The Therapeutic Community

As Treatment in Substance Use Disorders

 

Laura Pieri, MD

 

Prepared April 9, 2002

 

 

I.                   Introduction – Today we are going to discuss the therapeutic community also known as the TC (perhaps add a little bit about other treatment – 28 day rehab, intensive outpatient treatment programs, etc. involving relapse prevention perhaps focusing on 12 step principles – admit that one is not in control, etc.) – ask the students if they have ever heard of the TC and if so, what do they know –

A.      Understand the concept of the TC

1.      The TC will be defined

2.      History of the TC

B.      Philosophy of the TC – The TC approach is based on an explicit perspective of the following, each of which will be further explained in the lecture:

1.      Substance Use Disorders

2.      The patient

3.      The recovery process

4.      Healthy living

C.      Understand the component parts and the design of the TC

1.      Patient characteristics

2.      Social organization of the TC

3.      The TC process and regimen

D.      Be familiar with the factors that affect the success rate of a TC for a patient

1.      Predictors of retention in treatment

2.      Predictors of drop-out in treatment

II.                What is the TC

A.      Definitions

1.      TC: generic term for drug-free Residential Programs for Substance Use Disordered patients.  It is a “consciously-designed social environment and program within a residential or day unit in which the social and group process is harnessed with therapeutic intent.”  TC’s can differ in (Gallanter, 1999):

a.      Size (from 30 patients to 100’s)

b.      Patient demography (details will be addressed later in the lecture)

                                                                                                                                                   i.      TCs originally attracted opioid-dependent individuals

                                                                                                                                                 ii.      Most of the patient populations now are not involved with opioids

                                                                                                                                                iii.      Also backgrounds of:

1.      Social

2.      Economic

3.      Ethnic

4.      Cultural

5.      Severity of alcohol and drug problems

c.       Length of stay

                                                                                                                                                   i.      3 to 6 months (short term)

                                                                                                                                                 ii.      12 to 18 months (long term)

                                                                                                                                                iii.      Sometimes tailored to court orders (e.g. patients in intensive forensic rehabilitation units)

                                                                                                                                               iv.      Traditional TCs are 15-24 months

d.      Setting

                                                                                                                                                   i.      inpt./residential

                                                                                                                                                 ii.      day programs

                                                                                                                                                iii.      other ambulatory programs

2.      Comprehensive range of interventions and services in one treatment setting

3.      The “Primary Therapist” is the community itself

4.      There are two main types:

a.      One dealing with deeper intrapsychic change (Sugarman, 1984)

b.      One dealing with initial behavioral control

B.      History of TC

1.      TC in psychiatric facilities pioneered by M. Jones (1953)

2.      TC for substance use disorders emerged in the 1960s – independently of the psychiatric therapeutic community – we will focus on the TC treating the substance use disordered patient

a.      Daytop, 1963 (oldest and largest drug-free, self-help program in the U.S.)

b.      Phoenix House, 1967 (largest non-profit organization devoted to the prevention and treatment of substance abuse)

3.      Modern antecedents of TC can be traced to (both are self-help models):

a.      AA

b.      Synanon (an alternative lifestyle community that coined the phrase “today is the first day of the rest of your life”)

III.             Philosophy of the TC - The TC Perspective

A.      View of the “Disorder”

1.      Disorder of the whole person affecting some or all areas of functioning: cognitive, behavioral, emotional (mood), spiritual/moral/value system

2.      The “problem” is the individual, NOT the drug of abuse

3.      Detox is a condition of entry and is NOT the goal of treatment

4.      The goal is maintaining a drug-free existence

 

B.        View of the “Person” (read patient)

1.      The patient is assessed along dimensions of:

a.      Psychological dysfunction

b.      Social deficits

c.       Vocational/educational problems

2.      The patient is assessed for habilitative needs vs rehabilitative

i. Habilitation:   the development of a socially productive, conventional lifestyle for the first time.

ii. Rehabilitation:   the return to a lifestyle previously lived and known.

3.      Personality and social disturbances addressed for all  

a.      As cause or result

b.      Treatment regimen is the same

c.       Approaches tailored to the patient

C.        View of Recovery

1.       The AIM of treatment involves a change in lifestyle and in personal identity

a.      Psychological goal: to change negative patterns of behavior, thinking, and feeling that predispose the individual to drug use (cognitive-behavioral therapy)

b.      Social goal: to develop conduct, skills, attitudes, and values of a responsible, drug-free lifestyle

2.        Motivation- recovery depends on pressure(s) to change

a.      External pressures

                                                                                                                                                   i.       Family coercion

                                                                                                                                                 ii.       Legal mandates

                                                                                                                                                iii.       Occupational mandates

b.      Internal pressures

                                                                                                                                                   i.      Acceptance of the severity of the dependence

                                                                                                                                                 ii.      Acceptance of the need for treatment (patient thinks he or she “can’t do it alone”)

                                                                                                                                                iii.      Recognition of substance-related deterioration of physical, emotional, mental, and spiritual health

3.        Self-help and mutual self-help: treatment is “given” through staff and peers via:

a.      Daily regimen of work

                                                                                                                                                   i.      Job assignments related to the daily function of the unit: cleaning, cooking, supervising new members, etc.

                                                                                                                                                 ii.      “Homework” assignments from therapy sessions

b.      Daily individual counseling and groups (each for special needs)

                                                                                                                                                   i.      Gender specific groups (for example, in a womens’ group, issues addressed may include dependency in the face of pregnancy or prostitution as a behavior that may be part of their dependency)

                                                                                                                                                 ii.      Ethnic specific groups (addressing, for example, racial or cultural pressures that lead to dependency)

                                                                                                                                                iii.      Age specific groups (dependency as a coping mechanism in the elderly may be a result of issues different from those in adolescents)

                                                                                                                                               iv.      Controlled confrontational groups

1’.  Behavioral Focus to modify negative behavior and attitudes

2’.  Emotional Focus to effect psychological change (give insight)

3’.  Educational Focus to assist in the learning of concepts and specific coping/communication skills

v.   Dual diagnosis groups

c.       Meetings and Seminars

                                                                                                                                                   i.      AA/NA meetings

                                                                                                                                                 ii.      “Double Trouble” meetings (dual-diagnosis equivalent of AA/NA meetings)

                                                                                                                                                iii.      “House” meetings which address problems in the day to day function of the community

                                                                                                                                               iv.      “Emergency” meetings to address elopements, relapses, and other major infractions in the community

d.      Recreation to facilitate assimilation into the community (modeling acceptable behaviors for such activities)

                                                                                                                                                   i.      Movies (on the unit or off site)

                                                                                                                                                 ii.      Day trips to museums, parks, etc.

                                                                                                                                                iii.      Celebrations (holidays, birthdays, etc.)

                                                                                                                                               iv.      Other activities related to traditions (e.g. memorial observances)

4.      Social learning

a.      Community serving collectively as “teacher”

b.      An active process (of doing, participating, sharing, and confronting)

c.       Peers and staff as role models and examples

d.      Here and now (not then and when)

e.      Past explored only to illustrate the current patterns of dysfunction, negative attitudes and negative outlook

f.        Assume responsibility for their present reality and destiny

D.      View of healthy living

1.      Clear “moral” positions regarding social and sexual conduct

a.      Right and wrong behaviors are identified, with rewards and sanctions

b.      Specific values essential to personal growth

                                                                                                                                                   i.      Truth and honesty

                                                                                                                                                 ii.      A work ethic

                                                                                                                                                iii.      Self-reliance

                                                                                                                                               iv.      Earned rewards and achievement

                                                                                                                                                 v.      Personal accountability

                                                                                                                                               vi.      Social manners

                                                                                                                                              vii.      Community involvement

c.       Guilt is a central issue to promote affiliation with peers and self acceptance

2.      Focus is on personal present (“here and now”); past explored only to illustrate current patterns of dysfunction

IV.   Parameters/component parts of the prototypical TC

A.     Who comes for treatment, i.e. patient characteristics (Galanter, 1999)

   1.   Social profiles

a.   70-75% are male, but the female percentage is increasing

b.   Most are from broken homes or disrupted families

c.       Most with poor work histories (less than 33% were employed full time in the year PTA)

d.      Most have engaged in criminal activities (>66% have been arrested)

e.      30-40% have previous drug treatment encounters

2.   Psychological profiles

a.      High on anxiety and depression scales

b.      Poor socialization scores

c.       IQ = dull (70-84) to normal (85-115)

d.      Low self esteem

e.      MMPI showing: confusion, personality disorder, and disturbed thinking and affect

f.        Characteristics of immaturity and antisocial behaviors (a positive change in these is essential for stable recovery):

                                                                                                                                                   i.      Low tolerance for all forms of discomfort

                                                                                                                                                 ii.      Low tolerance for delayed gratification

                                                                                                                                                iii.      Problems with authority

                                                                                                                                               iv.      Inability to manage feelings

                                                                                                                                                 v.      Poor impulse control

                                                                                                                                               vi.      Poor judgment and reality testing

                                                                                                                                              vii.      Unrealistic self appraisal

                                                                                                                                            viii.      Prominence of lying, manipulation, and deception as coping behaviors

                                                                                                                                               ix.      Personal/social irresponsibility

                                                                                                                                                 x.      Deficits in learning and communication skills

3.      Psychiatric diagnoses

a.      >70% have lifetime psychiatric symptoms

b.      33% have a current serious psychiatric symptoms

c.       These include temporary, substance-induced conditions that clear with abstinence

d.      Can also represent independent disorders.   Several are over represented in substance use disordered patients including:

                                                                                                                                                   i.      Antisocial personality disorder

                                                                                                                                                 ii.      Bipolar (manic depressive) disorder

                                                                                                                                                iii.      Anxiety disorders

4.      Criteria for treatment

a.      Exclusionary criteria (The patient is a management burde or are a threat to the security and health of the TC)

                                                                                                                                                   i.      H/o arson

                                                                                                                                                 ii.      H/o suicide attempts

                                                                                                                                                iii.      Serious psychiatric disorder(s):

1’.  Severity of illness that has required psychiatric hospitalization in the past

2’.  Psychotic symptoms at the time of the initial interview

3’.  Symptoms of delirium at the time of the initial interview

                                                                                                                                               iv.      Patients on daily regimen of psychotropic medication

1’.  More addiction

2’.  Contradictory to a “drug-free” mentality)

3’.  Correlates with a chronic or severe psychiatric disorder

b.      Open-door policy (meaning that other than exclusionary criteria, anyone will be accepted for treatment)

c.       Modified TC’s can accommodate dually diagnosed patients (there is a place, in certain TC treatment settings, for those who would usually be excluded.)

                                                                                                                                                  i.      Psychiatric/mental health services are present

                                                                                                                                                ii.      Primary health care coverage (e.g. specifically geared towards HIV/AIDS patients)

                                                                                                                                              iii.      Expanded aftercare services to accommodate the special needs of the patient

                                                                                                                                              iv.      Greater tendency to rely on counselors (vs community)

                                                                                                                                                v.      Exclusionary criteria even for the modified TC setting:

1’.  H/o arson

2’.  Active suicidality without an established safety alliance

3’.  Florid psychosis

4’.  Delirium/dementia

B.   The TC approach

1. TC structure

a.   Staff  (director, assistant director, counselors, social worker, clerk; Modified TC staff also have psychiatrists, nurses, and therapists):

i.          Monitor and evaluate patient status

ii.                   Supervise groups

iii.                  Assign and supervise jobs

iv.                 Oversee house operations

v.                   Make decisions relating to resident status, discipline, promotion, transfers, discharges, furloughs, and treatment planning

b.   Resident (patients) at junior, intermediate or senior levels depending on their progress and length of stay

i.   Daily operation of the unit is the task of residents (under staff supervision) and jobs are assigned by staff and are arranged in a hierarchy according to seniority, clinical progress and productivity; examples of resident jobs include:

1’.   House services (cleaning, cooking, etc.)

2’.   Apprentices to any of the above services

3’.  Conducting house meetings

4’.  Conducting certain seminars and groups

2.   Fundamentals:

a.      Work as education and therapy: Job changes are therapeutic tools

b.      Mutual self-help: Residents teach one another the main messages and expectations of the community

c.       Peers as role models (and staff as role models and rationale authorities)

i.         Act “as if:” resident behaves as the person he/she should be rather than as he/she has been (feelings, insights, and altered self-perceptions)

ii.  Role models display “responsible concern:” willingness to confront others whose behavior is not in keeping with the rules of the TC or the spirit of the community.   Obligated to be aware of their environment, others’ moods, attitudes, appearance, and behaviors.

iii.  Staff as rationale authorities: as credible, supportive, corrective and protective authorities who provide reasons for their decisions and explain the meaning of consequences

3.   TC process (the recovery process)

  a.   Typical daily regimen of a TC (highly structured, begins at 7am and ends at 11pm) in which residents participate:

i.         A variety of meetings

ii.   Encounter and other therapeutic groups

iii.  Recreational activities

iv.   Perform job functions/assignments (work therapy)

                                                                                                                                               vi.      Individual counseling

b.   Program Stages

i.         Stage I: orientation (0-60 days) – the most vulnerable period for dropout

1’.  Educate the patient about the TC (cardinal rules and house regulations, expected conduct, the program structure itself)

2’.  Assimilate the patient into the community as rapidly as possible

3’.  Further assess the patient

ii.   Stage II: primary tx (2-12 mos)

1’.  Improving behaviors

2’.  Improving level of insight

3’.  Progressive elevation of status in the community

4’.  Development of maturity

5’.  Increasing personal autonomy

iii.  Stage III: (13-24 mos)

1’.  Early re-entry (13-24mos), patient must:

a’.  Strengthen skills for autonomous decision-making

b’.  Increase their capacity for self-management

c’.  Rely less on rational authorities

d’.  Rely less on a well-formed peer network

2’.  Late re-entry (18-24 mos), patient must:

a’.  Successfully separate from the community

b’.  Live out of the facility

c’.  Hold full-time job or be a full-time student

d’.  Maintain their own households

3’.  Graduation

a’.  An annual event marking the completion/end of active program involvement

b’.  Usually occurs 1 year after their residence is over

2’.  Aftercare

a’.  Continuing of psychiatric care on an outpatient basis

b’.  Continuing of care for patients with special needs (parenting classes, etc.)

IV.              Effectiveness of the TC approach

A.      Success rates

1.      Substantial improvements noted on (NIDA, 2001):

a.      Drug use (reduced from 40-60%)

b.      Criminality (decreased arrest rates of up to 40%)

c.       Employment (gains of up to 40% after completing treatment)

2.       “Time in Program” (TIP) and Post-treatment outcomes have a positive correlation (Galanter, 1999) and is the most important predictor of outcomes (Sells and Simpson, 1976); for example, 2 years after leaving the program the rate of “no drug use and no criminality” was:

3.      The land mark studies making the same point are:

a.      Simpson                 (1979), N=735, 24 TCs, LOS=90 days

b.      Bale, et al.              (1980), N=361,   3 TCs, LOS=50 days

c.       DeLeon, et al.         (1982), N=525,   1 TC,   LOS=120-180 days

d.      Hubbard, et al.       (1989), N=731, 10 TCs, LOS=190-365 days

4.      Other, smaller studies saying the same thing:

a.      In 2 studies, men released from prison who had completed 18 months or more in TC were less likely to re-offend than those who had less time. (Cullen, 1993 and 1997)

b.      Clients apparently need to complete the induction phase and work through at least the primary phase before they begin to realize favorable outcomes from programs (Condelli, 1994)

c.       In one study (Bleiberg et al, 1994), patients who remained in treatment for 6 months 50% were successful in remaining sober at 32 months post discharge, while patients who remained in treatment for only one month  23% remained sober at 15 months post discharge.

B.      Retention rates (Retention should NOT be confused with treatment effectiveness)

1.      Dropout rates are highest for the first 30 days of treatment (30-40%) (Galanter, 1999); this is especially true for antisocial personality disordered patients (Jones, 1997)

2.      Completion rates range from 10-25% of all admissions

3.      Most client variables do not powerfully predict retention, and those that do are generally weak and sporadic predictors (Condelli, 1994)

a.      Fixed client variables (difficult/impossible to change):

                                                                                                                                                   i.      Demography

                                                                                                                                                 ii.      History

b.      Dynamic client variables (can be addressed by TCs):

                                                                                                                                                   i.      Self esteem, self concept

                                                                                                                                                 ii.      Perceived hopefulness about the future

                                                                                                                                                iii.      Feeling comfortable in large groups of people

4.      Treatment entry variables have been stronger and more consistent predictors of retention (Condelli, 1994)

a.      Legal involvement

b.      Treatment Alternative to Street Crimes Program (TASC)

c.       In prison before admission

d.      Significant other’s pressure

C.      Predictors of drop-out, though weak (DeLeon, 1999)

1.      Severe criminality

2.      Severe psychopathology (for example antisocial personality disorder, borderline personality disorder)

3.      Perceived legal pressure

4.      Research which attempts to identify people for whom therapeutic community treatment seems most appropriate offers a practical means of establishing potential successes, but in practice TCs do not follow these guidelines (Rawlings, 1999)

D.      Recommendations based on a 1999 meta-analysis of 29 studies (sifted from 8,160 studies done in 38 countries, most from the USA and UK; Lees, et al, 1999)

1.      TCs produce changes in people’s mental health and functioning, but this needs to be further complemented by good quality qualitative and quantitative research studies

2.      Further research on the effectiveness of the TC for personality disorders is warranted

3.      There is evidence that the longer a resident stays in treatment, the better the outcome

4.      More research is needed to identify ways of reducing drop-out rates

V.                 Summary and Wrap-up

A.      I hope that I have given you an understanding of

1.      The purpose and development of the TC

2.      The basic philosophy in the TC approach to treating those with Substance Use Disorders

3.      The structure and design of the TC as the method of treatment

4.      The TC is an effective treatment method with several factors that effect success rate

5.      More research is needed with reference to reducing drop-out rates

B.      Think about this type of treatment for patients you encounter

 

 

BIBLIOGRAPHY: THE THERAPEUTIC COMMUNITY AS TREATMENT IN SUBSTANCE USE DISORDERS

Laura Pieri, MD

February, 2002

 

1. Bleiberg J, Devlin P, Croan J, Briscoe R: Relationship between treatment length and outcome in a therapeutic community. International Journal of the Addictions. 1994, 29: 729-740.

 

2. Condelli WS: Domains of variables for understanding and improving retention in therapeutic communities. The International Journal of the Addictions. 1994, 29: 593-607.

 

3. Condelli WS: Predictors of retention in therapeutic communities. Therapeutic Community: Advances in Research and Application (NIDA Res Monogr No 144). 1994: 117-127.

 

4. Condelli WS, Hubbard RL: Client outcomes from therapeutic communities. Therapeutic Community: Advances in Research and Application (NIDA Res Monogr No 144). 1994: 80-98.

 

5. Cullen E: Can a prison be a therapeutic community: the Grendon template. Therapeutic Communities for Offenders. 1997: 73-79.

 

6. Cullen E: The Grendon Reconviction Study Part 1. Prison Service Journal. 1993, 90: 35-37.

 

7. DeLeon G: The therapeutic community: toward a general theory and model. Therapeutic Community: Advances in Research and Application (NIDA Res Monogr No 144). 1994: 16-53.

 

8. DeLeon G: The Therapeutic Community: study of effectiveness (NIDA Treatment Research Monograph ADM-84-1286). Rockville, MD. 1984: 1-95.

 

9. DeLeon G, Schwartz S: The Therapeutic Community: what are the retention rates? Am J Drug Alcohol Abuse. 1984, 10: 267-284.

 

10. DeLeon G: Modified Therapeutic Community for homeless mentally ill chemical abusers: emerging subtypes. Am J Drug Alcohol Abuse. 1999, 25: 495-515.

 

11. Galanter, M and H Kleber, editors. Textbook of Substance Abuse Treatment. American Psychiatric Press, Inc. Washington, D.C. 1999: 447-462.

 

12. Jones L: Developing Models for Managing Treatment Integrity and Efficacy in a Prison-based TC: The Max Glatt Center. Therapeutic Communities for Offenders. 1997: 121-157.

 

13. Melnick G: Therapeutic communities: diversity in treatment elements. Subst Use Misuse. 2000, 35(12-14): 1819-47. Mertens JR: Predictors of substance abuse treatment retention among women and men in an HMO. Alcohol Clin Exp Re. 2000, 24:1525-1533.

 

14. Nemes S: Comparing the impact of standard and abbreviated treatment in a therapeutic community. J Subst Abuse treat. 1999, 17:339-347.

 

15. Rawlings B: Therapeutic Communities in prisons: a research review. Therapeutic Communities. 1999, 20:  177-193.

 

16. Sacks S, Sacks J, DeLeon G, et al: Modified therapeutic community for mentally ill chemical abusers: background; influences; program description; preliminary findings. Substance Use and Misuse.1997, 32: 1217-1259.

 

17. Sugarman B: Towards a new, common model of the therapeutic community: structural components, learning processes and outcomes. International Journal of Therapeutic Communities. 1984, 5: 77-98.

 

18. Tims F, Jainchill N, DeLeon G: Therapeutic communities and treatment research. Therapeutic Community: Advances in Research and Application (NIDA Res Monogr No 144). 1994: 1-15.