Therapeutic Communities

What is a therapeutic community?

The therapeutic community (TC) for the treatment of drug abuse and addiction has existed for about 40 years. In general, TCs are drug-free residential settings that use a hierarchical model with treatment stages that reflect increased levels of personal and social responsibility. Peer influence, mediated through a variety of group processes, is used to help individuals learn and assimilate social norms and develop more effective social skills. TCs differ from other treatment approaches principally in their use of the community, comprising treatment staff and those in recovery, as key agents of change. This approach is often referred to as “community as method.” TC members interact in structured and unstructured ways to influence attitudes, perceptions, and behaviors associated with drug use. Many individuals admitted to TCs have a history of social functioning, education/vocational skills, and positive community and family ties that have been eroded by their substance abuse. For them, recovery involves rehabilitation—relearning or re-establishing healthy functioning, skills, and values as well as regaining physical and emotional health. Other TC residents have never acquired functional life-styles. For these people, the TC is usually their first exposure to orderly living. Recovery for them involves habilitation—learning for the first time the behavioral skills, attitudes, and values associated with socialized living. In addition to the importance of the community as a primary agent of change, a second fundamental TC principle is “self-help.” Self-help implies that the individuals in treatment are the main contributors to the change process. “Mutual self-help” means that individuals also assume partial responsibility for the recovery of their peers—an important aspect of an individual’s own treatment.

How beneficial are therapeutic communities in treating drug addiction?

For three decades, NIDA has conducted several large studies to advance scientific knowledge of the outcomes of drug abuse treatment as typically delivered in the United States. These studies collected baseline data from over 65,000 individuals admitted to publicly funded treatment agencies. They included a sample of TC programs and other types of programs (i.e., methadone maintenance, out-patient drug-free, short-term inpatient, and detoxification programs). Data were collected at admission, during treatment, and in a series of followups that focused on outcomes that occurred 12 months and longer after treatment. These studies found that participation in a TC was associated with several positive outcomes. For example, the Drug Abuse Treatment Outcome Study (DATOS), the most recent long-term study of drug treatment outcomes, showed that those who successfully completed treatment in a TC had lower levels of cocaine, heroin, and alcohol use; criminal behavior; unemployment; and indicators of depression than they had before treatment.

What is the typical length of stay in a TC?

In general, individuals progress through drug addiction treatment at varying speeds, so there is no predetermined length of treatment. Those who complete treatment achieve the best outcomes, but even those who drop out may receive some benefit. Good outcomes from TC treatment are strongly related to treatment duration, which likely reflects benefits derived from the underlying treatment process. Still, treatment duration is a convenient, robust predictor of good outcomes. Individuals who complete at least 90 days of treatment in a TC have significantly better outcomes on average than those who stay for shorter periods.

Traditionally, stays in TCs have varied from 18 to 24 months. Recently, however, funding restrictions have forced many TCs to significantly reduce stays to 12 months or less and/or develop alternatives to the traditional residential model. For individuals with many serious problems (e.g., multiple drug addictions, criminal involvement, mental health disorders, and low employment), research again suggests that outcomes were better for those who received TC treatment for 90 days or more. In a DATOS study, treatment outcomes were compared for cocaine addicts with six or seven categories of problems and who remained in treatment at least 90 days. In the year following treatment, only 15 percent of those with over 90 days in TC treatment had returned to weekly cocaine use, compared to 29 percent of those who received over 90 days of outpatient drug-free treatment and 38 percent of those receiving over 3 weeks of inpatient treatment.

The relationship between retention and good treatment outcomes identified in DATOS has been replicated in many studies. However, many TCs have a high dropout rate, although about one-third of dropouts seek readmission. A significant research effort is underway to better understand and improve TC treatment retention by examining external factors, program services and processes, and attributes of individuals in treatment. External factors related to retention include level of association with family or friends who use drugs or are involved in crime, and legal pressures to enroll in treatment. Inducements — sanctions or enticements by the family, employment requirements, or criminal justice system pressure — can improve treatment entry and retention and may increase the individual’s internal motivation to change with the help of treatment. In the TC, the level of treatment engagement and participation is related to retention and outcomes. Treatment factors associated with increased retention include having a good relationship with one’s counselor, being satisfied with the treatment, and attending education classes. One study tested a strategy to enhance motivation by increasing new residents’ exposure to experienced staff, in contrast to the more traditional approach of largely relying on junior staff as role models. The senior staff provided seminars for new residents based on their own experiences with retention-related topics. This strategy appeared to increase the 30-day retention rate and was particularly effective for those whose pretreatment motivation was the weakest.

Important attributes linked to treatment retention include self-esteem, attitudes and beliefs about oneself and one’s future, and readiness and motivation for treatment. Retention can be improved through interventions to address these areas. One approach focuses on teaching cognitive strategies to improve self-esteem, develop “road maps” for positive personal change, improve understanding of how to benefit from drug abuse treatment, and develop appropriate expectations for treatment and recovery. This approach was particularly effective for individuals with lower educational levels.

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