Drug-free Therapeutic Community Research Articles

Therapeutic communities in Santa Catarina, Brazil

Purpose The purpose of this paper is to present a case study of a programme aimed at raising standards of care and levels of professionalism in private, drug-free therapeutic communities (TCs) in Santa Catarina, Brazil. Design/methodology/approach The paper describes the Reviver intervention in detail and draws on subjective insights collected during its implementation. Findings Over 100 TCs applied to the Reviver project, of which 83 qualified to participate. The large majority of TCs were found to combine community-as-method, religious worship and abstinence in their treatment model. Research limitations/implications The paper highlights the significant role religious organisations have in the treating substance dependency in Brazil and raises ethical and practical questions regarding the incorporation of religious TCs into mainstream public mental health provision. Practical implications The paper outlines the qualification process, control systems and monitoring procedures employed by the Reviver project. Originality/value The paper attends to the gap in English language publications regarding TCs in Brazil and raises important questions regarding the role of religion, faith and spirituality in the treatment of substance dependency.

Doing time on a TC: how effective are drug-free therapeutic communities in prison? A review of the literature

PurposeTherapeutic communities (TC’s) are consciously designed, living-learning environments designed to evoke social, psychological and behavioural change. The success of the residential TC model saw these community-led, self-help environments for addicts move into custodial settings and early evidence suggests this transition was effective. The purpose of this paper is to examine the evidence relevant to the effectiveness of prison based, drug-free TCs.Design/methodology/approachIn order to establish their true efficiency, particular focus has been placed on studies conducted over the last ten years (2007-2017).FindingsTo date, the TC remains superior to other forms of drug treatment in reducing recidivism and drug relapse amongst addicts who offend.Originality/valueOutcomes of this review highlighted the importance of aftercare in providing transitional support; a fundamental aspect of treatment necessary for success and for maintaining long-term recovery post release.

Drug-free therapeutic communities in Europe

Drug-free therapeutic communities in Europe

Identity change in a drug-free Therapeutic Community: a Lacanian interpretation of former residents’ perspectives on treatment process and outcome

PurposeIn drug-free Therapeutic Communities (TCs), people with addictions live together in order to achieve recovery in terms of a modified drug-free lifestyle. Central to the TC approach is the assumption that this shift is only achievable when “identity change” has taken place. However, this claim has rarely been addressed in TC research. Further insight into the nature and realization of such identity change might help to understand how this community approach contributes to long-term recovery. The paper aims to discuss these issues.Design/methodology/approachThe present qualitative interview study explores the perspectives of ten former TC residents on their treatment and their process of change. To organize the interview data, Lacanian psychoanalytic theory on identity formation/change is used as a framework.FindingsThe common thread in the participants’ process of change is presented in three parts: their life before, in and after the TC. The substeps within these parts are illustrated with several quotes.Originality/valueThe findings highlight the value of innovative qualitative research designs to address the many challenges to addiction treatment research. A Lacanian reading of the data makes it possible to describe the subjective logic of the process of change in the TC, focusing on how substance (mis)use functions as an attempted solution in dealing with identity issues. By linking crucial TC ingredients such as the TC law and TC tools to the process of the identity change, a new reading of this long-term group approach is achieved.

In Search of Evidence-Based Treatment in TCs for Addictions: 40 Years of Research in TC De Kiem (Belgium)

ABSTRACTDespite more than 40 years of research, limited evidence is available for the effectiveness of drug-free therapeutic communities (TCs). Worldwide, TCs have attempted succesfully to integrate innovative and evidence-based interventions, while adhering to the “community as method” (De Leon, 2000). This article is a case study of scientific research on practice and innovations in a TC, De Kiem (Belgium), over the past 40 years, illustrating how research and innovative approaches have shaped the TC into its current practice. From the start, scientific research was used to develop and adapt the TC program. International collaboration introduced new ideas, instruments, and methods and promoted a culture of inquiry. Several interventions that were implemented have contributed successfully to increased program retention, like the introduction of a welcome house phase, social network support, and a mother and child program.

Work as a therapeutic resource: Case study of a rehabilitation community for persons with chemical dependency

Studies involving the therapeutic nature of the work done by chemically dependent individuals undergoing treatment in therapeutic communities are scarce, not only in Brazil, but also in the international literature. To clarify the role played by work as a therapeutic element for patients who are undergoing treatment in a drug-free therapeutic community setting in Brazil. Clients are free to choose their occupations during treatment, that exercise their creativity and their responsability for their recovery. The Biographical Method was employed in two case studies. The approach adopted by the community enabled clients to recognize how they became chemically dependent, as well as their possibilities for recovery. Clients expanded their interests and their daily activities that were once exclusively directed towards the consumption of drugs. Their personal development improved through their contact with reality through work activities, in the context of a therapeutic community. From there, clients were increasingly able to plan and execute life projects aimed at their full recovery.

P01-24 - The black box of the therapeutic community for addiction clarified by means of mentalisation theory: A participant observation study

Drug free Therapeutic Communities (TC’s) for addiction developed outside the medical and mental health care. Although these programs have proven to be effective, the why and how of the treatment process stays misunderstood. This ‘Black Box of the TC's’ threatens their continued existence and has led to a call for qualitative research.To investigate the treatment process, the first author fully immersed herself in the Belgian TC ‘Trempoline’ for 3 weeks. The full participation strongly affected research possibilities: record equipment was taken away and the exigent day’s schedule left few moments to note.Paradoxically, such frustrating experience proved to be an integral part of the treatment process. The data-set was analyzed with thematic analysis.This resulted in a model consisting of 5 main themes which clarifies how the TC-program (themes 2 and 4) influences its residents (themes 1, 3, 5) (see figure 1).The frustrating but at the same time holding environment reactivates the residents’ drowned emotional life. By applying symbolization-tools they learn to deal with the increasing tension in a mentalised way instead of acting out their discontent.We conclude that a TC tackles the disruptive affect-regulation in people suffering from addiction by triggering and developing their mentalisation process.

Spiritual Orientation among Adolescents in a Drug-Free Residential Therapeutic Community

Clinically, the treatment of substance abuse has relied on the Twelve Steps model, which is heavily focused on issues of spirituality. Adolescents may have cognitive and developmental issues that preclude them from taking advantage of the Alcoholics Anonymous (AA) model. To this end, we examined the spiritual orientation and spiritual behaviors among adolescent substance abusers in a drug-free residential therapeutic community (TC). One hundred and eighty-six adolescent clients of a drug-free residential therapeutic community were given a self-report questionnaire about their substance abuse and attitudes toward spirituality. The adolescents had a mean Spiritual Orientation Score of 21.48, reflecting a significantly lower level of spiritual orientation than adults in a similar setting. Also, adolescents who were heavy marijuana users were less spiritual than those adolescents who used marijuana less. Spirituality and affiliation with religious institutions may be considered a protective factor because they represent more conventional beliefs and attitudes and indicate a stronger social bond to conventional society.

Gang Membership and Subsequent Engagement into a Drug Free Therapeutic Community

The purpose of the present study was to assess the relationship of history of gang involvement to engagement in Therapeutic Community (TC) treatment. Residents (N = 222) at two Daytop facilities completed a survey assessing sociodemographic characteristics, prior gang involvement and multiple aspects of TC functioning. Residents with prior gang involvement (21%) were younger and less educated than those without prior gang involvement. Although gang involved residents were more likely to achieve a high work role status in the program they scored lower on multiple indicators of engagement in treatment including acceptance of Daytop philosophy and TC clinical progress.

Somatization, Anxiety and Depression in a Drug-Free Residential Therapeutic Community

Somatization, Anxiety and Depression in a Drug-Free Residential Therapeutic Community

Conducting a Therapeutic Community Program Evaluation with Limited Resources

Abstract Aims: Demonstration of treatment effectiveness at the local program level within the limits of available funding and resources. Design: Evaluating program graduates by comparing their admission status to their post-treatment discharge status. Setting: A residential, drug-free therapeutic community. Participants: 79 of 152 program graduates. Measurements: The Tennessee Self-Concept Scale:2 (TSCS:2) and the Post-Treatment Follow-Up Survey (PTFUS). Findings: The TSCS:2 distinguished between participants who were “faking good” and/or “avoiding self-criticism” and those responding in a more genuine fashion. Significant gains in several areas of the self-concept were noted for those with valid TSCS:2 profiles when compared to an unmatched admission sample. Improvements on other indicators of treatment improvement (e.g., employment, no criminal justice status) were also noted through use of the PTFUS. Conclusions: The effectiveness of treatment can be demonstrated at the local program level with minimal resources.

Healing through social and spiritual affiliation.

Two very different approaches can be employed to promote recovery from psychiatric disorders. One approach is grounded in an understanding of individual psychopathology, and it is clearly central to contemporary care. The second approach to recovery, which is based on group psychology and the support derived from participation in a group, can also be valuable in promoting recovery. In examining this second approach, I consider Alcoholics Anonymous (AA) and other movements that operate through social and ideologically grounded support. The term “spiritual recovery movement” (1) can be applied to them. On the basis of studies that I and my colleagues have conducted, I describe a psychological model to clarify the operation of such groups. Charismatic groups Social and spiritual recovery can be considered from the perspective of naturally occurring, highly cohesive, and religiously oriented cultic groups, two of which I have studied. One was the Divine Light Mission, headed by a guru who began preaching at the age of six in his native India. Members’ responses to a research questionnaire indicated a reduction in their symptoms of psychological distress after they joined the group, and the extent of the reduction was significantly correlated with the intensity of the social cohesiveness a member felt toward the group (2). Further clarification of the psychology of cultic groups emerged from our studies of the Unification Church, the “Moonies.” Using two scales I found that the stronger an individual’s affiliative feelings toward the group, the greater his or her psychological wellbeing (3). A study of long-term members who were matched to their future spouses by the Reverend Moon

Hair morphine concentrations of fatal heroin overdose cases and living heroin users.

To compare heroin and other opiate use of heroin overdose fatalities, current street heroin users and drug-free therapeutic community clients. Hair morphine concentrations that assess heroin use and other opiate use in the 2 months preceding interview or death were compared between heroin overdose fatalities diagnosed by forensic pathologists (FOD) (n = 42), current street heroin users (CU) (n = 100) and presumably abstinent heroin users in a drug-free therapeutic community (TC) (n = 50). Sydney, Australia. The mean age and gender breakdown of the three samples were 32.3 years, 83% male (FOD), 28.7 years, 58% male (CU) and 28.6 years, 60% male (TC). The median blood morphine concentration among the FOD cases was 0.35 mg/l, and 82% also had other drugs detected. There were large differences between the three groups in hair morphine concentrations, with the CU group (2.10 ng/mg) having concentration approximately four times that of the FOD group (0.53 ng/mg), which in turn had a concentration approximately six times that of the TC group (0.09 ng/mg). There were no significant differences between males and females in hair concentrations within any of the groups. Hair morphine concentrations were correlated significantly with blood morphine concentrations among FOD cases (r = 0.54), and self-reported heroin use among living participants (r = 0.57). The results indicate that fatal cases had a lower degree of chronic opiate intake than the active street users, but they were not abstinent during this period.

Improved Psychological Status in a Modified Therapeutic Community for Homeless MICA Men

An adaptation of the drug-free therapeutic community (TC) model to homeless men with comorbid mental illness and chemical addiction (MICA) was evaluated with respect to change in psychological status over the course of a six-month residential treatment. Psychological status was assessed by: the Symptom Checklist-90-R (SCL90-R), Beck Depression Inventory (BDI), Shortened Manifest Anxiety Scale (SMAS), and Tennessee Self-Concept Scale (TSCS). A total of 52 out of an original study cohort of 124 residents were followed in longitudinal analyses to treatment midpoint, with a subset of 34 assessed through treatment completion. Significant, widespread psychological improvements were found during both the first and second half of treatment; it would appear that distress reduction was ongoing throughout treatment, with intrapersonal preceding interpersonal relief. The premise of applying a socially-based treatment to this population is discussed in light of these findings.

Outcome related electrophysiological subtypes of cocaine dependence.

We previously described the existence of two quantitative EEG (QEEG) subtypes of cocaine dependent males, identified at baseline, displaying differential proneness to relapse. The current study expands the population to include females and enhances the measure set to include both QEEG and somatosensory EP (SEP) features. Fifty-seven cocaine dependent adults (16 F, 41 M) were evaluated 5-14 days after last cocaine use, while in residence at a drug-free therapeutic community. The median length of stay in treatment (continued abstinence) was 25 weeks. Using a small subset of QEEG and SEP baseline features, three subtypes (CLUS) were identified. CLUS 2 (n = 25) and CLUS 3 (n = 23) replicated the published subtypes, while CLUS 1 (n = 9) was previously undescribed. Cluster membership was significantly associated with length of stay in treatment (chi 2 = 13.789, P < 0.001), but not with length of exposure to crack cocaine or to any demographic or clinical features. Seventy-eight percent of CLUS 1 and 65% of CLUS 3 left treatment < or = 25 weeks, whereas 80% of CLUS 2 remained in treatment > 25 weeks. The existence of outcome related subtypes may reflect: [1] differential neurophysiological vulnerability, "traits," predisposing individuals to cocaine addiction; or [2] differential neurosensitivity, "states," due to the effects of chronic cocaine exposure, and associated differences in treatment outcome. Using Variable Resolution Electrical Tomographic Analysis (VARETA), the mathematically most probable neuroanatomical source of the scalp recorded EEG data was localized. Computation of VARETA on the baseline Cluster profiles suggest significant differences in the underlying pathophysiology of these subtypes.

Self-help treatment for combined addiction and mental illness.

New approaches to treating patients with combined mental illness and substance abuse continue to be developed. This rethinking of treatment is particularly important because of the acknowledged organizational barriers to effective management of persons with dual diagnoses and the excessive costs associated with their recidivism. This column describes a model for treatment that combines peer-led self-help from the addiction field with professional treatment from general psychiatry. This approach represents a paradigm shift from the way treatment is applied in the conventional mental health system in that patient peers assume many of the roles that are usually carried out by professionals, and these services are then integrated across levels of care. The model is based on a theoretically grounded perspective on behavioral change. We have evaluated its application in empirical studies in our system of acute inpatient, stepdown, and ambulatory units. This column should help convey how the self-help peer-led approach can be applied to bring about systems-level change in a variety of treatment settings where people with dual diagnoses are encountered, such as large hospital centers, smaller private programs, or multisite health maintenance organizations. The problem Combined substance abuse and mental illness was evident in communitybased populations at the time of the National Institute of Mental Health Epidemiologic Catchment Area survey in 1980‐1985. The survey found that 29 percent of mentally ill persons had substance use disorders. Among psychiatric inpatients, a 1988 New York State survey estimated the prevalence of substance abuse to be 34 percent. In a study the following year at New York City’s Bellevue Hospital Center, our treatment site, we found the remarkably high prevalence of 64 percent of substance use disorders among general psychiatric patients (1). Most notable in terms of likely recidivism was that 38 percent of those admitted to the general psychiatric service were cocaine abusers. Addiction rehabilitation, however, was not integrated into our hospital’s approach to general psychiatric care, and dual diagnosis patients were offered no resources for undertaking recovery from addictive illness. There was no access to peer-led self-help, as in the 12-step programs and drug-free therapeutic communities that were typical of community-based addiction rehabilitation. These circumstances are now widely known to lead to recidivism and a compromised clinical outlook. Furthermore, it is now understood that a material change in the care delivery system is needed to address this population’s needs, and no such adaptation had been made at Bellevue—or at similar institutions.

The "new" drug-free therapeutic community. Challenging encounter of classic and open therapeutic communities.

In view of a rapidly changing society, reflected in many changes within the drug-free Therapeutic Communities (TCs), the question has been raised: "What can and cannot be changed in this modality?" This question was addressed at a European conference of experienced therapeutic community workers, who concluded that many changes have occurred and will continue to occur, but some basic concepts should be preserved. The changes inherent in postmodern society are examined here in an effort to foresee their impact on the evolution of the TC. Necessary changes and additions are discussed.

Treatment level progress and time spent in treatment in the prediction of outcomes following drug-free therapeutic community treatment.

Previous research has suggested that time spent in treatment is the most important predictor of therapeutic community treatment outcomes. Although level divisions or treatment stages represent the basic structure for segmenting responsibility and authority within traditional therapeutic communities, the relationship of this treatment component to treatment outcome has not previously been investigated. To test the hypothesis that higher treatment level attainment, more time spent in treatment and additional time spent within a treatment level has a linear association with improvements at outcome. Retrospective quasi-experimental. Four hundred and twenty-seven ex-residents, stratified according to their highest level of treatment in the Melbourne Odyssey House therapeutic community between 1984 and 1988 were targeted for follow-up and 60% were successfully located and interviewed an average of 5.6 years after their first Odyssey entry. Analysis of official records of methadone treatment, convictions and incarcerations demonstrated no post-treatment differences comparing those interviewed with those not interviewed. Drug use, criminal involvement and employment. FINDINGS. Although both level attainment and time spent in treatment had a linear relationship to improved outcomes, level attainment was a better predictor of outcomes at treatment exit. An unexpected finding was that those who had spent the median time or longer in particular levels demonstrated worse outcomes on official conviction records and on self-reports of employment compared to those remaining for less than the median time. The results suggest that it may be level progress rather than simply time spent in treatment that best explains improved functioning following exit from the therapeutic community.

Dual Diagnosis Patients in the Modified Therapeutic Community

ABSTRACT The efficacy of the drug-free therapeutic community (TC) in treating patients with chemical dependence and in rehabilitating persons with criminal histories has been extensively studied and is well established since the late 1960's. More recently, this format has been modified in order to treat individuals suffering from both addictive disorders and chronic, severe mental illness. In an indigent inner-city population, this latter group includes many patients who also have significant histories of criminal behavior. To date, there have been no systematic attempts to assess the impact of a history of criminality on the course of treatment of these patients, as they might be thought less adaptable to the milieu of a TC. In the current study, data from a sample of homeless male MICA patients were analyzed to determine if those patients with a history of criminal convictions were as likely as non-criminal patients to adjust effectively to the social milieu of a modified drug-free therapeutic community. Of 183 sequential admissions studied, 76 had never been convicted of a crime, 46 had 1 conviction, and 61 had 2 or more. No differences were observed between the groups with respect to length of stay, social adjustment on admission, and change in social adjustment during the first two months of treatment. These findings suggest that a history of criminal conduct does not compromise a dually diagnosed patient's likelihood of engaging in the social contract necessary for successful treatment in a TC.

Heroin addiction careers: downward spiral or controlled descent?

For the public and for most policy makers there is no doubt that the career of heroin addiction necessarily involves gradually losing everything one has: health, income, a home, a stable network of relatives and friends, and, last but not least, any sense of self as a moral agent. Although this view is factually incorrect insofar as there are examples of controlled heroin use without such negative effects (cf. Zinberg, 1984), the image of the addiction career as a necessarily downward spiral is represented in the literature as well. The clearest example is the medical model of addiction, in which the addiction career is described as a process of inevitable social deterioration: the drug addict becomes more and more involved in deviant and illegal behavior. The addiction career can be terminated only by therapy or death. Other literature, however, describes the course of addiction as a process of maturing out (Prins, 1995), in which a considerable number of addicts are able to kick the habit by themselves, step by step (Winick, 1962). The latter implies that addicts are able to control their career to a certain extent. The two approaches can be represented by different metaphors: downward spiral and controlled descent. This article, which is based on 48 interviews, discusses how heroin addicts portray their careers and the extent to which they control the downward process. It is supposed that information of this kind will enhance our knowledge of addicts' methods of controlling their situation, which can be relevant for policy and therapy. Our main question, therefore, is whether addicts portray themselves as victims of forces beyond their control or, at least partially, as capable of regulating their situation. Methods In the frame of a more extensive study of differences between heroin addicts in and outside treatment settings in the city of The Hague (The Netherlands), interviews were conducted with 48 addicts who had been using heroin regularly (three days a week or more) for at least two years. Among the respondents were eight women. The sample consisted of 21 heroin addicts who had not been in contact with drug treatment agencies for at least two years, five clients of an outpatient methadone program, 11 participants in a clinical detoxification center, and 11 addicts staying in a drug-free therapeutic community. The 21 non-treatment respondents were selected by a snowball sampling method (see ElandGoossensen et al., in press). The treatment group were interviewed between two and four weeks after admission. Respondents were invited to tell about how heroin use was embedded in their lives. Experiences with treatment and, if relevant, reasons for rejecting and quitting treatment were also explored. In the interviews we used a topic list corresponding to the life areas that are distinguished in the Addiction Severity Index (McLellan et al., 1981; Hendriks et al., 1993); these include chemical abuse, medical, psychological, legal, family/social, employment/support. Housing was added as a topic. Obviously, in the respondents' stories the different life areas were not so clearly separated. Interviews took approximately one hour each and were audio-taped. The interviews were transcribed. Results are presented in three sections. First we discuss to what extent respondents portray their careers as dominated by forces beyond their control. Next we present data on respondents' descriptions of controlling behaviors. Finally we show how personal values are related to control and, consequently, are of influence on the addiction career. Downward spiral In response to the request to tell about how heroin use was embedded in their lives, all respondents spontaneously described aspects of their careers as (part of) a downward spiral. The following extract from the interview with a respondent in the detox group is an example: I: Our first question is . . . What has been the meaning of heroin use in your life, what has been its influence? …