Therapeutic Community Treatment Research Articles

The Different Faces of Religion in Therapy: An Exploratory Qualitative Study of a Religion-Based Therapeutic Community for Addiction Recovery in Israel.

This article examines the impact of the integration of religion and psychological treatment in a religion-based therapeutic community for persons in recovery from addiction in Israel. Based on an exploratory qualitative study that includes participant observation in a Jewish forgiveness therapy training course and in-depth interviews with counselors working in the community, we identify three themes that characterize the therapeutic process. First, religion emerges as a challenge in therapy, one that should be addressed with sensitivity. Second, religion can be turned into a spiritual and cultural resource in the recovery process, with a cautious and sensitive approach. Third, religion can offer a remedial experience, without necessarily involving an intensification of faith. We offer principles that can help guide decisions regarding the integration of religion into therapy, with a focus on addiction treatment oriented to clients with a religious background.

Relapse rates after treatment in Therapeutic Communities: A systematic review.

Therapeutic Communities (TC) are residential settings that provide psychosocial rehabilitation for substance-using individuals. In general, TCs have been proven effective, although a large part of the evidence is from studies with methodological shortcomings. Therefore, the aim of this systematic review was to evaluate the effectiveness of TCs in terms of relapse rates. The search used EBSCO, PubMed, and Web of Science up to July 29, 2021 and was based on the international Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Of the 94 studies, eight met selection criteria including a total of 2,064 participants from 40 TCs. Of the eight studies, seven were cohort studies and one was a randomized controlled trial (RCT). Findings reveal that TCs were effective in reducing substance use, although some uncertainty remains regarding the long-term persistence of the improvements. Thus, further research is necessary to compare relapse rates in TC programs for substance-related disorders.

Factors related to motivation and barriers influencing treatment and recovery process of methamphetamine use disorder through in-depth, semi-structured, qualitative interviews

ABSTRACT Objective Inpatients with substance use disorders often go unheard. Through qualitative interviews, this study lends voice to their views and beliefs about the factors that affect their recovery. Methods In-depth interviews were conducted from February 10 to 11, 2020 with 15 in- patients with methamphetamine use disorder residing at the Marikina Rehabilitation Center in the Philippines. Semi-structured qualitative interviews were thematically analyzed to determine the factors that promote and hinder methamphetamine use disorder treatment and recovery. Results We identified six barriers to recovery: homesickness, lack of family visitation and support, fear of treatment, financial stress, social stigma and criticism, and boredom. Four motivating factors that influenced treatment and recovery included the therapeutic community treatment program, familial relationships, and visitations, belief in God, and hope. Conclusions A treatment integration program that combines psychotherapy and cognitive behavioral therapy, as well as strong familial support, is imperative for patients’ recovery from methamphetamine use disorder.

Mediators of quality of life change in people with severe psychotic disorders treated in integrated care: ACCESS II study.

Patients with severe psychotic disorders exhibit a severely reduced quality of life (QoL) at all stages of the disease. Integrated care often led to an improvement in QoL. However, the specific mediators of QoL change are not yet well understood. The ACCESS II study is a prospective, long-term study investigating the effectiveness of an integrated care program for people with severe psychotic disorders (IC-TACT) that includes Therapeutic Assertive Community Treatment within a care network of in- and outpatient services at the University Medical Center Hamburg-Eppendorf, Germany. We examined longitudinal associations between QoL and the hypothesized mediators of change (i.e., negative symptoms, depression, and anxiety), using cross-lagged panel models. The sample includes 418 severely ill patients treated in IC-TACT for at least 1 year. QoL increased, whereas symptom severity decreased significantly from baseline to 6-month follow-up (p-values ≤ 0.001), and remained stable until 12-month follow-up. QoL and symptom severity demonstrated significant auto-correlated effects and significant cross-lagged effects from QoL at baseline to negative symptoms (6 months, β = -0.20, p < 0.001) to QoL (12 months, β = -0.19, p < 0.01) resulting in a significant indirect, mediated effect. Additionally, negative symptoms after 6 months had a significant effect on the severity of depression after 12 months (β = 0.13, p < 0.05). Negative symptoms appear to represent an important mechanism of change in IC-TACT indicating that improvement of QoL could potentially be achieved through optimized intervention on negative symptoms. Moreover, this may lead to a reduction in the severity of depression after 12 months.

Health-related quality of life in severe psychotic disorders during integrated care: 5-year course, prediction and treatment implications (ACCESS II)

PurposeStudies on outcomes mapping Quality of Life (QoL) as patient-reported outcome over a longer period in severe psychotic disorders are scarce. However, such data would be particularly important for structuring, implementing and operating effective and efficient care models and for promoting satisfaction with care, service engagement and adherence.MethodsThe ACCESS II study is a prospective long-term study of an integrated care model for people with severe psychotic disorders. The model includes Therapeutic Assertive Community Treatment within a cross-sectoral and interdisciplinary network. This publication analyses the course of QoL assessed with the Q-LES-Q-18 using a mixed model for repeated measures.ResultsMapping the course of QoL in N = 329 participants, there is a significant increase in the first 6 weeks of treatment (early course). Comparison to a published norm show significant lower QoL for severe psychotic disorders. The variable having a traumatic event before the age of 18 was significantly negatively associated with QoL. A decrease in the severity of depressive as well as in positive symptomatology in the first six weeks after admission was associated with increase of QoL.ConclusionResults indicate that the overall symptom burden at time of inclusion is not decisive for the perceived QoL in the long-term course while the reduction in the severity of depressive and positive symptoms is important. This means focusing even more on the treatment of depressive symptoms and include traumatherapeutic aspects in the long-term treatment of severe psychotic disorders if needed.Trail registrationClinicalTrials.gov (identifier: NCT01888627).

Characteristics of psychoses in adolescence-Longitudinal data of integrated care

Integrated care according to the Hamburg model combines therapeutic assertive community treatment (TACT) with initiatives for early detection and early treatment of schizophrenia and affective psychoses. The aim of this study was to identify the clinical characteristics of adolescents in comparison to adult patients and to derive knowledge for transition-specific treatment approaches. Sociodemographic and clinical variables as well as treatment performance and clinical outcome were investigated over aperiod of 12months in 167patients with psychoses (16-25years, n = 88; and >25years, n = 79). Patients with psychosis in adolescence had significantly more outpatient treatment contacts (3.5/week vs. 1.6/week; p < 0.001), while adults were hospitalized for twice as long (10 days vs. 21 days; p = 0.003). The duration of untreated psychoses was significantly shorter in the adolescent group than in adults (122 weeks vs. 208 weeks; p = 0.002). The proportion of comorbid mental disorders was significantly higher in the adolescent group (87% vs. 63%; p < 0.001). In addition, the adolescence patients already showed greater impairment of daily functions and ahigher severity of illness at the start of treatment. The treatment of psychoses in adolescence was characterized by aparticularly high need for flexibility across all sectors and support systems, taking comorbid problem areas into account. Care models for adolescents and young adults with psychoses should therefore combine treatment approaches for severely ill patients with transition psychiatric interventions to avoid breaks in care and to meet the complex requirements of young patients with severe mental illnesses.

Hospitalisation following therapeutic community drug and alcohol treatment for young people with and without a history of criminal conviction

IntroductionThis study examines the association between treatment in a therapeutic community for adolescents with drug and alcohol problems on hospitalisation outcomes up to 15 years later for all clients, and separately for those with and without a history of criminal conviction. MethodA quasi-experimental design was used to examine the linked administrative health and criminal justice records for all adolescents admitted to the Program for Adolescent Life Management (PALM) from January 2001 to December 2016 (n = 3059) in Sydney, Australia. ICD-10AM codes were used to designate hospitalisation outcomes as either physical injury, mental health problems, substance use disorders, or organic illness. The treatment and comparison groups were matched on factors associated with program retention, resulting in a final sample of 1266 clients. We examined the rate of hospitalisation up to 15 years posttreatment for all clients and stratified by prior conviction status using Cox regression analyses. ResultsThe treatment group had significantly lower rates of hospitalisation for a physical injury (HR = 0.77 [95% CI = 0.61–0.98]), mental health problem (HR = 0.62 [95% CI = 0.47–0.81]), substance use disorder (HR = 0.59 [95% CI = 0.47–0.75]), and organic illness (HR = 0.71 [95% CI = 0.55–0.92]). There was a significant interaction between treatment and prior criminal conviction status on rate of hospitalisation for physical injury, suggesting that the effect of treatment on physical injury was significantly greater for clients with a prior criminal conviction. ConclusionsAdolescents who engage in a therapeutic community treatment program may have a long-lasting reduction in the risk of subsequent hospitalisation. This also appears to apply to those with a history of criminal conviction.

Attachment and Therapeutic Alliance in Substance Use Disorders: Initial Findings for Treatment in the Therapeutic Community.

Background: There is convincing evidence that individuals suffering from Substance Use Disorder (SUD) often present insecure attachment patterns. In contrast, a strong therapeutic alliance in treatment of SUD has been found to lead to a more positive treatment outcome. However, insecure attachment has been observed to be linked with weaker therapeutic alliance strength. The primary aim of this explorative study was to gain initial insights regarding the influence of attachment and personality characteristics on therapeutic alliance and therapy motivation in SUD patients undergoing treatment at a therapeutic community. Furthermore, SUD patients were compared to healthy controls regarding attachment, personality and mood pathology.Methods: A total sample of 68 participants, 34 inpatients in SUD treatment and 34 age-gender and education adjusted controls, were investigated. Both groups filled in the Adult Attachment Scale (AAS), the Inventory of Personality Organization (IPO-16), and the Brief Symptom Inventory (BSI-18) questionnaires. Additionally, SUD patients filled in the Working Alliance Inventory (WAI-SR) and the adapted German version of the University of Rhode Island Change Assessment scale (FEVER).Results: In line with our assumptions, SUD patients exhibited a decreased amount of attachment security (AAS) which was related to higher personality (IPO-16) and mood pathology (BSI-18). Furthermore, correlational analysis revealed the WAI-SR dimension Bond being positively associated with more secure attachment. A strong task alliance was linked to the Action stage of change (FEVER) and decreased mood but not personality pathology.Conclusion: Our findings confirm the putative negative effect of attachment and personality pathology on therapy motivation and therapeutic alliance in addiction therapy as well as more specifically in therapeutic community treatment. Future research in enhanced samples might focus more on the long-term effects of the interaction of attachment, personality and therapeutic alliance variables.

Providing Treatment in a Prison-Based Therapeutic Community for Those Who Have Committed Sexual Offences.

This article explores some of the difficulties inherent in managing risk in those who have committed sexual or other violent offences and how this may impact on their ability to re-integrate into the community. It discusses the work undertaken at HMP Grendon, a prison-based therapeutic community (TC), to address these difficulties and help residents develop a pro-social lifestyle starting in custody and continuing on release. The article aims to describe how the TC model offers a containing and adaptive environment, and how this can provide opportunities to address offence-related behaviour, which is not always possible in other prison settings. Furthermore, it describes some of the difficulties inherent in undertaking work of this nature, in the need for an accurate understanding of the relevant areas of risk, and the tensions developing a therapeutic relationship with individuals with complex needs. Methods of assessment of risk and need are discussed, and how they are used in a collaborative manner to have the most accurate picture of what will help residents to maintain their pro-social lifestyle on release.

Impact of Cluster B Personality Disorders in Drugs Therapeutic Community Treatment Outcomes: A Study Based on Real World Data.

Background: The impact of dual pathology on treatment outcomes is unclear, with the literature reporting both favorable and unfavorable evidence. The main aim of this study was to determine how dual pathology affects treatment outcomes using real world data obtained from inpatients that began treatment in therapeutic communities. Method: The data of 2458 inpatients were used. Clinical information was obtained from electronic medical records. Reliability of diagnosis was checked and revealed a mean kappa value of 0.88. Results: Of the sample, 41.8% were discharged after achieving the therapeutic objectives. Patients diagnosed with Cluster B personality disorders were found to have a higher risk of dropping out of treatment (HR = 1.320; z = 2.61; p = 0.009). Conclusions: Personality traits exhibited by Cluster B patients can interfere with treatment in therapeutic communities. There is a need to develop specific interventions for these inpatient groups, which could be implemented in therapeutic communities.

Treating Prisoners with Drug Abuse and Addiction Problems : An Evaluation of the Effectiveness of Therapeutic Communities (TCs) in the United States Correctional Institution

The increasing numbers of drug-abusing prisoners is a severe problem in South Korean correctional institutions. Despite the high recidivism and re-incarceration rates among ex-convicts with drug abuse and addiction problems, the issue of treating drug-abusing prisoners has long been ignored by correctional authorities and researchers in South Korea. To reduce recidivism and drug relapse among prisoners with drug abuse and addiction problems, policy makers and corrections personnel in South Korea should be encouraged to implement Therapeutic Communities (TCs) that have positive impacts on recidivism and drug relapse among drug-abusing prisoners in correctional institutions. TCs are drug-free residential settings and use a hierarchical model with three intensive drug treatment stages. In order to ensure the levels of TCs integrity and achieve desired outcomes in South Korean correctional institutions, recruiting trained and experienced staff, educating correctional staff about the crucial TCs principles, and adhering to TCs' principles such as full segregation and intensive, long-term, and structured treatments are required. In addition, TCs treatment should be rigorously monitored and evaluated by qualified supervisory personnel. Evidence-based research on the effectiveness of TCs adopting three major approaches including impact assessment, process evaluation, and efficiency analysis should be encouraged.

Pre-incarceration polysubstance use involving opioids: A unique risk factor of postrelease return to substance use

ObjectiveJustice-involved populations are at increased risk of overdose following release from prison and jail. This risk is exacerbated by polysubstance use, including the use of opioids with other substances. This study explored pre-incarceration polysubstance use involving opioids as a unique risk factor for postrelease return to substance use. MethodsThe study examined data from a cohort of 501 justice-involved persons who were enrolled in a therapeutic community treatment program while incarcerated. Latent profile validation identified profiles of polysubstance use involving opioids prior to incarceration. Multivariate logistic regression examined return to substance use, defined as self-reported relapse, and a time series model examined time in the community until a relapse event occurred. ResultsA latent profile validation found six unique polysubstance opioid patterns prior to incarceration. Two of these profiles, primarily alcohol and primarily buprenorphine, were at increased and accelerated risk for relapse postrelease relative to a less polysubstance use profile. Both profiles at increased risk had pre-incarceration co-use of marijuana (≈45% of month) and nonmedical use of opioids (≈40% of month) but were unique in their respective near daily use of alcohol and nonmedical buprenorphine. ConclusionsAmong persons who use opioids returning to the community, return to substance use occurs along a continuum of risk. Providers' consideration of polysubstance use patterns during treatment may assist in mitigating adverse outcomes for patients postrelease.

NIVEIS DE ESTRESSE EM DEPENDENTES QUÍMICOS SOB TRATAMENTO EM COMUNIDADE TERAPÊUTICA

NIVEIS DE ESTRESSE EM DEPENDENTES QUÍMICOS SOB TRATAMENTO EM COMUNIDADE TERAPÊUTICA

Are prison-based therapeutic communities effective? Challenges and considerations.

The purpose of this paper is to detail the impact and efficacy of Her Majesty's Prison and Probation Service ((HMPPS) Therapeutic Communities (TCs) (both democratic and hierarchical). This paper outlines recent developments in the TC literature, to provide readers with an up-to-date overview of the outcomes of prison-based TC treatment, while highlighting the strengths and challenges of this treatment approach. Trends within the research are discussed, and the authors draw attention to any gaps in the current knowledge. This paper uses a narrative literature review approach to review the most current literature around the effectiveness of prison-based TCs in HMPPS. Academic literature published predominantly from 2010 onwards is discussed because of limited literature review publications on this topic post-2010. To obtain literature, searches of relevant databases were conducted, and/or clinical leads at prison sites were contacted for relevant publications. There is a body of research which demonstrates that TCs are an effective form of treatment for people with an offending history and personality difficulties. Evidence indicates that Democratic TC treatment plays a part in reducing reoffending rates, as well as improving psychological features. Further research is needed in a number of areas, specifically with female offenders and individuals who undertake treatment in hierarchical TCs in the UK. It is also suggested that TC treatment aftercare may help to further the positive outcomes identified. To the best of the authors' knowledge, there is no up-to-date review of the impact and efficacy of HMPPS TC treatment. This paper reflects on available research within the current context of TC treatment and provides an original overview of the current UK TC practice. It has value in recommending areas for further research and consideration.

Personality Traits and Impulsivity Tasks Among Substance Use Disorder Patients: Their Relations and Links With Retention in Treatment.

BackgroundVarious authors have described the elements of impulsive approach and inhibitory control in drug users. These two components have been studied in terms of personality traits, performance on tasks that measure impulsive behavior, and neurophysiology. However, few studies have analyzed the association between these constructs. Thus, the aim of the present study is to analyze the associations between personality traits and performance on impulsivity tasks.MethodsA follow-up study was conducted with a baseline assessment at the beginning and end of treatment. The sample was composed of 121 patients undergoing treatment in therapeutic communities. Personality domains were evaluated through the PID-5. The impulsivity tasks employed were the Iowa Gambling Task (IGT), Delay Discounting Test (DDT), Go/No-Go and Stroop test.ResultsA correlation was found between DDT scores and the domains of detachment (r = -.315; p<.01), antagonism (r = -.294; p<.01), and disinhibition (r = .215; p<.05). Performance on the Stroop task was significantly associated with psychoticism (r = .232; p<.05) and negative affect (r = .212; p<.05). Multivariate analysis revealed that IGT scores and negative affect predict retention in treatment.ConclusionsThese findings partially support the hypothesized association between sensation-seeking personality traits and detachment with impulsive choice tasks; and the relationships between negative affect and psychoticism traits with performance on inhibitory control tasks. Further, impulsive choice task scores and negative affect are both shown to predict retention in treatment.

A Computational Phenotype of Disrupted Moral Inference in Borderline Personality Disorder

BackgroundBorderline personality disorder (BPD) is a serious mental disorder characterized by marked interpersonal disturbances, including difficulties trusting others and volatile impressions of others’ moral character, often resulting in premature relationship termination. We tested a hypothesis that moral character inference is disrupted in BPD and sensitive to democratic therapeutic community (DTC) treatment. MethodsParticipants with BPD (n = 43; 20 untreated and 23 DTC-treated) and control participants without BPD (n = 106) completed a moral inference task where they predicted the decisions of 2 agents with distinct moral preferences: the “bad” agent was more willing than the “good” agent to harm others for money. Periodically, participants rated their subjective impressions of the agent’s moral character and the certainty of those impressions. We fit a hierarchical Bayesian learning model to participants’ trialwise predictions to describe how beliefs about the morality of the agents were updated by new information. ResultsThe computational mechanisms of moral inference differed for patients with untreated BPD relative to matched control participants and patients with DTC-treated BPD. In patients with BPD, beliefs about harmful agents were more certain and less amenable to updating relative to both control participants and participants who were treated with DTC. ConclusionsThe findings suggest that DTC may help the maintenance of social relationships in BPD by increasing patients’ openness to learning about adverse interaction partners. The results provide mechanistic insights into social deficits in BPD and demonstrate the potential for combining objective behavioral paradigms with computational modeling as a tool for assessing BPD pathology and treatment outcomes.

A Computational Phenotype of Disrupted Moral Inference in Borderline Personality Disorder

Borderline Personality Disorder (BPD) is a serious mental disorder characterized by marked interpersonal disturbances, including difficulties trusting others and volatile impressions of others’ moral character, often resulting in premature relationship termination. We tested a hypothesis that moral character inference is disrupted in BPD and sensitive to Democratic Therapeutic Community (DTC) treatment.

Does the effectiveness of mutual aid depend on compatibility with treatment philosophies offered at residential rehabilitation services?

BackgroundResidential rehabilitation treatment (including both Therapeutic Communities (TC) and non-TC rehabs) is a key component of service delivery for people seeking treatment for substance use disorders in Australia and globally. While mutual aid is often associated with better long-term outcomes, there is little evidence about whether inconsistencies between residential rehabilitation philosophies and particular types of mutual aid influence subsequent engagement and treatment outcomes. ObjectiveTo assess the uptake of mutual aid groups (12-step and other) on individuals leaving TC (n = 58) or non-TC (n = 78) residential treatment, and measure its impact on substance use outcomes. MethodsUsing secondary analysis of existing data, the current paper reports on 12-month outcomes from a prospective cohort study of 230 individuals entering specialist alcohol and other drug residential rehabilitation treatment in two Australian states. ResultsParticipants who attended TC settings were more likely to attend non-spiritual mutual aid groups (i.e., SMART Recovery) than non-TC residents. Engaging in mutual aid groups was associated with significantly improved outcomes for the non-TC residents only, where it significantly predicted abstinence (OR = 5.8, CI = 1.5–18.46) and reduced frequency of use of participants’ primary drug of concern (OR = 8.6, CI = 2.6–28.6). Conclusions/ImportanceAlthough 12-step is the most readily available and accessible form of mutual aid in Australia and benefited those attending non-TC residential rehabilitation, individuals exiting a TC program (whether they have completed treatment or not) may benefit from other forms of post-treatment recovery support, including alternative forms of peer-based support. The findings suggest treatment outcomes may be enhanced when the philosophies of residential treatment and post-discharge mutual aid are more compatible.

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.

Attachment Patterns in Subjects Diagnosed With a Substance Use Disorder: A Comparison of Patients in Outpatient Treatment and Patients in Therapeutic Communities.

The purpose of the present study is to analyze the quality of attachment in substance abuse patients in outpatient treatment vs. patients in therapeutic communities in order to identify the role of attachment insecurity in choosing a care system. The sample consisted of 127 subjects (107 males and 20 females); 97 were outpatients (83 males) and 30 therapeutic community patients (24 males). Attachment with respect to current, significant relationships was assessed using the Relationship Questionnaire. In the outpatient subgroup, the prevailing attachment style was preoccupied; for the therapeutic community patients, the prevailing attachment style was dismissive. The dimensions of care (how the caregiver is perceived as loving and caring) and overprotection (how the caregiver is perceived as intrusive and interfering)—evaluated by means of the Parent Bonding Instrument—were higher in the outpatient subgroup. Scores were higher with respect to maternal subscales regardless of treatment modality. No differences emerged with respect to self-perceived symptoms (SCL-90-R) between the subgroups; however, fearful-avoidant and dismissive-avoidant individuals reported higher self-perceived symptom regardless of treatment modality. Understanding the distribution of different attachment patterns with respect to the treatment modality may improve efficacious interventions, attuning them to the individual and his or her developmental environment.