“I have received no advice suggesting that the [Henderson] model is far superior to other clinical interventions for people with personality disorders….I know that there is a debate about the strength of the evidence for the interventions from the Henderson.
“There is no professional unanimity about whether its care model delivers outcomes so consistently that it would be superior to alternative interventions and models of care.”
A quick rummage through the Cochrane Collaboration finds a review of psychological treatments for people with personality disorder by Binks et al(2006)
People with borderline personality disorder, are often anxious, depressed, self-harm, in crisis and are difficult to engage in treatment. In this review of the talking/behavioural therapies for people with borderline personality disorder, we identified seven studies involving 262 people, over five separate comparisons. Dialectical behaviour therapy (DBT) included treatment components such as prioritising a hierarchy of target behaviours, telephone coaching, groups skills training, behavioural skill training, contingency management, cognitive modification, exposure to emotional cues, reflection, empathy and acceptance. DBT seemed to be helpful on a wide range of outcomes, such as admission to hospital or incarceration in prison, but the small size of included studies limit confidence in their results. A second therapy, psychoanalytic orientated day hospital therapy, also seemed to decrease admission and use of prescribed medication and to increase social improvement and social adjustment. Again, this is an experimental treatment with too few data to really allow anyone to feel too confident of the findings. Even if these are trials undertaken by enthusiasts and difficult to apply to everyday care, they do suggest that the problems of people with borderline personality disorder may be amenable to treatment. More well-designed studies are both justifiable and urgently needed
Hmm, all well and good except the Henderson isn’t a day hospital and a search through its own literature (PDF) unearths no mention of DBT.
OK, so it would appear that there are no systematic reviews of the Henderson therapeutic community model of care. So let’s go to Scopus and have a look through some of the articles there. Again, a quick rummage using the terms ‘therapeutic community AND outcomes’ and excluding articles that focus on the use of TC to treat substance abuse (something the Henderson specifically does not treat, requiring people with substance use issues to stop using before entering the community) uncovers about 140 odd articles with some positive results for children and adolescents (another group the Henderson does not treat) and one review of previous studies which my Athens account wouldn’t let me get hold of. Perhaps that one review contained the Holy Grail of evidence for the utility of therapeutic communities. However, seeing as it was published over 10 years ago in a journal called Therapeutic Communities: the International Journal for Therapeutic and Supportive Organizations and one of its authors was a certain B Dolan of the Henderson Hospital, I’m left wondering about its usefulness as evidence.
Could it be that there is no evidence for the Henderson model of care? Could it be that it is, indeed, a rather costly resource that can’t justify its own existence? Could it be that alternatives to residential treatment, already being developed all over the country might actually produce better results for less money? Could it be that the Henderson is considered a good in and of itself, and yet when you look closely, there isn’t much there? You might think that, I couldn’t posibly comment. But let’s have a heated debate!
Loading ...
*hides*
10 Comments
If you want a heated debate, you have to light a fire. Or at least raise smoke (ing).
Liberal MP Paul Burston urged Mr Lewis to stop the closure. He said: “Unless the minister acts, the NHS is in danger of sleepwalking into the closure of this nationally and internationally-renowned service.”
I can’t accept that is true. Heck, nationally it’s not seen as desirable when folk are voting with their feet (and wallets), with referrals being just 15% of what they were only 9 months ago. People simply aren’t seeking to use this service.
You can no longer make up a service, run it, charge for it, have some people like it and say that it’s therefore a great service that has to be kept.
I’m happy that just ’cause there are no robust clinical trials on their methodology that this isn’t a reason to close them. Trial data isn’t everything.
I am unhappy with a service that doesn’t collect outcome measures. Every service should. We’re all in the habit (hopefully) of looking at patient, carer and service outcomes in our clinical practice. Specialist services usually have audit built in to routine data collection.
How else can you justify services to patients, if you’ve no evidence that what you’re suggesting you do with them does/doesn’t work and what results/disadvantages you’ve found?
How else can you justify to commissioners that it’s worth spending cash on a therapy if the therapists can’t give you any clue as to what results (if any) you’ll get?
Placebo effects and optomism for improvement and spending time with interested supportive folk all contribute to an expected 30% to 40% of people walking through a community should feel better in the short/medium term. Unless they’ve outcome data for their interventions making meaningful, sustained changes in folk over the long term, I’d not want to go through it as a patient and I can’t see commissioners investing in it when there’s no clear/honest results to report.
Can opened, worms out
i used to work for a Trust that ran a Henderson-model TC, it used to really pee me off how they sold themselves as the experts in PD and self-harm, when it seemed to a lot of people (service users mainly) that they didn’t have a bloody clue (about self-harm in particular). rar!
anyway, from what i can tell about the TC i have the most knowledge of, the drop out rate was very high and only a fairly small percentage of residents actually complete the year. in fact, i think the TC in question has had to change its rules in order to hang on to more residents. i think it can be quite life-changing (in a good way) for people who do manage to complete the year, but as I said, that’s not very many people at all.
more local specialist resources for PD can only be a good thing, but I think at the moment, things like the Henderson still need to exist for the people who have been failed by the lack of services in the past & who the new services just don’t have the expertise to help yet. maybe the Henderson itself doesn’t need to exist if the other TCs have the capacity to deal with this particular group, but only the commissioners can answer that one.
The recidivist/reincarceration rates for offenders and the re-admission rates for ‘traditional’ mental health care are nothing much to shout about either.
I believe the principles of TC are sound and can provide a lot of usefulness - however, they’re considered much like ’scientology’ becasuse they don’t give out tablets.
More to follow.. maybe
however, they’re considered much like ’scientology’ becasuse they don’t give out tablets.
I’m totally okay with the absence of medication.
Changes could be through relationships, experiential learning, diet, meditation and exercise, whatever . . . if it works, I really don’t mind.
It’s not the mode of treatment I object to, at all.
It’s the lack of evidence of benefit. With no evidence of what your outcomes are, howcan patients or commissioners make valid choices on whether it’s a useful treatment or not?
The recidivist/reincarceration rates for offenders and the re-admission rates for ‘traditional’ mental health care are nothing much to shout about either.
This is very true. However, I don’t see anyone mounting a campaign to allow prisons and traditional mental health units to remain exactly as they are and still receive public money.
Great - a topic I can really comment on!
I was a resident in a Henderson style TC. I stayed for 3 months before I was forced to leave for various reasons. These were mainly:
a. No money - JSA less than my debt repayments meant I couldn’t afford to be out of work.
b. The staff were too hands off and let other patients rule the roost. I was being verbally threatened by another resident, sometimes even in groups, and NOTHING was done about it.
c. I kept a blog which was discovered and the staff were unhappy about it.
d. I was unable to talk in groups (mainly due to reason b).
Anyway… I hated it most of the time but I no longer self harm and am able to deal with a good deal more than I could before. I discharged myself from the care of the MH services when I left the TC (over 2 years ago) and have been working full time since then, with only about 5 days off work sick! I haven’t taken medication for depression or impulsive behaviour since I left and have maintained my sobriety for over 3 years now, even though the TC referred to my AA membership as a “negative coping mechanism”.
It did work for me, but I am extremely stubborn and don’t want to be anything like majority of those people I spent 3 months of my life with!
Of the others from the TC with whom I am still in touch (most of whom completed 12 months there), few of them have recovered from their “maladaptive behaviours” and many are back on medication and still not working.
The therapy at the TC was hit and miss. It seemed to work by making you feel a sense of responsibility for your actions and show you how your behaviour impacted on others. If you harmed yourself in there, you were shunned at best and, at worst, publicly humiliated. However, those with eating disorders were almost revered and, at times, almost encouraged. I hope very much that this isn’t the reason that my (previously fairly dormant) weight issues have exploded since I left the TC… I would be very resentful of that!!!
elliecat - sounds like the TC worked for you in ways it probably wouldn’t put in its adverts.
“Come to us, meet people you wouldn’t want to be in a million years and get better as a result”
LOL
The ghost of Christmas-yet-to-be therapy?
I think my point re medication etc above (and I’m being very laissez faire in commentaries here) is that TC has not attracted much support becuase it doesn’t have a scientific basis such as pharmacology and it certainly doesn’t attract the same sort of research funding as Big Pharma can provide.
I am not sure if a NHS-TC or the like has ever been trialled and I don’t think there’s any harm in looking at one. It would also be useful as it may teach people to utilise the non-medicinal approaches to problem-solving (ie solving the patient’s problems - not the staff’s problem).
Can’t remember the link but I note that Farm Communities are now actually back on the options list as a therapeutic option - some live-in too, much like TC’s or the old psych bins - but with the ‘moral’ issues of slave labour and ‘volunteer’ principles apparently resolved.
It doesn’t need to be a double blind randomised placebo controlled trial.
I’m quite happy for it not to be randomised, not to be external, not to be blinded, not to used standardised assessments, not to use validated tools.
All I’d ask (erm, or require, really) is that they collect and present some decent internal audit information on outcome measures.