Democratic Therapeutic Community Research Articles

Psychometric attributes associated with attrition within a prison-based democratic therapeutic community

PurposeThe purpose of this paper is to examine the psychometric characteristics of male offenders who joined a democratic therapeutic community and their relationship to attrition.Design/methodology/approachResidents who left therapy prematurely during the assessment phase (N = 46) and residents who left therapy prematurely during core therapy (N = 202) were compared to residents who completed therapy (N = 52) on two psychometric measures: Raven’s Standard Progressive Matrices and The Blame Attribution Inventory.FindingsA multinomial logistic regression analysis showed higher levels of external blame can predict attrition during therapy; those with higher levels of external attribution are significantly more likely to leave therapy prematurely, including both during the assessment phase and during core therapy. Raven's Standard Progressive Matrices score did not significantly predict whether an individual left therapy prematurely.Originality/valueSupport was found for existing research within the academic evidence base. The findings have both empirical and clinical utility, suggesting during the assessment phase of therapy, practitioners can identify residents that may require additional support to maintain engagement, minimising the potential for premature departure. The implications of the findings are discussed, with suggestions made for future research.

Compassion focused cultures: Introducing compassion into a democratic therapeutic community

Forensic services can present residents with several challenges, from a poverty of developmental opportunity to the experience of violence, drugs, and sustained threat. The nature of a residential forensic service is therefore likely to influence the readiness, willingness, and ability of its members to engage with interventions and, ultimately, to recover. In this paper, we explore how the residential treatment milieu can be organised in order to enhance the prospect of rehabilitation and reintegration. We draw on the experience of working in therapeutic communities (both prison and hospital based) and describe a model that integrates a compassionate and trauma sensitive methodology into such environments. An evaluation of the impact of this model is presented along with suggestions for future practice.

Prison-based democratic therapeutic communities, medication, and the power to exclude.

In 1962, the first custodial Democratic Therapeutic Community (DTC) was established in the English prison estate at HMP Grendon. Today, the Category B male prison estate in England and Wales has three DTCs and three 'TC+' units for prisoners with learning disabilities. There is one DTC in the female estate at HMP Send. The services fall under the remit of the Offender Personality Disorder Pathway, a jointly commissioned initiative that aims to provide a pathway of psychologically informed services for a highly complex and challenging group of prisoners who are likely to have a severe personality disorder. Several of these units make clear that prisoners prescribed psychotropic medicines are specifically excluded from entry and participation in the available therapy. This analysis paper explores whether an evidence-based rationale exists for this practice and examines the impact on those whose care pathways may comprise hospitals and prisons.

Me-thinking: report on a pilot intervention with women in custody

PurposeThis pilot study aims to assess the feasibility of conducting shared philosophical inquiry with women at risk of re-offending to improve motivation to change. The philosophy sessions aimed to give participants new ways to think about their lives and to help them have more control over their own mind by learning new ways to think differently.Design/methodology/approachThe pilot study adopted a mixed-methods approach to collect and analyse data pre- and post-intervention. Ten women serving a custodial sentence at the Democratic Therapeutic Community (DTC) in HMP Send were recruited to take part in ten weekly sessions of philosophical discussion. The intervention was adjunctive and not meant to replace other treatments an inmate may already be receiving.FindingsThe results showed that most participants experienced improved levels of well-being and mental health post-intervention, and that the intervention has the potential to help participants better critically assess their own behaviour and ways of thinking. It also suggested that the intervention has the potential to help participants engage more effectively with the therapeutic process.Research limitations/implicationsThe results of this study are limited by the small sample size and the lack of a control group. As such this study cannot rule out that the changes observed in participants were a function of time or the specific therapeutic environment they were in (or both).Originality/valueThis pilot study is innovative not just for introducing philosophy classes to the women’s prison estate for the first time in England and Wales, but also in its ambition to contribute to the “what works” agenda in offender rehabilitation.

Good practices in Italian therapeutic communities. Outcomes 2020 of quality accreditation program “Visiting DTC Project”

PurposeThis paper aims to present results achieved by the first, and to date only, Democratic Therapeutic Communities (DTC) quality improvement program developed in Italy, in the past 10 years, named “Visiting DTC Project.” Process of bottom-up identification, definition and evaluation of good practices of TCs for adult users with long term severe mental disorders will be described. In addition, a five-phase clinical care pathway will be presented for the same user category, developed by the “Visiting DTC Project” to comply with Italian National Health Service accreditation standards for TCs.Design/methodology/approach“Visiting DTC Project” involved 40 Italian TCs, since 2012 until 2020, in an action research on good practices developed throw a democratic and bottom-up methodology. Project’s methodology is the “Democratic Peer-to-peer Accreditation,” a kind of professional scientific quality accreditation and continuous improvement process for community mental health services. Scientific model for the definition of service standards and principles of treatment is the British “Democratic Therapeutic Community,” which the “Visiting DTC Project” is organizationally inspired by.FindingsIn the eighth annual cycle of the program for TC with adult users of mental health services a significantly effective good practice procedure (GPP), with good practical efficacy, was finally identified (for the first time after eight years), but still no best practice. GPP with the title “Multi-family Community Meeting” is the Good Practice of the year 2020. No Best Practice has yet been identified. An integrated clinical care pathway for Adult DTCs Users in five phases is also presented. This care pathway organizes advanced standards of Community Group Quality in a map, to support the description and planning of the five phases of the user’s clinical work in DTC treatment.Originality/valueCooperation with local community services, organizations and networks, as well as a therapeutic environment based on informal coexistence and cooperation between TC members, are thus, together with care of family relationships, the main characteristics of the Italian experience of implementing and developing the Italian DTC treatment model. These characteristics make it clear how fragile Italian DTCs are at this moment. They are still in an early stage of development. All the most applied and effective best practice procedures are dependent on a wide and dense network of relationships, formal and informal, which cross the therapeutic environment and interconnect TC members with all other stakeholders.

Are prison-based therapeutic communities effective? Challenges and considerations.

The purpose of this paper is to detail the impact and efficacy of Her Majesty's Prison and Probation Service ((HMPPS) Therapeutic Communities (TCs) (both democratic and hierarchical). This paper outlines recent developments in the TC literature, to provide readers with an up-to-date overview of the outcomes of prison-based TC treatment, while highlighting the strengths and challenges of this treatment approach. Trends within the research are discussed, and the authors draw attention to any gaps in the current knowledge. This paper uses a narrative literature review approach to review the most current literature around the effectiveness of prison-based TCs in HMPPS. Academic literature published predominantly from 2010 onwards is discussed because of limited literature review publications on this topic post-2010. To obtain literature, searches of relevant databases were conducted, and/or clinical leads at prison sites were contacted for relevant publications. There is a body of research which demonstrates that TCs are an effective form of treatment for people with an offending history and personality difficulties. Evidence indicates that Democratic TC treatment plays a part in reducing reoffending rates, as well as improving psychological features. Further research is needed in a number of areas, specifically with female offenders and individuals who undertake treatment in hierarchical TCs in the UK. It is also suggested that TC treatment aftercare may help to further the positive outcomes identified. To the best of the authors' knowledge, there is no up-to-date review of the impact and efficacy of HMPPS TC treatment. This paper reflects on available research within the current context of TC treatment and provides an original overview of the current UK TC practice. It has value in recommending areas for further research and consideration.

"I've Got the Energy to Change, But I Haven't Got the Energy for This Kinda Therapy": A Qualitative Analysis of the Motivations Behind Democratic Therapeutic Community Drop-Out for Men With Sexual Convictions.

Prison-based democratic therapeutic communities (TCs) provide an alternative to mainstream prison, where prisoners can work on psychological difficulties and address offending behavior. Research demonstrates TCs are effective at reducing reoffending rates for residents who stay in therapy 18+ months, and those who drop out of TCs offend at a significantly higher rate than those who complete therapy. Thus, it is important to reduce attrition in TCs. No research has yet explored the explanations for TC drop out offered by those with sexual convictions. The present study uses Interpretive Phenomenological Analysis to qualitatively explore the accounts of men with sexual convictions (n = 7) who dropped out of a TC in a UK prison. Results highlight that issues surrounding external responsivity, therapeutic relationships, and treatment readiness were salient in the participants’ accounts of drop out. This research has implications for TCs seeking to better understand and address attrition of people with sexual convictions.

A Computational Phenotype of Disrupted Moral Inference in Borderline Personality Disorder

BackgroundBorderline personality disorder (BPD) is a serious mental disorder characterized by marked interpersonal disturbances, including difficulties trusting others and volatile impressions of others’ moral character, often resulting in premature relationship termination. We tested a hypothesis that moral character inference is disrupted in BPD and sensitive to democratic therapeutic community (DTC) treatment. MethodsParticipants with BPD (n = 43; 20 untreated and 23 DTC-treated) and control participants without BPD (n = 106) completed a moral inference task where they predicted the decisions of 2 agents with distinct moral preferences: the “bad” agent was more willing than the “good” agent to harm others for money. Periodically, participants rated their subjective impressions of the agent’s moral character and the certainty of those impressions. We fit a hierarchical Bayesian learning model to participants’ trialwise predictions to describe how beliefs about the morality of the agents were updated by new information. ResultsThe computational mechanisms of moral inference differed for patients with untreated BPD relative to matched control participants and patients with DTC-treated BPD. In patients with BPD, beliefs about harmful agents were more certain and less amenable to updating relative to both control participants and participants who were treated with DTC. ConclusionsThe findings suggest that DTC may help the maintenance of social relationships in BPD by increasing patients’ openness to learning about adverse interaction partners. The results provide mechanistic insights into social deficits in BPD and demonstrate the potential for combining objective behavioral paradigms with computational modeling as a tool for assessing BPD pathology and treatment outcomes.

Long sentenced women prisoners: Rights, risks and rehabilitation

This paper re-examines critically the role of rehabilitative interventions for a seriously neglected group of prisoners: women serving long sentences. Drawing on empirical research conducted in a democratic therapeutic community in a women’s prison in the south of England, it considers how far established criticisms identify insuperable difficulties that exacerbate existing harms and inequalities. It argues that evidence can be adduced to support rehabilitative interventions that are not predominantly concerned with the reduction of criminal risk but which provide tangible benefits to the personal wellbeing of women in prison and may increase their prospects of integration post release. It explores how such rehabilitative policies and practices could be supported and protected from attrition by penal power, by embedding them within a doctrine of human rights. By challenging and replacing prevalent assumptions and justifications that uphold existing power relations in prisons, we argue that a specific duty of care, owed by the prison service to women serving long sentences, can protect, support and re-imagine their right to rehabilitative opportunities.

A Computational Phenotype of Disrupted Moral Inference in Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a serious mental disorder characterized by marked interpersonal disturbances, including difficulties trusting others and volatile impressions of others’ moral character, often resulting in premature relationship termination. We tested a hypothesis that moral character inference is disrupted in BPD and sensitive to Democratic Therapeutic Community (DTC) treatment.

Henderson and beyond: Did the Northfield experiments influence Henderson Hospital and its Legacy?

This article is the talk I gave at the GASI Winter Workshop 2018 and looks at whether the Northfield Experiments influenced the development of the Henderson Hospital and other democratic therapeutic communities that arose from it. It describes Maxwell Jones’ work with military personnel before and at the Henderson Hospital, his ‘marginal consciousness’ of, and the similarities with, the Northfield Experiments especially in the use of psychodrama. It describes the later indirect influence of Northfield on the Henderson Hospital, through Foulkes and group analysis. The article then looks at the legacy of the Henderson Hospital in terms of other therapeutic communities and how those in prisons in the UK seem to be surviving better than those in the mental health system as they have been ‘owned’ by the system and so not seen as counter-cultural. In having a place in our society’s wish to keep offenders behind bars they are more able to withstand the effect of the changes in society whereby everything is wanted or accessible instantly and where change is the only constant, drawing on Bauman’s concept of liquid modernity.

Prison democratic therapeutic communities: Treatment experiences and staff resilience, presented by staff of HMP Grendon, hosted and introduced by Laura Jacobs

Prison democratic therapeutic communities: Treatment experiences and staff resilience, presented by staff of HMP Grendon, hosted and introduced by Laura Jacobs

The Theory and Practice of Democratic Therapeutic Community Treatment

The Theory and Practice of Democratic Therapeutic Community Treatment

Training for democratic therapeutic community practitioners, and workers in therapeutic and enabling environments

PurposeTraining in therapeutic community and related approaches has not been widely available, and there is debate about the form this should take. This has had a negative impact on the field. The paper aims to discuss this issue.Design/methodology/approachThe authors consider the history of training in democratic therapeutic community methods in the UK in particular, and trace some of the reasons for its lack of development.FindingsWith the expansion of TC methodology into new areas, such as therapeutic and enabling environments, the ability to provide training in DTC approaches and techniques is increasingly important. The developing evidence base, and the increasing detail in which the method has been described, make dedicated TC training increasingly important.Originality/valueTraining in therapeutic community methods, and enabling and therapeutic environment approaches, provides a grounding in technique and theory that would otherwise be impossible to acquire for most workers, and can lead to a general increase in the level of competence and confidence in the way these environments operate.

Gangs and groups: the impact on therapeutic processes

PurposeThe purpose of this paper is to consider the impact having been in a gang has on being in a group in a democratic therapeutic community (DTC). In particular what characteristics attract (in this case) males to join a gang and or group, and what is the impact on a DTC of having former gang members in it.Design/methodology/approachThe paper is a discussion paper considering the implications of the points raised above. It also includes results of research relating to the “Changing the Game” programme.FindingsThe findings result from experience of having worked in the environment, reviewing available literature, conducting research and having managed some of the issues raised. It is not a research paper but does present findings.Research limitations/implicationsThis is a conceptual paper which incorporates findings from this author and others on the impact of gangs in a DTC. There is limited research in this area and so much is drawn from findings in other settings.Originality/valueLittle is written on the impact of having been in a gang and the dynamics that introduces in a forensic DTC. Therefore, it is hoped that it will encourage further research in this area.

Hope, harmony and humanity: creating a positive social climate in a democratic therapeutic community prison and the implications for penal practice

PurposeThere has been growing attention given to the concept of social climate as an element of prison practice. Research has indicated that more positive social climates can improve safety, psychological well-being, quality of life and contribute towards reduced reoffending. The purpose of this paper is to consider how the more positive social climates found in democratic therapeutic communities are constructed and how these practices can be replicated in other settings.Design/methodology/approachThis paper adopts a reflective practice approach. The intention is to look back at the concept of social climate in prisons and in particular within a prison-based democratic therapeutic community (DTC); draw upon research and theory in order to critically evaluate the nature and effectiveness of that social climate, and; draw wider lessons about the nurturing and maintenance of social climates that may have broader relevance in prisons.FindingsIt is concluded that understanding and managing social climate is an essential aspect of improving the safety and effectiveness of prisons. Developing practices that enhance social climate requires looking beyond mainstream prison practices, towards niches such as specialist units and prisons, including DTCs and other therapeutic communities, and psychologically informed environments, as well as looking at practices in other settings including forensic mental health. Taking this wider perspective can be source of ideas and practice that could inform a profound culture change.Originality/valueThe paper offers an attempt to understand the distinct practices that create a more positive social climate in DTCs and consider how elements of this could be exported to other prisons. This has implications for both penal theory and practice.

Therapeutic communities and planned environments for serious offenders in English prisons

SummarySeveral English prisons contain democratic therapeutic communities (TCs) for personality disordered offenders, and addiction TCs for serious substance misusers. This article describes how these are organised and comments on how they are specifically tailored and accredited for use in custodial settings. It also describes ‘psychologically informed planned environments’ (PIPEs), offender pathways for those with personality disorders and psychopathy which provide additional support for psychological treatment. It ends by explaining how ‘enabling environments’ are assessed, since these are now becoming widely adopted in prisons to reverse toxic environments – which affect staff, the prison and the outside world as well as the individual prisoner – and to counter negative learning found in custodial institutions.Learning Objectives• Understand the key components of treatment in democratic and addiction TCs• Understand how TCs can operate in a custodial environment• Appreciate the differences between a planned environment and a psychological treatment programme in a custodial environment

Book Review: The Theory and Practice of Democratic Therapeutic Community Treatment

Book Review: The Theory and Practice of Democratic Therapeutic Community Treatment

On the advancement of therapeutic penality: therapeutic authority, personality science and the therapeutic community.

In this article I examine the advancement of therapeutic penality in the UK, a penal philosophy that reimagines prison policy, practices and environments utilising psychological knowledge. Adopting a historical approach, I show how modern therapeutic penality is linked to the emergence of personality science in the nineteenth century and the development of the democratic therapeutic community (DTC) model in the twentieth century. I outline how at the turn of the twenty-first century a catalytic event generated a moral panic that led the British government to mobilise psychological knowledge and technologies in an attempt to manage dangerous people with severe personality disorder. Tracing subsequent developments, I argue psychological ways of talking, thinking and acting have obtained unparalleled salience in domains of penality and, in turn, radically transformed the conditions of imprisonment.

Therapeutic communities enter the world of evidence-based practice

This editorial provides the modern-day context for a long-established psychiatric treatment, democratic therapeutic communities. As this treatment is now such a small field in psychiatry, readers may not have enough background to be able to place the research in a suitable context. This includes the previous gap in experimental research, the difference between the modern model and the one used in the 20th century and the general field of personality disorder evidence.