another aim of the study was to evaluate the effectiveness of the TC according to treatment outcomes measuring functioning, wellbeing, presenting problems, and risk. A comparison of CORE scores at the beginning and end of treatment revealed that CORE scores were significantly lower at the end of treatment in the TC.
Therefore, this investigation indicates the clinical effectiveness of treatment in a TC for complex needs patients, and suggests cost-effectiveness with regards to significantly reduced health care service contacts post-treatment.

The Longer-term Clinical Outcomes of a DBT-informed Residential Therapeutic Community; An Evaluation and Reunion

Mark McFetridge and Julia Coakes

ABSTRACT: A new synthesis of therapeutic interventions (dialectical behaviour therapy within a therapeutic community) developed from the growing evidence of positive outcomes for these apparently distinct approaches for people with the complex difficulties currently considered to represent a borderline personality disorder. All clients who joined between 2000 and 2007 completed a brief self-report measure and gave information about their experience of therapy. With the questionnaire, they received an invitation to a reunion group/day to further share and discuss their experience. Participants were women from across the UK with a history of severe self-harm and self-defeating behaviour. People responding to postal contact included those who left without completing the therapy programme. Responders were indistinguishable from those who did not respond on a range of indices. However, there was a clear difference between those women who completed the programme and those who had not at a mean follow-up period of five years. Those completing therapy had highly significant reductions on the CORE-OM in contrast to those not completing, who did not improve on this measure. Further qualitative analysis of written and verbal responses using interpretative phenomenological analysis indicated three major themes concerning change for clients: changes in sense of identity, changes in life, and changes in thinking. The longer-term changes in individuals that may be attributable to participating in a DBTinformed therapeutic community are explored.

Implementing Routine Outcome Measurement Within a Therapeutic Community Setting: The Ashburn Clinic Experience

Brett Ferguson

ABSTRACT: Ashburn Clinic is a general psychiatric hospital which functions as a democratic therapeutic community. For over a decade both patients and clinicians have participated in measuring outcome in day-to-day clinical practice. This paper describes the planning, implementation and development of a system for routine outcome measurement (ROM). With an emphasis on practical issues, it discusses ways of facilitating the involvement of staff and patients in the outcome assessment process, and describes some of the main factors to be taken into account in selecting outcome instruments. Both the potential gains and difficulties of ROM are considered, with regard to the collection and utilisation of outcome data. It is concluded that, in this therapeutic community setting, the costs of routinely assessing outcome are outweighed by the benefits both for individual patients and staff and for the community as a whole.

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