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Democratic therapeutic community treatment for personality disorder: Randomised controlled trial

  • Steve Pearce (a1), Lisle Scott (a1), Gillian Attwood (a1), Kate Saunders (a2), Madeleine Dean (a3), Ritz De Ridder (a4), David Galea (a5), Haroula Konstantinidou (a6) and Mike Crawford (a7)...
Abstract
Background

Democratic therapeutic community (DTC) treatment has been used for many years in an effort to help people with personality disorder. High-quality evidence from randomised controlled trials (RCTs) is absent.

Aims

To test whether DTC treatment reduces use of in-patient services and improves the mental health of people with personality disorder.

Method

An RCT of 70 people meeting DSM-IV criteria for personality disorder (trial registration: ISRCTN57363317). The intervention was DTC and the control condition was crisis planning plus treatment as usual (TAU). The primary outcome was days of in-patient psychiatric treatment. Secondary outcomes were social function, mental health status, self-harm and aggression, attendance at emergency departments and primary care, and satisfaction with care. All outcomes were measured at 12 and 24 months after randomisation.

Results

Number of in-patient days at follow-up was low among all participants and there was no difference between groups. At 24 months, self- and other directed aggression and satisfaction with care were significantly improved in the DTC compared with the TAU group.

Conclusions

DTC is more effective than TAU in improving outcomes in personality disorder. Further studies are required to confirm this conclusion.

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Copyright
Corresponding author
Steve Pearce, Oxford Health NHS Foundation Trust, Manzil Way, Oxford, OX4 1XE, UK. Email: steve.pearce@oxfordhealth.nhs.uk
Footnotes
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Declaration of interest

None.

Footnotes
References
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1 Coid, J, Yang, M, Tyrer, P, Roberts, A, Ullrich, S. Prevalence and correlates of personality disorder in Great Britain. Br J Psychiatry 2006; 188: 423–31.
2 Skodol, AE, Gunderson, JG, McGlashan, TH, Dyck, IR, Stout, RL, Bender, DS, et al Functional impairment in patients with schizotypal, borderline, avoidant, or obsessive-compulsive personality disorder. Am J Psychiatry 2002; 159: 276.
3 Hayward, M, Slade, M, Moran, P. Personality disorders and unmet needs among psychiatric inpatients. Psychiatr Serv 2006; 57: 538–43.
4 Bender, DS, Skodol, AE, Pagano, ME, Dyck, IR, Grilo, CM, Shea, MT, et al Prospective assessment of treatment use by patients with personality disorders. Psychiatr Serv 2006; 57: 254–7.
5 Pompili, M, Girardi, P, Ruberto, A, Tatarelli, R. Suicide in borderline personality disorder: a meta-analysis. Nord J Psychiatry 2005; 59: 319–24.
6 Zanarini, MC, Frankenburg, FR, Dubo, ED, Sickel, AE, Trikha, A, Levin, A, et al Axis I comorbidity of borderline personality disorder. Am J Psychiatry 1998; 155: 1733–9.
7 Crawford, MJ, Price, K, Rutter, D, Moran, P, Tyrer, P, Bateman, A, et al Dedicated community-based services for adults with personality disorder: Delphi study. Br J Psychiatry 2008; 193: 342–3.
8 Bateman, AW, Gunderson, J, Mulder, R. Treatment of personality disorder. Lancet 2015; 385: 735–43.
9 Levy, KN. Psychotherapies and lasting change. Am J Psychiatry 2008; 165: 556–9.
10 Lieb, K, Völlm, B, Rücker, G, Timmer, A, Stoffers, JM. Pharmacotherapy for borderline personality disorder: Cochrane systematic review of randomised trials. Br J Psychiatry 2010; 196: 412.
11 Kliem, S, Kroger, C, Kosfelder, J. Dialectical behavior therapy for borderline personality disorder: a meta-analysis using mixed-effects modeling. J Consult Clin Psychol 2010; 78: 936.
12 Bateman, A, Fonagy, P. 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. Am J Psychiatry 2008; 165: 631–8.
13 Bateman, A, Fonagy, P. Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry 2009; 166: 1355–64.
14 Whiteley, S. The evolution of the therapeutic community. Psychiatr Q 2004; 75: 233–48.
15 Campling, P. Therapeutic communities. Adv Psychiatr Treat 2001; 7: 365–72.
16 Hirst, O, Paget, S. Service Standards for Therapeutic Communities. Royal College of Psychiatrists, College Research Unit, 2005.
17 Pearce, S, Pickard, H. How therapeutic communities work: specific factors related to positive outcome. Int J Soc Psychiatry 2013; 59: 636–45.
18 Dolan, B, Warren, F, Norton, K. Change in borderline symptoms one year after therapeutic community treatment for severe personality disorder. Br J Psychiatry 1997; 171: 274–9.
19 Davies, S, Campling, P. Therapeutic community treatment of personality disorder: service use and mortality over 3 years' follow-up. Br J Psychiatry 2003; 182: s247.
20 Chiesa, M, Fonagy, P, Holmes, J, Drahorad, C. Residential versus community treatment of personality disorders: a comparative study of three treatment programs. Am J Psychiatry 2004; 161: 1463–70.
21 Lees, J, Manning, N, Rawlings, B. Therapeutic Community Effectiveness: A Systematic International Review of Therapeutic Community Treatment for People with Personality Disorders and Mentally Disordered Offenders. University of York, 1999.
22 Craig, P, Dieppe, P, Macintyre, S, Michie, S, Nazareth, I, Petticrew, M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 2008; 337: a1655.
23 First, MB, Spitzer, RL, Gibbon, M, Williams, JBW. Structured Clinical Interview for DSM-IV Personality Disorders, (SCID-II). American Psychiatric Press, 1997.
24 Borschmann, R, Barrett, B, Hellier, JM, Byford, S, Henderson, C, Rose, D, et al Joint crisis plans for people with borderline personality disorder: feasibility and outcomes in a randomised controlled trial. Br J Psychiatry 2013; 202: 357–64.
25 Pickard, H. Responsibility without blame: empathy and the effective treatment of personality disorder. Philos Psychiatr Psychol 2011; 18: 209–24.
26 Rapoport, R. Community as Doctor. Tavistock Publications, 1960.
27 Main, T. The concept of the therapeutic community: variations and vicissitudes. Group Analysis 1977; 10: S216.
28 Filstead, WJ, Rossi, JJ. Therapeutic milieu, therapeutic community, and milieu therapy: some conceptual and definitional distinctions. In The Therapeutic Community: A Sourcebook of Readings (eds Rossi, JJ, Filstead, WJ): 313. Behavioural Publications, 1973.
29 Hodgson, R, Alwyn, T, John, B, Thom, B, Smith, A. The Fast Alcohol Screening Test. Alcohol Alcohol 2002; 37: 61–6.
30 Gavin, DR, Ross, HE, Skinner, HA. Diagnostic validity of the drug abuse screening test in the assessment of DSM-III drug disorders. Br J Addict 1989; 84: 301–7.
31 Goldberg, D. General Health Questionnaire (GHQ-12). Nfer-Nelson, 1992.
32 Tyrer, P, Nur, U, Crawford, M, Karlsen, S, MacLean, C, Rao, B, et al The Social Functioning Questionnaire: a rapid and robust measure of perceived functioning. Int J Soc Psychiatry 2005; 51: 265–75.
33 Sorgi, P, Ratey, JJ, Knoedler, DW, Markert, RJ, Reichman, M. Rating aggression in the clinical setting: a retrospective adaptation of the Overt Aggression Scale: preliminary results. J Neuropsychiatry Clin Neurosci 1991; 3: S5256.
34 Larsen, DL, Attkisson, CC, Hargreaves, WA, Nguyen, TD. Assessment of client/patient satisfaction: development of a general scale. Eval Program Plann 1979; 2: 197207.
35 Rutter, D, Tyrer, P. The value of therapeutic communities in the treatment of personality disorder: a suitable place for treatment? J Psychiatr Pract 2003; 9: 291302.
36 Pearce, S, Autrique, M. On the need for randomised trials of therapeutic community approaches. Ther Communities 2010; 31: 338–55.
37 Shaw, C. External assessment of health care. BMJ 2001; 322: 851.
38 Worrall, A. The service context for clinical guidelines: supporting guideline implementation by assuring and improving the quality of service in which clinicians work. Int Rev Psychiatry 2011; 23: 336–41.
39 Haigh, R, Tucker, S. Democratic development of standards: the community of communities – a quality network of therapeutic communities. Psychiatr Q 2004; 75: 263–77.
40 Autrique, M, Pearce, S, Vanderplasschen, W, Haigh, R. The impact of a randomised trial on TC environments. Ther Communities 2015; 36: 137–44.
41 Moos, R. Community Oriented Programs Environment Scale Manual. Mind Garden, 2003.
42 Crawford, MJ, Price, K, Gordon, F, Josson, M, Taylor, B, Bateman, A, et al Engagement and retention in specialist services for people with personality disorder. Acta Psychiatr Scand 2009; 119: 304–11.
43 Pearce, S, Haigh, R. Mini therapeutic communities – a new development in the United Kingdom. Ther Communities 2008; 29: 111–24.
44 Mahlke, CI, Bock, T. Peer to peer support in severe mental disorders: affective disorders, psychosis and personality disorder – a randomized controlled trial. Eur Psychiatry 2015; 30: 165.
45 Baumeister, RF, Leary, MR. The need to belong: desire for interpersonal attachments as a fundamental human motivation. Psychol Bull 1995; 117: 497529.
46 National Institute for Care and Health Excellence. Borderline Personality Disorder: Recognition and Management. NICE, 2015 (https://www.nice.org.uk/guidance/cg78).
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Democratic therapeutic community treatment for personality disorder: Randomised controlled trial

  • Steve Pearce (a1), Lisle Scott (a1), Gillian Attwood (a1), Kate Saunders (a2), Madeleine Dean (a3), Ritz De Ridder (a4), David Galea (a5), Haroula Konstantinidou (a6) and Mike Crawford (a7)...
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