Staff and service users’ evaluations of therapeutic principles at a High Secure Learning Disability Therapeutic Communityud(LDTC)

摘要

Background: Growing evidence has been provided on the efficacy ofudDemocratic Therapeutic Community (DTC) treatment in forensic LDudpopulations (known as learning disability therapeutic communities, LDTC) inudthe form of reduced violence, personality pathology and interpersonaluddifficulties. Recently, the LDTC model has been introduced within a highudsecure setting at one of three high secure hospitals in the U.K., for males withuda dual diagnosis of mild LD and PD, and produced equally successful results.udWhile a number of outcome studies exist, on-going difficulties have remainedudin regard to applying a post-positivist approach to research design ofudTherapeutic Communities (TCs) as the approach fails to capture its matrix ofudinterrelated treatment components. Consequently, there has been a call forudinvestigation of processes within DTCs to identify important treatmentudmechanisms that support therapeutic change. While Haigh (2013) hasudupdated the theoretical background on DTCs via formulating ‘quintessentialudprinciples’ within a given therapeutic environment the principles have notudbeen empirically validated within a TC setting.udStudy aims: To explore service user and staff members’ evaluations of theudquintessence principles as outlined by Haigh (2013) and identify whether anyudfurther important principles exist within the social climate of the LDTC that wereudnot captured by current TC theory.udDesign: A single case study design was employed, with the ‘case’ beinguddefined as the LDTC based at one of three high secure hospitals in the U.K. Audqualitative approach was employed within the case study to enable initialudanalysis of TC members’ experience of therapeutic principles, any additionaludprinciples and to also permit identification of any shared experiences.udThe results of the qualitative analysis were used to develop a set of statementsudthat can be used by future research to determine the importance of existing TCudprinciples and additional elements identified in qualitative findings to TCudmembers.udMethod: A qualitative approach was employed to enable analysis of TCudmembers’ experience and evaluation of therapeutic principles in addition toudidentification of shared experiences. Data were collected via semi-structuredudinterviews with 12 participants (6 staff members and 6 service users). Theudinterview transcripts were initially analysed via deductive content analysisud(Mayring, 2001) in order to identify whether Haigh’s (2013) quintessenceudprinciples were evident in the LDTC. Inductive thematic analysis (Braun &udClarke, 2006) was then performed on remaining data, which also involvedudcompletion of saliency analysis (Buetow, 2010) in the final stage to justifyudselection of themes and ensure identification of codes that did not recur butudremained important to the research questions posed.udResults:udThe deductive content analysis identified all five quintessence principles wereudexperienced in the LDTC environment by staff and service users. Some limits toudthe principle of ‘agency’ were highlighted, with specific reference to difficultiesudimplementing a flattened hierarchy in a forensic setting. Additional themes wereudidentified via inductive thematic analysis and a saliency analysis indicated theudfollowing themes as both important and recurrent; security and risk,udresponsivity, trust, more physical freedom. Further themes that were identifiedudas important but not recurrent within the saliency analysis included: staff fit withudLDTC, moving on, being reflective.udThe theme of security and risk was specifically related to the context of theudLDTC functioning in a high secure environment and ‘trust’ was understood to falludwithin Haigh’s (2013) conceptualization of the containment quintessenceudprinciple.udWhile the remaining themes may not primarily contribute to the experience ofudsecondary emotional development outlined by Haigh’s (2013) five quintessenceudprinciples they remain important considerations within therapeutic environmentsudin light of their role in facilitating enactment of TC principles within secureudenvironments, such as the LDTC.udConclusions: This is the first research paper that has attempted to test whetherudHaigh’s (2013) quintessence principles are evident within a given therapeuticudcommunity. The single case study provides empirical evidence for theudquintessence principles in a novel TC setting along with further elements in theudenvironment that help support implementation of quintessence principles.udFundamentally, the study suggests important recommendations for futureudresearch.