Abstract

Background: Growing evidence has been provided on the efficacy of
Democratic Therapeutic Community (DTC) treatment in forensic LD
populations (known as learning disability therapeutic communities, LDTC) in
the form of reduced violence, personality pathology and interpersonal
difficulties. Recently, the LDTC model has been introduced within a high
secure setting at one of three high secure hospitals in the U.K., for males with
a dual diagnosis of mild LD and PD, and produced equally successful results.
While a number of outcome studies exist, on-going difficulties have remained
in regard to applying a post-positivist approach to research design of
Therapeutic Communities (TCs) as the approach fails to capture its matrix of
interrelated treatment components. Consequently, there has been a call for
investigation of processes within DTCs to identify important treatment
mechanisms that support therapeutic change. While Haigh (2013) has
updated the theoretical background on DTCs via formulating ‘quintessential
principles’ within a given therapeutic environment the principles have not
been empirically validated within a TC setting.
Study aims: To explore service user and staff members’ evaluations of the
quintessence principles as outlined by Haigh (2013) and identify whether any
further important principles exist within the social climate of the LDTC that were
not captured by current TC theory.
Design: A single case study design was employed, with the ‘case’ being
defined as the LDTC based at one of three high secure hospitals in the U.K. A
qualitative approach was employed within the case study to enable initial
analysis of TC members’ experience of therapeutic principles, any additional
principles and to also permit identification of any shared experiences.
The results of the qualitative analysis were used to develop a set of statements
that can be used by future research to determine the importance of existing TC
principles and additional elements identified in qualitative findings to TC
members.
Method: A qualitative approach was employed to enable analysis of TC
members’ experience and evaluation of therapeutic principles in addition to
identification of shared experiences. Data were collected via semi-structured
interviews with 12 participants (6 staff members and 6 service users). The
interview transcripts were initially analysed via deductive content analysis
(Mayring, 2001) in order to identify whether Haigh’s (2013) quintessence
principles were evident in the LDTC. Inductive thematic analysis (Braun &
Clarke, 2006) was then performed on remaining data, which also involved
completion of saliency analysis (Buetow, 2010) in the final stage to justify
selection of themes and ensure identification of codes that did not recur but
remained important to the research questions posed.
Results:
The deductive content analysis identified all five quintessence principles were
experienced in the LDTC environment by staff and service users. Some limits to
the principle of ‘agency’ were highlighted, with specific reference to difficulties
implementing a flattened hierarchy in a forensic setting. Additional themes were
identified via inductive thematic analysis and a saliency analysis indicated the
following themes as both important and recurrent; security and risk,
responsivity, trust, more physical freedom. Further themes that were identified
as important but not recurrent within the saliency analysis included: staff fit with
LDTC, moving on, being reflective.
The theme of security and risk was specifically related to the context of the
LDTC functioning in a high secure environment and ‘trust’ was understood to fall
within Haigh’s (2013) conceptualization of the containment quintessence
principle.
While the remaining themes may not primarily contribute to the experience of
secondary emotional development outlined by Haigh’s (2013) five quintessence
principles they remain important considerations within therapeutic environments
in light of their role in facilitating enactment of TC principles within secure
environments, such as the LDTC.
Conclusions: This is the first research paper that has attempted to test whether
Haigh’s (2013) quintessence principles are evident within a given therapeutic
community. The single case study provides empirical evidence for the
quintessence principles in a novel TC setting along with further elements in the
environment that help support implementation of quintessence principles.
Fundamentally, the study suggests important recommendations for future
research.