Psychotherapy for severe personality disorder

Editor—Kisely bases his ideas of what comprises a therapeutic community on a model that has undergone considerable evolution and development over 50 years.1 The Henderson Hospital and its offshoots are based on a specific type of therapeutic community, which started the social psychiatry movement after the second world war. Although it still provides a robust and effective treatment, several other types of therapeutic community are now used in the treatment of severe personality disorder. Perhaps the most radical departure is to run the programmes as day services, as occurs in Reading. Francis Dixon Lodge in Leicester does not use small group therapy, and the Cassell Hospital is unusual in incorporating individual psychotherapy in the programme. Research is clearly needed, but the methodological difficulties are formidable. The treatment is complex and volatile and is delivered in very different ways; patient drop out is often part of the clinical process, long term follow up is essential, and measuring robust and useful personality change is difficult. Randomised controlled trials are being considered, for day units as well as the new Henderson units, but they will not answer the question “Is a different type of therapeutic community better than this one?” or “What is going on here that is important?” As each therapeutic community differs considerably from every other, findings from randomised controlled trials will be difficult to generalise. And as evolution in response to the administrative environment is part of the therapeutic process of these communities, they could not be considered therapeutic communities if they were exactly defined and not allowed to change. A project funded by the National Lottery and covering 10 centres is under way to isolate the “active ingredients” across a range of therapeutic communities for severe personality disorder. It is being coordinated by the Association of Therapeutic Communities and should help to define meaningful outcomes and identify relevant processes. The methodology is path analytic structural equation modelling. This is much more complex than a randomised controlled trial and, in the hierarchy of acceptable evidence, is not far below it. The protocol is available at www.pettarchiv.org.uk/atc-protocol.htm . In his commentary on the article Pelosi writes in a belittling way of people with personality disorder. They have nearly always suffered extreme disturbance of emotional development (usually neglect, trauma, abuse, or loss in early life) and find it difficult to establish and sustain a normal life. To describe deeply disturbed people in the way that he does is surely unprofessional.