Therapeutic Community Residents Research Articles

Attention-Deficit/Hyperactivity Disorder Symptoms, Sensation-Seeking, and Sensory Modulation Dysfunction in Substance Use Disorder: A Cross Sectional Two-Group Comparative Study

Background: Attention-deficit/hyperactivity disorder (ADHD) and sensation-seeking, a trait characterized by risk-related behaviors, have been recognized as risk factors in substance use disorder (SUD). Though ADHD co-occurs with sensory modulation dysfunction (SMD), SMD has scarcely been explored in SUD. Thus, this study aimed to characterize ADHD symptomology, sensation-seeking, and SMD, as well as to explore their contribution to SUD likelihood. Methods: A cross sectional two-group comparative study including therapeutic community residents with SUD (n = 58; study group) and healthy individuals (n = 62; comparison group) applying the MOXO continuous performance test (MOXO-CPT) evaluating ADHD-related symptoms. In addition, participants completed the ADHD Self-Report Scale—Version 1.1 for ADHD screening; the Brief Sensation Seeking Scale quantifying risk-taking behaviors; and the Sensory Responsiveness Questionnaire-Intensity Scale for identifying SMD. Results: The study group demonstrated higher SMD incidence (53.57% vs. 14.52%) and lower performance in three MOXO-CPT indexes: Attention, Impulsivity, and Hyperactivity, but not in Timing, compared to the comparison group. Sensory over-responsiveness had the strongest relationship with SUD, indicating 27-times increased odds for SUD (95% CI = 5.965, 121.216; p ≤ 0.0001). A probability risk index is proposed. Conclusion: We found SMD with the strongest relation to SUD exceeding that of ADHD, thus contributing a new perspective for developing future therapeutic modalities. Our findings highlight the need to address SMD above and beyond ADHD symptomology throughout the SUD rehabilitation.

Difference in Response to Feedback and Gender in Three Therapeutic Community Units.

Therapeutic communities (TCs) for substance abuse incorporate a system of peer feedback through written affirmations and corrections. Previous research has found that TC residents show a response to affirmations that is detectable for roughly 8 weeks, with response to corrections being of shorter duration and weaker overall. It is not clear whether and to what extent response to feedback in TCs varies between men and women. Previous research in other settings suggests that women should be more responsive to feedback than men. In order to test this hypothesis we draw on a large dataset of affirmations and corrections sent and received in three 80 bed TC units, two of which house men and one of which houses women. The analysis uses a multilevel negative binomial model, treating affirmations and corrections that TC residents receive as predictors of affirmations that they send over a 9 week period (week 0, the week during which affirmations and corrections are actually sent, and eight subsequent weeks). The model controls for gender, age, race, unit and scores on the Level of Service Inventory-Revised (LSI-R). The relationship between affirmations received and those sent is stronger for women during the initial week and on lags 1-2 and 5-8. The relationship between corrections received and affirmations sent is stronger for women on lags 2 and 8. Graphs suggest that response to affirmations falls off in an exponential curve, while that to corrections appears to include a periodic element. These results indicate that both men and women respond to feedback, but that the strength of the women's response is somewhat greater. These results suggest that any difference in suitability by gender to the feedback approach that characterizes TCs may favor women.

Social and programmatic interactions in a therapeutic community for women: an exponential random graph model analysis

Purpose To analyze networks of social interactions between the residents of a therapeutic community (TC) for women and the way, in which such interactions predict the discussion of issues that arise in treatment. Design/methodology/approach In total, 50 residents of a corrections-based TC for women were surveyed on the peers with whom they socialized informally, shared meals, shared letters from home and discussed issues that arose in treatment over a 12 h period. The data were analyzed using exponential random graph models (ERGM). Findings Reciprocity occurred in all networks while transitivity (a tendency of two residents who are connected to both connect to a third peer) occurred in all networks measuring informal social interactions. When controlling for reciprocity and transitivity, residents avoided spending social time or sharing meals with the same peers. There was no evidence of homophily by race, age or years of education. Homophily by entrance time and case manager occurred in social time. Case manager homophily occurred in the discussion of treatment issues but disappeared when controlling for social time and sharing letters from home. Research limitations/implications Social networks in this TC arise from factors endogenous to the TC itself. It should be possible to determine the characteristics of optimal social networks in TCs. External validity is limited. Practical implications It should be possible to intervene to optimize the social networks of TC residents. Originality/value This is the first ERGM analysis of both informal and formal interactions in a TC.

Testing an Interactionist Theory of Treatment Engagement in a Pennsylvania Prison-Based Therapeutic Community

The prison-based Therapeutic Community (TC) is a promising substance use treatment program that emphasizes peer influence. Although program evaluations demonstrate positive results, the cognitive, behavioral, and social processes that define the prison-based TC are largely unknown. The TC model presumes that residents increase their treatment engagement and willingness to change through peer interactions and role modeling, but this process has received virtually no research attention. This study explores these peer-driven mechanisms by examining self, reflected, and peer appraisals of willingness to change of 177 male TC residents, predicting within-person changes in treatment engagement by changes in appraisal measures. Results suggest that self, peer, and reflected appraisals converge over time in treatment. In addition, fixed effects models demonstrate that changes in reflected appraisals are most predictive of changes in treatment engagement. Such results, consistent with symbolic interactionist perspectives, inform prison-based programming and contribute to research on individual-level trajectories of desistance and recovery.

Building the community: Endogenous network formation, homophily and prosocial sorting among therapeutic community residents

BackgroundResearchers have begun to consider the ways in which social networks influence therapeutic community (TC) treatment outcomes. However, there are few studies of the way in which the social networks of TC residents develop over the course of treatment. MethodologyWe used a Temporal Exponential Random Graph Model (TERGM) to analyze changes in social networks totaling 320,387 peer affirmations exchanged between residents in three correctional TCs, one of which serves men and two of which serve both men and women. The networks were analyzed within weekly and monthly time-frames. ResultsWithin a weekly time-frame residents tended to close triads. Residents who were not previously connected tended not to affirm the same peers. Residents showed homophily by entry cohort. Other results were inconsistent across TC units. Within a monthly time-frame participants showed homophily by graduation status. They showed the same patterns of triadic closure when connected, tendency not to affirm the same peers when not connected and homophily by cohort entry time as in a weekly time frame. ConclusionsTCs leverage three human tendencies to bring about change. The first is the tendency of cooperators to work together, in this case in seeking graduation. The second is the tendency of people to build clusters. The third is homophily, in this case by cohort entry time. Consistent with TC clinical theory, residents spread affirmations to a variety of peers when they have no previous connection. This suggests that residents balance network clustering with a concern for the community as a whole.

Treatment engagement in a prison-based Therapeutic Community: A mixed-methods approach

Given the high proportion of inmates with histories of substance use disorders in the era of mass incarceration, many correctional institutions have integrated the prison-based Therapeutic Community (TC) into their programming. While most evaluations provide evidence of lowered rates of relapse and recidivism, the majority of TC graduates still have negative outcomes post-release. Filling an important gap in the TC treatment literature, we analyze quantitative measures of treatment engagement alongside qualitative narratives from prison-based TC residents, providing an essential look into the black box of TC treatment mechanisms. Quantitative results show more between-person variation than within-person change, reflecting trivial increases in treatment engagement throughout time in the program. Qualitative results unpack these findings, pointing to processes of selection bias, heterogeneous treatment effects, and program fidelity lapses. In combination, our mixed data identify tangible modifications to program implementation that could strengthen desired post-release outcomes.

The alumni club: interpersonal contact and the exchange of recovery oriented helping in a sample of former residents of a therapeutic community for women

Purpose Aftercare is an important predictor of outcomes following treatment for substance abuse. Despite this, there is evidence that the great majority of substance abusing clients choose not to participate in aftercare. Aftercare programs that are tied to specific residential treatment facilities, sometimes known as alumni groups or alumni clubs, might increase participation by offering former residents the opportunity to maintain treatment oriented social networks. Therapeutic communities (TCs), which emphasize mutual aid between residents, are ideal candidates for such programs. The paper aims to discuss these issues. Design/methodology/approach In total, 100 randomly chosen former TC residents were randomly surveyed regarding their contact with fellow alumni and their exchange of recovery oriented helping behaviors. A thirty day timeline follow-back methodology was used. Findings Contact was primarily through electronic means, particularly phone calls, texts and the alumni club Facebook page. Participants who reported more electronic contact also reported more days in which they offered and received recovery oriented help. Participants who were African American or had spent more time in TC treatment offered and received recovery oriented help on more days. Research limitations/implications While this is an exploratory study limited to one TC, this alumni club allows for the maintenance of a mutual aid network after termination. That network primarily consists of electronic forms of contact. A longer time spent in TC treatment may allow for the internalization of the practice of mutual aid. Further research on alumni clubs is warranted. Originality/value This is the first survey of TC alumni club members.

Relationship between network clustering in a therapeutic community and reincarceration following discharge

Recent qualitative work on Therapeutic Communities (TCs) suggests that they help residents change by creating an environment that is simultaneously challenging and supportive. There is evidence that social networks that feature numerous closed triads are both more supportive and more likely to influence individual behavior. This implies that TC residents whose peer social networks include more closed triads should have improved outcomes. The social network in this study consists of the affirmations exchanged between 1312 men who resided at a 90 bed TC in a Midwestern state over a period of eight years and includes a total of 34,667 weighted edges. The network was analyzed using the Temporal Network Autocorrelation Model (TNAM) based semiparametric Cox model, thereby using a statistical methodology that accounts for dependence between individuals in the network. Participants whose social networks of TC peers included a higher percentage of closed triads were at a decreased hazard of reincarceration following termination when controlling for age, length of stay and the number of peers who eventually graduated who affirmed the residents. These results support the longstanding TC contention that the community as a whole is the method of clinical treatment. Further quantitative research into TC processes and outcomes should ideally include social network surveys and statistics in order to avoid biases associated with violations of statistical independence assumptions.

Māori Men's Experiences of Rehabilitation in the Moana House Therapeutic Community in Aotearoa/New Zealand: A Qualitative Enquiry.

In Aotearoa/New Zealand, culturally embedded rehabilitation programmes have been developed to reduce criminal offending among the indigenous Māori population. Currently, there is a lack of research investigating the experiences of these programmes from clients' perspectives. This study aimed to enhance understandings of the lived experiences of Māori men who were participating in a residential therapeutic community (TC) programme in Aotearoa/New Zealand. Semistructured interviews were conducted one-on-one by a psychology master's student who was a staff member at the TC and also of Māori descent. Seven Māori TC residents aged 22 to 48 were interviewed about life in a TC. Thematic analysis of the interview data yielded three themes: (a) "The importance of healing family relationships"; (b) "The relevance of Māori culture in rehabilitation"; (c) "Increased self-awareness." The findings highlight the significance of holistic approaches that emphasize culturally relevant approaches and the involvement of family members in the treatment of substance-use disorders and offending behaviour among indigenous populations.

Completion rates and psychosocial intervention effectiveness in an Australian substance use therapeutic community

BackgroundProgram attrition is a major problem in substance use treatment. It is not clear which client and treatment variables are related to successful completion. This study aimed to identify client variables associated with Therapeutic Community (TC) completion. A secondary aim was to investigate changes in entry and exit scores on psychosocial outcome measures.MethodsRetrospective quantitative analysis of data collected from 193 Australian TC residents, over 3.5 years. Variables measured included: demographics; Depression, Anxiety, Stress Score (DASS-21) and World Health Organisation Quality of Life 8 questions (WHOQOL-8).ResultsCompletion rates were 30.6%. High Money WHOQOL-8 scores, suggestive of minimal financial stressors, positively predicted completion. Multivariate analyses showed that negative predictors of completion were: amphetamine being primary substance of concern, aggression, high Relationship WHOQOL-8 scores, suggestive of positive relationships, and younger or older age. Those in the program demonstrated clinically significant psychological improvement and significant improvement in all quality of life scores over time. The degree of psychometric improvement was most pronounced in those who completed the course, with the exception of depression, stress, and money problems.ConclusionThe findings provide an understanding of specific predictors of program completion which may help to identify high-risk clients and inform program improvement. Early attrition rates may be reduced by monitoring and supporting high-risk clients. Overall, psychometric improvement occurred amongst both completers and non-completers overtime but is most prominent amongst course completers, with the exception of depression, stress, and money problems. Future research could potentially focus on amphetamine users and shortened TC programs, focusing on acute psychosocial intervention.

Generosity, fairness, trust and time: the performance of therapeutic community residents in economics experiments

PurposeTherapeutic communities (TCs) assume that residents are capable of working together to overcome substance abuse and criminal behavior. Economic games allow us to study the potential of cooperative behavior in TC residents. The paper aims to discuss this issue.Design/methodology/approachThe authors analyze results from a sample of 85 corrections-based TC residents and a comparison group of 45 individuals drawn from the general population who participated in five well-known economic experiments – the dictator game, the ultimatum game, the trust game, risk attitude elicitation and time preference elicitation.FindingsTC residents keep less money in the dictator game and return more in the trust game, and prefer short-term rewards in the time preference elicitation. In the ultimatum game, nearly half of all residents refuse offers that are either too low or too high.Research limitations/implicationsWhile the study involves a sample from one TC and a comparison group, the results suggest that residents are at least comparable to the general public in generosity and appear willing on average to repay trust. A substantial minority may have difficulty accepting help.Practical implicationsRapid peer feedback is of value. Residents will be willing to offer help to peers. The TC environment may explain residents’ tendency to return money in the trust game. Residents who refuse to accept offers that are either too low or too high in the ultimatum game may also have difficulty in accepting help from peers.Social implicationsEconomic games may help to clarify guidelines for TC clinical practice.Originality/valueThis is the first use of economic games with TC residents.

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.

What is inside the “black box”? Therapeutic community residents’ perspectives on each treatment phase

Although the Therapeutic Communities (TCs) have been considered a useful drug addiction treatment resource, much remains to be understood about the process of change in this treatment. The TC residents’ perspectives on their change can contribute towards an understanding of this process of change. This study aims to describe residents’ perspectives on change through each of the three treatment phases. We used a longitudinal and prospective research design with 25 residents from the three treatment phases. All residents filled in the Helpful Aspects of Therapy sheet after their weekly therapies; those who ended the treatment phase were interviewed using the Change Interview. A total of 427 documents were analysed using grounded theory data procedures. According to residents’ views, the study results suggest that their agency was the core factor in change, while treatment tasks and healing relationships established the context for change. During each phase, contextual factors acquired particular features, with the common factor being conduciveness to action by the residents themselves. Such agency enabled the residents to appropriate treatment resources across three phases. By the end of the treatment residents had made major changes to the way in which they relate to themselves and others and could envisage a new life in which drugs had no place. Based on the results of the study, we suggest that clinicians should monitor and support the agency of the residents. We also propose that further studies focus on residents’ perspectives about the events that limited their mobilisation for change as agents.

Saving My Life: Dynamics of Peer and Staff Corrections Among Therapeutic Community Residents

ABSTRACTBackground: Therapeutic communities (TCs) maintain order and encourage behavior change through a system of peer corrections. This study is the first quantitative analysis of the dynamics of the exchange of peer corrections at TCs. Objectives: We applied longitudinal social network analysis to compare the reactions of TC residents to peer versus staff intervention, while analyzing dynamics of correction exchange among residents. Method: The data consisted of a large database of staff and peer affirmations and corrections at four therapeutic community units that occurred between the years 2006 and 2008. We modeled the data as a directed temporal social event network, using a generalized linear mixed effects model to analyze predictors of corrections among residents. Results: Residents were more likely to send a correction following peer affirmations and corrections than following staff affirmations and corrections. Residents reciprocated corrections to individual peers. Autocorrelation was evident in both sending and receiving corrections and residents were more likely to send a correction after having sent an affirmation. Residents who arrived at roughly the same time were more likely to exchange corrections. Residents tended to send and receive more corrections in the middle 3 months of their treatment. European American residents and those with higher scores on the LSI-R were more likely to receive corrections than others. Conclusions: TC residents respond more strongly and more positively to peer than to staff intervention. The pattern of exchange of peer corrections in TCs is complex. This suggests possible paths to improved outcomes.

Drug use patterns and demographic correlations of residents of Saudi therapeutic communities for addiction.

ObjectivesThis study describes the characteristics of residents in Saudi therapeutic communities (TCs), their patterns of drug use, and the correlations between these variables.MethodsThis retrospective study examined all Saudi TC residents admitted since the establishment of the first TC in 2000 until mid-2014. The TCs include three governmental and two non-governmental enterprises: two TCs in Dammam and one each in Riyadh, Jeddah, and Taif, with a total population of 2023 residents.ResultsAll TC residents were adult males; 85.6% were Saudis, and almost all remaining residents were from the Gulf Cooperation Council countries. The mean age of residents was 33.9 years (±8.8 years), and their educational levels were mostly high school or lower; 25% were married, and 70.8% were jobless. The pattern of drug use indicated that 35.8% used opioids, 15% used hash, 11.9% used both hash and amphetamine, 11.1% used amphetamine, 7.9% used alcohol, and 10.9% used 3 or more drugs simultaneously. Amphetamine and hash dependencies were more prevalent among younger residents in comparison to opioids and alcohol, which were more common among older residents. Opioids were more used by the western region residents, while northern and southern regions residents preferred amphetamine.ConclusionThis study showed that the residents' drug use patterns are similar to those in other inpatient treatment services. However, opioid dependency is overrepresented. Furthermore, the type of drug used differs according to the residence region, which may warrant consideration when planning services for these regions.

A network of helping: generalized reciprocity and cooperative behavior in response to peer and staff affirmations and corrections among therapeutic community residents

Background: Clinical theory in therapeutic communities (TCs) for substance abuse treatment emphasizes the importance of peer interactions in bringing about change. This implies that residents will respond in a more prosocial manner to peer versus staff intervention and that residents will interact in such a way as to maintain cooperation.Method: The data consist of electronic records of peer and staff affirmations and corrections at four corrections-based TC units. We treat the data as a directed social network of affirmations. We sampled 100 resident days from each unit (n = 400) and used a generalized linear mixed effects network time series model to analyze the predictors of sending and receiving affirmations and corrections. The model allowed us to control for characteristics of individuals as well as network-related dependencies.Results: Residents show generalized reciprocity following peer affirmations, but not following staff affirmations. Residents did not respond to peer corrections by increasing affirmations, but responded to staff corrections by decreasing affirmations. Residents directly reciprocated peer affirmations. Residents were more likely to affirm a peer whom they had recently corrected. Residents were homophilous with respect to race, age and program entry time.Conclusion: This analysis demonstrates that TC residents react more prosocially to behavioral intervention by peers than by staff. Further, the community exhibits generalized and direct reciprocity, mechanisms known to foster cooperation in groups. Multiple forms of homophily influence resident interactions. These findings validate TC clinical theory while suggesting paths to improved outcomes.

Changing encounters with the other: A focus group study on the process of change in a therapeutic community.

Democratic Therapeutic Communities (TCs) are long-term group programs that address severely ingrained clinical populations. These psychodynamically informed social environments can facilitate improvement in people suffering from personality pathology. However, the TCs’ working principle is not well documented, which threatens its continued existence. To gain further insight into how TCs work, this study explores former TC residents’ perspectives on their treatment, its outcome, and the process of change they underwent. Four steps that might explain this process were identified through focus group interviews (using qualitative analyses) with 24 former residents of a Belgian democratic TC: (1) I encounter a safe, caring and challenging Other, (2) I unfold my particular way of interacting with the Other, (3) I am confronted with the Otherness in me, and (4) I live an Other life. This fourth step refers to the reported treatment outcome that consists of three main changes: (a) residents became more resilient and capable of coping with their problems, (b) residents became more involved in pleasant social relations, and (c) residents developed the capacity to make choices in their own lives. We recommend a reappraisal of social psychiatry, emphasizing the social aspect of human life, psychopathology and its treatment. Limitations of the study and suggestions for further research are discussed.

Behavioral and demographic predictors of staff ratings of role model status in a corrections-based therapeutic community for women

Purpose– The purpose of this paper is to examine personal and social network characteristics that predict staff ratings of therapeutic community (TC) resident role model status.Design/methodology/approach– In all, 49 incarcerated female residents tracked interactions with peers, including verbal affirmations and corrections, during a 12-hour period. Two weeks later, staff members were surveyed about their view of participants as role models. Poisson regression was used to analyze resident interactions and demographics as predictors of role model status.Findings– The number of corrections given to peers was positively related to staff ratings of role model status (B=0.234, SE=0.088,p=0.008). The number of affirmations given was negatively related to staff ratings (B=−0.112, SE=0.051,p=0.028). Resident phase was positively related to staff ratings (B=0.256, SE=0.102,p=0.012). These values did not significantly change when controlling for affirmations and corrections received from peers, non-programmatic interactions between residents, or resident demographics.Research limitations/implications– These results imply that TC staff judge role model status by resident actions in the community rather than demographics or peer reactions. External validity is limited by the single site, case study design, and the fact that only female TC residents were sampled.Originality/value– This study is the first to track resident peer interactions over the course of a day and to link those interactions to role model status.

Social and transitional identity: exploring social networks and their significance in a therapeutic community setting

Purpose – There is considerable literature indicating the importance of social connectedness and its relationship to wellbeing. For problem substance users, a similar literature emphasises the importance of the transition from a social network supportive of use to one that fosters recovery. Within this framework, the therapeutic community (TC) is seen as a critical location for adopting a transitional identity (i.e. from a “drug user” to a “member of the TC”), as part of the emergence of a “recovery identity” following treatment. The purpose of this paper is to outline a model for conceptualising and measuring identity based on the theories of social identity and recovery capital, and pilots this model within a TC setting. Design/methodology/approach – A social identity mapping was used with TC residents to test their identification with “using” and “TC” groups, and their relationship to recovery capital. Findings – The network mapping method was acceptable to TC residents, and provided valuable insights into the social networks and social identity of TC residents. Research limitations/implications – This paper explores issues around mapping social identity and its potential in the TC and other residential settings. Originality/value – The paper integrates a number of conceptual models to create a new framework for understanding transitions in social networks during treatment and reports on a novel measurement method underpinning this.

Predictors and treatment outcomes of perceived ward atmosphere among therapeutic community residents

Poor retention has been an impediment to the effectiveness of therapeutic communities (TCs) for substance use disorders. We assessed the impact of the resident's perception of the therapeutic environment through the Ward Atmosphere Scale (WAS) on TC retention and examined predictors of the WAS in order to better understand this construct. Among a sample of admissions (N=123) to a 9-month residential TC, forward entry logistic regression analyses using WAS, demographic and clinical variables revealed that heightened perceptions of the orderliness of the therapeutic environment (i.e., the WAS domain of system maintenance) best predicted treatment completion. Furthermore, scores on WAS variables were best explained by the formal therapeutic elements of the TC (as measured by the Survey of Essential Elements Questionnaire) using linear regression. Efforts to improve the resident's perception of these aspects of the ward atmosphere may assist in improving TC completion rates.