T he therapeutic community (TC) for the treatment of drug abuse and addiction has existed for about 40 years. In general, TCs are drug-free residential settings that use a hierarchical model with treat- ment stages that reflect increased levels of personal and social responsibility. Peer influence, mediated through a variety of group processes, is used to help individuals learn and assimilate social norms and develop more effective social skills. TCs differ from other treatment approaches principally in their use of the community, comprising treatment staff and those in re- covery, as key agents of change. This approach is often referred to as “community as method.” TC members interact in structured and unstructured ways to influence attitudes, perceptions, and behav- iors associated with drug use. Many individuals admitted to TCs have a history of social functioning, education/vocational skills, and positive community and family ties that have been eroded by their substance abuse. For them, recovery involves rehabilitation— relearning or re-establishing healthy function- ing, skills, and values as well as from the director Each year, therapeutic commu- nities (TCs) serve tens of thousands of people with varying degrees of drug problems, many of whom also have complex social and psychological problems. Research supported by the National Institute on Drug Abuse (NIDA) has helped document the important role TCs serve in treating individuals with drug-related problems. Further research is being con- ducted on the treatment processes in TCs to better understand how TCs work. Links between treatment elements, experiences, and outcomes need to be further studied to fully appreciate and enhance the con- tributions of TCs. NIDA’s research program is currently focused on expanding our knowledge of the TC treatment process and improving our understanding of organiza- tional and management strategies to deliver more effective and efficient treatment services. This Research Report is one of several aimed at providing information on approaches and modalities used to prevent and treat drug abuse. Based on over 30 years of scientific inquiry and observation, this report addresses some of the most frequently asked questions about TCs. Federal and other national resources are listed at the end of the report. It is hoped that this Research Report will help establish a common framework and understanding about TCs for health care providers, researchers, policymakers, and individuals and their families in need of treatment for drug-related problems. Glen R. Hanson, Ph.D., D.D.S. Acting Director National Institute on Drug Abuse U.S. Department of Health and Human Services • National Institutes of Health Research Report NATIONAL INSTITUTE ON DRUG ABUSE SERIES THERAPEUTIC COMMUNITY What is a therapeutic community?
Transcript
T he therapeutic community(TC) for the treatment ofdrug abuse and addiction
has existed for about 40 years. In general, TCs are drug-free residential settings that use ahierarchical model with treat-ment stages that reflect increasedlevels of personal and socialresponsibility. Peer influence,mediated through a variety ofgroup processes, is used to helpindividuals learn and assimilatesocial norms and develop moreeffective social skills.
TCs differ from other treatmentapproaches principally in theiruse of the community, comprisingtreatment staff and those in re-covery, as key agents of change.This approach is often referredto as “community as method.” TCmembers interact in structured andunstructured ways to influenceattitudes, perceptions, and behav-iors associated with drug use.
Many individuals admitted toTCs have a history of social functioning, education/vocationalskills, and positive community
and family ties thathave been erodedby their substanceabuse. For them,recovery involvesrehabilitation—relearning or re-establishinghealthy function-ing, skills, and values as well as
fro
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he
dir
ecto
r
Each year, therapeutic commu-nities (TCs) serve tens of thousandsof people with varying degrees ofdrug problems, many of whom also have complex social and psychological problems. Researchsupported by the National Instituteon Drug Abuse (NIDA) has helpeddocument the important role TCsserve in treating individuals withdrug-related problems.
Further research is being con-ducted on the treatment processesin TCs to better understand howTCs work. Links between treatmentelements, experiences, and outcomesneed to be further studied to fullyappreciate and enhance the con-tributions of TCs. NIDA’s researchprogram is currently focused onexpanding our knowledge of the TCtreatment process and improvingour understanding of organiza-tional and management strategiesto deliver more effective and efficient treatment services.
This Research Report is one of several aimed at providing information on approaches andmodalities used to prevent andtreat drug abuse. Based on over 30 years of scientific inquiry andobservation, this report addressessome of the most frequently askedquestions about TCs. Federal andother national resources are listedat the end of the report.
It is hoped that this ResearchReport will help establish a commonframework and understandingabout TCs for health care providers,researchers, policymakers, andindividuals and their families inneed of treatment for drug-relatedproblems.
Glen R. Hanson, Ph.D., D.D.S.Acting DirectorNational Institute on Drug Abuse
U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s • N a t i o n a l I n s t i t u t e s o f H e a l t h
ResearchReportN A T I O N A L I N S T I T U T E O N D R U G A B U S E
S E R I E S
THERAPEUTICCOMMUNITY
What is a therapeutic community?
regaining physical and emotionalhealth. Other TC residents havenever acquired functional life-styles. For these people, the TCis usually their first exposure toorderly living. Recovery for theminvolves habilitation—learningfor the first time the behavioralskills, attitudes, and values associated with socialized living.
In addition to the importanceof the community as a primaryagent of change, a second fundamental TC principle is “self-help.” Self-help implies that the individuals in treatmentare the main contributors to thechange process. “Mutual self-help” means that individuals alsoassume partial responsibility forthe recovery of their peers—animportant aspect of an individual’sown treatment.
How beneficialare therapeuticcommunities intreating drugaddiction?
For three decades, NIDA has conducted several large studies to advance scientific
knowledge of the outcomes ofdrug abuse treatment as typicallydelivered in the United States.These studies collected baselinedata from over 65,000 individualsadmitted to publicly funded treatment agencies. They includeda sample of TC programs andother types of programs (i.e.,methadone maintenance, out-patient drug-free, short-terminpatient, and detoxification programs). Data were collectedat admission, during treatment,and in a series of followups thatfocused on outcomes that
occurred 12 months and longerafter treatment.
These studies found thatparticipation in a TC was associ-ated with several positive out-comes. For example, the DrugAbuse Treatment Outcome Study(DATOS), the most recent long-term study of drug treatment outcomes, showed that those who successfully completed treat-ment in a TC had lower levels ofcocaine, heroin, and alcohol use;criminal behavior; unemployment;and indicators of depression thanthey had before treatment.
Who receivestreatment in atherapeutic community?
TCs treat people with a rangeof substance abuse prob-lems. Those treated often
have other severe problems,
2NIDA RESEARCH REPORT SERIES
Pre- and posttreatment self-reported changes among those in long-term residential TCs
*p<.01 for changes pre- and posttreatment.Pretreatment measures are for the 12 months before admission. Posttreatment measures are for the 12 months after treatment.Source: Hubbard et al., Psychology of Addictive Behaviors, 11:261-278, 1997.
100
80
60
40
20
0Cocaine Heroin Heavy Illegal No full-time Suicidal
such as multiple drug addictions,involvement with the criminaljustice system, lack of positivesocial support, and mental health problems (e.g., depression,anxiety, posttraumatic stress dis-order, and antisocial and otherpersonality disorders).
For example, in DATOS, whichtracked 2,345 admissions to resi-dential TC treatment between1991 and 1993, two-thirds ofadmissions had a criminal justicestatus (e.g., on probation, onparole, or pending trial) atadmission, and about a third had been referred to treatmentfrom the criminal justice system.Nearly a third of admissionswere women, and nearly halfwere African American. Sixtypercent had prior drug abusetreatment experience.
What is the typicallength of treatmentin a therapeuticcommunity?
In general, individuals progressthrough drug addiction treat-ment at varying speeds, so
there is no predetermined lengthof treatment. Those who com-plete treatment achieve the bestoutcomes, but even those whodrop out may receive some benefit.
Good outcomes from TC treatment are strongly related totreatment duration, which likelyreflects benefits derived from theunderlying treatment process.Still, treatment duration is a convenient, robust predictor ofgood outcomes. Individuals who
complete at least 90 days oftreatment in a TC have signifi-cantly better outcomes on aver-age than those who stay forshorter periods.
Traditionally, stays in TCs havevaried from 18 to 24 months.Recently, however, fundingrestrictions have forced many TCsto significantly reduce stays to 12months or less and/or developalternatives to the traditional residential model (see “How elsecan TCs be modified?”).
For individuals with many seri-ous problems (e.g., multiple drugaddictions, criminal involvement,mental health disorders, and lowemployment), research againsuggests that outcomes were better for those who received TC treatment for 90 days ormore. In a DATOS study, treat-ment outcomes were comparedfor cocaine addicts with six orseven categories of problemsand who remained in treatmentat least 90 days. In the year following treatment, only 15 per-cent of those with over 90 daysin TC treatment had returned toweekly cocaine use, compared to 29 percent of those who re-ceived over 90 days of outpatientdrug-free treatment and 38 per-cent of those receiving over 3weeks of inpatient treatment.
The relationship betweenretention and good treatmentoutcomes identified in DATOShas been replicated in manystudies. However, many TCshave a high dropout rate,although about one-third ofdropouts seek readmission. Asignificant research effort is
NIDA RESEARCH REPORT SERIES31-year outcomes for shorter and longer
stays in TC treatment
< 90 days
90+ days
Cocaine(any use)*
UA+(any drug)*
Alcohol(daily use)*
Any jail*
0 20 40 60Percent of TC patients (N=342)
*p<.01 for all four measures.Cocaine use, alcohol use, and being jailed are self-report measures for the 12 months after treatment. UA+ indicates a positive urinalysis test at the followup interview.Source: Simpson et al., Psychology of Addictive Behaviors, 11:264-307, 1997.
55%
28%
53%
19%
15%
9%
54%
24%
underway to better understandand improve TC treatment retention by examining externalfactors, program services andprocesses, and attributes of individuals in treatment.
External factors related toretention include level of asso-ciation with family or friendswho use drugs or are involved in crime, and legal pressures toenroll in treatment. Inducements—sanctions or enticements by thefamily, employment requirements,or criminal justice system pres-sure—can improve treatmententry and retention and mayincrease the individual’s internalmotivation to change with thehelp of treatment.
In the TC, the level of treatmentengagement and participation isrelated to retention and outcomes.Treatment factors associated with increased retention include having a good relationship withone’s counselor, being satisfiedwith the treatment, and attendingeducation classes. One studytested a strategy to enhancemotivation by increasing newresidents’ exposure to experi-enced staff, in contrast to themore traditional approach oflargely relying on junior staff asrole models. The senior staff pro-vided seminars for new residentsbased on their own experienceswith retention-related topics. Thisstrategy appeared to increase the30-day retention rate and wasparticularly effective for thosewhose pretreatment motivationwas the weakest.
Important attributes linked totreatment retention include self-esteem, attitudes and beliefsabout oneself and one’s future,
and readiness and motivation for treatment. Retention can beimproved through interventionsto address these areas. Oneapproach focuses on teachingcognitive strategies to improveself-esteem, develop “road maps”for positive personal change,improve understanding of howto benefit from drug abuse treat-ment, and develop appropriateexpectations for treatment andrecovery. This approach was par-ticularly effective for individualswith lower educational levels.
What are the fundamental components oftherapeutic communities?
Research spanning morethan 30 years has identifiedkey concepts, beliefs,
clinical and educational practices,and program components com-mon to most TC programs. Theseelements reflect the two principlesthat drive TC operations: thecommunity as change agent andthe efficacy of self-help.
Typically, TCs are residentialfacilities separate from other pro-grams and located away from thedrug-related environment. As aparticipant in the community, theresident in treatment is expectedto adhere to strict and explicitbehavioral norms. These normsare reinforced with specific contingencies (rewards and punishments) directed towarddeveloping self-control andresponsibility. The resident willprogress through a hierarchy ofincreasingly important roles, with
greater privileges and responsi-bilities. Other aspects of the TC’s“community as method” thera-peutic approach focus on chang-ing negative patterns of thinkingand behavior through individualand group therapy, group sessionswith peers, community-basedlearning, confrontation, games,and role-playing.
TC members are expected tobecome role models who activelyreflect the values and teachingsof the community. Ordered routine activities are intended to counter the characteristicallydisordered lives of these residentsand teach them how to plan, set, and achieve goals and beaccountable.
Ultimately, participation in aTC is designed to help peopleappropriately and constructivelyidentify, express, and managetheir feelings. The concepts of“right living” (learning personaland social responsibility andethics) and “acting as if ” (behaving as the person shouldbe rather than has been) areintegrated into the TC groups,meetings, and seminars. Theseactivities are intended to heightenawareness of specific attitudes or behaviors and their impact on oneself and the social environment.
How are therapeutic communitiesstructured?
TCs are physically and pro-gramatically designed toemphasize the experience of
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community within the residence.Newcomers are immersed in thecommunity and must fully partic-ipate in it. It is expected that indoing so, their identification with and ties to their previousdrug-using life will lessen andthey will learn and assimilate newprosocial attitudes, behaviors,and responsibilities.
Although the residential capacity of TCs can vary widely, atypical program in a community-based setting accommodates 40
to 80 people. TCs are located invarious settings, often determinedby need, funding sources, andcommunity tolerance. Some, for example, are situated on thegrounds of former camps andranches or in suburban houses.Others have been established in jails, prisons, and shelters.Larger agencies may support several facilities in different settings to meet various clinicaland administrative needs.
In DATOS, there was an aver-age of one counselor reportedfor every 11 residents in treat-ment. About two-thirds of thecounseling staff had themselvessuccessfully completed drugabuse treatment programs.Increasingly, TCs rely on degreedstaff (e.g., social workers, nurses,and psychologists) for someaspects of treatment.
How is treatmentprovided in atherapeutic community?
TC treatment can be dividedinto three major stages.
Stage 1. Induction and early treatment typically occurs during the first 30 days to assimilate the individual intothe TC. The new resident learnsTC policies and procedures;establishes trust with staff andother residents; initiates an assistedpersonal assessment of self, circumstances, and needs; beginsto understand the nature ofaddiction; and should begin tocommit to the recovery process.
Stage 2. Primary treatmentoften uses a structured model ofprogression through increasinglevels of prosocial attitudes,behaviors, and responsibilities.The TC may use interventions tochange the individual’s attitudes,perceptions, and behaviors relatedto drug use and to address thesocial, educational, vocational,familial, and psychological needsof the individual.
NIDA RESEARCH REPORT SERIES5
What is daily life like in a therapeutic community?
The TC day is varied but regimented. A typical TC daybegins at 7 a.m. and ends at 11 p.m. and includes
morning and evening house meetings, job assignments,groups, seminars, scheduled personal time, recreation, and individual counseling. As employment is considered an important element of successful participation in society,work is a distinctive component of the TC model.
In the TC, all activities and interpersonal and social inter-actions are considered important opportunities to facilitateindividual change. These methods can be organized by their primary purpose, as follows:
■ Clinical groups (e.g., encounter groups and retreats)use a variety of therapeutic approaches to address significant life problems.
■ Community meetings (e.g., morning, daily house, and general meetings and seminars) review the goals, procedures, and functioning of the TC.
■ Vocational and educational activities occur in group sessions and provide work, communication, and interpersonal skills training.
■ Community and clinical management activities(e.g., privileges, disciplinary sanctions, security, and surveillance) maintain the physical and psychological safety of the environment and ensure that resident life is orderly and productive.
Stage 3. Re-entry is intendedto facilitate the individual’s separation from the TC and successful transition to the largersociety. A TC graduate leaves theprogram drug-free and employedor in school. Postresidential aftercare services may includeindividual and family counselingand vocational and educationalguidance. Self-help groups suchas Alcoholics Anonymous andNarcotics Anonymous are oftenincorporated into TC treatment,and TC residents are encouragedto participate in such groupsafter treatment.
Can therapeuticcommunities treatpopulations withspecial needs?
Research shows that thosewith special or complexneeds can be treated in
TCs. For example, individualswith co-occurring mental illnessand substance abuse may betreated in TC-oriented programsbased in shelters, community residences, day treatment clinics, partial hospitalization settings, or on hospital wards.Community-based TC programsprovide effective treatment forclients with criminal involvement,but successful TC programs for drug-involved offenders have also been established incorrectional settings. Other special populations with sub-stance abuse problems that may benefit from TC-orientedprograms include adolescents,women and their children,
persons with HIV/AIDS, andhomeless people.
Specialized treatment strategiesand services are often incorpor-ated as part of the TC for thesepopulations. Support may includechild care services for mothers;programs aimed at normalizingthe developmental process foradolescents; access to mentalhealth and social services forindividuals with co-occurringmental illness and substanceabuse; attention to changingcriminal thinking and behaviorfor the criminal offender; andlinks to medical and social serv-ices for those with HIV/AIDS.Individualized treatment, includ-ing lengths of stay tailored to theperson’s needs, is especiallyimportant due to the complexityof possible problems. In addition,TC clinical and managementactivities may need to be modifiedin terms of disciplinary sanctions,peer interactions, and degree ofconfrontation in groups.
Women Women who enter drug abusetreatment often have many seri-ous problems. Many suffer fromlow self-esteem, depression, orother mental health disorders;are in abusive relationships; havelittle access to medical, mentalhealth, and social services; lackmarketable job skills; and havechild custody concerns.
Both women-only programsand mixed-gender programs canbe helpful in treating the drugproblems of women. As mightbe expected, women-only pro-grams and programs that servehigher percentages of womenusually provide more servicesthat women need. The evidencesuggests that these services can contribute to significantlylonger lengths of stay in treat-ment, which is related to bettertreatment outcomes.
Newer TC approaches fortreating women with drug addic-tions often focus on issues relatedto family and children. Some
6NIDA RESEARCH REPORT SERIES
Therapeutic communities often incorporate specialized
strategies and services to treat thosewith special or complex needs.
model programs have found that allowing a woman’s childrento live with her in the TC canimprove her mental health andlengthen retention. Although evidence tends to support thebenefits of specialized servicesfor women, more research isneeded to determine the optimalstructure of TC treatment inmeeting women’s needs.
AdolescentsThe closely supervised residentialTC environment provides bene-fits for troubled youth. A studyon adolescent drug treatmentoutcomes showed that adoles-cents treated in TC programswere more likely than those inoutpatient drug-free programs tohave prior drug abuse treatmentexperience, more severe prob-lems, and a criminal justice histo-ry. Despite being more difficultto treat, however, adolescents inthese programs had significantlyimproved outcomes in drug use, psychological adjustment,
school performance, and criminalactivities.
Another study compared the outcomes for adolescentsreferred through probation toTC treatment to outcomes forthose referred to group homeswith no specialized drug treat-ment services. The group homes were the same size and offeredthe same length of stay as the TC setting. The study foundrobust reductions in drug use,criminal behavior, and measuresof psychological dysfunction at 3 months for all placements.However, after that period, thosein the TC sustained or increasedtheir improvements in problem-atic behaviors, while those in thegroup homes did not.
Several studies have examinedlonger term effects for adoles-cents participating in TCs. Forexample, one study followedadolescents treated in six TCs.One year after treatment, theseadolescents showed significant
declines in alcohol, marijuana,and other illicit drug use, as wellas reductions in criminal activityand other deviant behavior.Although the planned length ofstay varied among the six partici-pating TCs, completing treatmentwas significantly related to betteroutcomes. Reductions in druguse were also strongly related to having good relationships with counselors and to avoidingdeviant peers after treatment.Posttreatment criminal activitywas higher for those who associated with deviant peers.
It is often necessary to modifysome of the traditional compo-nents of the TC to accommodateadolescent developmental differences and to facilitate theirmaturation. The modificationsmay include less hierarchy andconfrontation and greater priorityto education than work. Forexample, many TCs for adoles-cents have an onsite school. Inaddition, such programs offer a range of family services thatrequire family participation. After formal treatment is com-pleted, continuing care is oftenarranged.
Individuals with co-occurring mental health disordersIndividuals with co-occurringmental health and substanceabuse disorders are among themost difficult to treat. Such indi-viduals often have serious andcomplex impairments in multipleareas, in addition to drug abuseand mental illness. TCs can beadapted to treat individuals withmental disorders, including, in
NIDA RESEARCH REPORT SERIES7
some cases, the use of psy-chotropic medications to treatserious mental illness. A recentstudy compared a TC for peoplewho were homeless, mentally ill,and substance abusers to a com-munity residence based on a tra-ditional mental health treatmentmodel. In the mental healthmodel, individuals were housedwithin a less restrictive alterna-tive to the psychiatric hospital bycoupling a high level of personalfreedom with counseling, skillstraining, and monitoring of med-ication compliance. The TC pro-vided integrated mental healthand drug abuse treatment in ahighly structured, hierarchicalenvironment that stressed mutualself-help and treatment commu-nity participation. Those in theTC showed more improvementon all measures of psychopathol-ogy than those in the communityresidence. In addition, the TCprogram retained the mostimpaired individuals longer thandid the community residence.The investigators concluded thatthe increased structure providedby the TC may be a better optionfor this population than the lessrestrictive community residencemodel.
Another study that tested mod-ifications to the TC to accom-modate homeless drug abuserswith co-occurring mental healthproblems included greater flexi-bility in program requirements,reduced duration of activities and level of confrontation, andgreater responsiveness to individ-ual needs. A second set of modi-fications, for a low-intensity TC, allowed residents greater
freedom to leave the facility dur-ing the early stages of treatment,offered services in day treatmentsettings outside the residence,decreased the level of peerresponsibility, and increased theamount of direct staff assistance.The modified TCs were com-pared to “treatment as usual,”which consisted of a heteroge-neous mix of alternatives oftenencountered after discharge fromshelters or psychiatric facilities.Analyses comparing the out-comes of modified TC treatmentto the usual options found thatdrug use was reduced in bothgroups, although participation inthe modified TCs led to signifi-cantly greater improvements forcriminal activity and indicators of depression.
Populations involved inthe criminal justice systemAs drug abuse and crime areoften linked, many drug-abusingor addicted individuals also areinvolved with the criminal justicesystem. Some of the most exten-sive research studies on TCshave been conducted on treat-ment for populations involved in the criminal justice system.These studies have found bene-fits for prison-based TC treatmentin preparing inmates to return tothe community and for creating a safer, better managed prisonenvironment. Drug-involvedoffenders have the best out-comes when they participate incommunity-based TC treatmentwhile transitioning from incar-ceration to re-entry to the community.
One such study followed drug-abusing and addicted inmates inthe Delaware CorrectionalSystem to determine the effec-tiveness of a continuum of careon relapse to drug use andrecidivism to criminal activity.The continuum of care began inprison with a State-funded TCprogram called The Key. Inmatestransitioned back into the com-munity through a work-releaseprogram that allowed them towork in the community butrequired their return to a securefacility overnight. Some inmateswere randomly assigned to usualwork release, and some wereassigned to Crest, a TC work-release program. In the thirdstage of treatment, some whohad completed the Crest work-release TC and were living in the community continued in an aftercare program, which provided continued monitoringby TC counselors, outpatientcounseling, group therapy, andfamily sessions.
One year after scheduled completion of work release, significantly higher percentagesof inmates who had participatedin Crest or in both Key and Crestwere drug-free and arrest-freethan those assigned to usualwork release. Further, outcomesfor those who participated inboth Key and Crest were betterthan for all three other groups.
At 3 years after work release,Crest treatment graduates andespecially those who continuedwith aftercare had significantly
8NIDA RESEARCH REPORT SERIES
better outcomes than those whodropped out in terms of avoidingboth relapse to drug use and re-arrest. This study also highlightsthe value of continuing treatmentof offenders during their transi-tion back into the community.
Another study conducted inthe R.J. Donovan CorrectionalFacility in San Diego, California,investigated the effect of the TCon criminal recidivism for inmateswith drug problems. This studycompared rates of re-incarcerationand time until re-incarcerationfor those randomly assigned to aprison-based TC (the Amity pro-gram) to rates for a no-treatmentcontrol group. After prison, somewho completed the Amity pro-gram chose to enter Vista, acommunity-based TC aftercareprogram designed to comple-ment and continue the prisonprogram’s curriculum. Thosewho benefited most were theindividuals who continued andcompleted treatment in Vista.
Similar outcomes were foundat 3 years after release fromprison. Only 27 percent of thosecompleting Vista treatment hadbeen returned to custody, com-pared to 75 percent of the no-treatment controls. Among thosewho were re-incarcerated, theamount of exposure to treatmentwas significantly related to thenumber of days until return tocustody, with greater treatmentexposure related to a longer timeuntil re-incarceration.
NIDA RESEARCH REPORT SERIES9
*p<.05 from no treatment.Percentages show any use of drugs (either self-reported or detected by urinalysis) and any arrestsin the year after work release. Note that prisoners were allowed to access treatment on their own,and some of those in the no treatment condition did receive services that were not part of the Keyor Crest programs. Total number of patients was 448.Source: Martin et al., The Prison Journal 79:294-320, 1999.
100
80
60
40
20
0No Tmt Key Crest Key-Crest
Perc
ent o
f pat
ients
16%
46%
22%31%
57%
47%
77%
43%
Drug-free Arrest-free
Delaware Correctional System participants in prison TC (Key) and work release TC (Crest)
Drug-free and arrest-free 1 year after work release
No treatment controls
Prison TC dropouts
Prison TC completers
Prison TC completersaftercare dropouts
Prison TC completersaftercare completers
0 10 20 30 40 50Percent of participants
Bars show the percentage of individuals re-incarcerated in the year following release from prison.Total number of participants was 715. Source: Wexler et al., Criminal Justice and Behavior, 26:147-167, 1999.
50%
45%
40%
39%
8%
R.J. Donovan Correctional Facility participants in prison TC (Amity) and community-based TC aftercare (Vista)
Re-incarceration rates 12 months after prison release
*
**
*
Persons living withHIV/AIDS Several studies have shown thatthe TC can be effective in caringfor HIV-infected substanceabusers and in modifying riskbehavior to reduce HIV transmis-sion. In the late 1980s, whenAIDS was considered a terminalillness, several approaches tomodifying the TC were devel-oped to provide a comprehen-sive, multilayered therapeuticmilieu addressing the multipleproblems of individuals withHIV/AIDS.
One such model in New Yorkmerged modified TC principleswith nursing home standards ofmedical and psychiatric care toimprove physical and psycho-logical health. This model hasevolved in step with advances in treatment for AIDS. Anothermodified TC model in SanFrancisco was designed toengage HIV-infected persons intreatment, retain them, and linkthem to appropriate medical,psychiatric, and other social services. The modifications tothis TC included providing theseindividuals with accelerated entryinto the program, a more com-prehensive assessment, a higherratio of professional mentalhealth and medical staff, andgreater attention to staff issuessuch as stress, grief, and burnout.
Several studies have found that TC treatment reduces HIVrisk by reducing injection druguse. Length of treatment, animportant predictor of drug useoutcomes, may also be important
in reducing some HIV riskbehaviors. In a study conductedin San Francisco, reductions ininjection drug use and risky sexual practices were found for both a traditional TC and a modified day-treatment TC. The longer the person was intreatment, the less likely he or she was to engage in riskybehaviors.
How else can therapeutic communities bemodified?
M ore recently, researchefforts have sought to determine how to
modify TCs to accommodate the realities and constraints of amanaged care health environ-ment. Major adaptations beingtested include the impact ofshorter lengths of stay and theuse of a day treatment model.
Shorter lengths of stayOriginally, the TC was envisionedas an alternative community thathad no specific length of stay. As the TC developed into amainstream treatment modalityand external pressures emergedto manage treatment resourcesmore efficiently, the expectedlength of treatment becameshorter—first to around 24 monthsand now to around 12 months.
One study compared two TCs differing in the length of residential stay. The planned
treatment duration was 12months in each program, butone was designed as a 9-monthresidential/3-month outpatientprogram and the other was a 6-month residential/6-month outpatient phase. No statisticallysignificant differences in out-comes were found between thesetreatment designs, except thatthe program with the 9-monthresidential phase producedbetter employment outcomes.However, successful outcomesdepended more on completingboth phases of the programs thanon the length of the residentialphase.
The day treatment TC The day treatment TC is lessintensive than residential TCtreatment but more intensivethan the typical outpatient drugtreatment program. Day treat-ment TCs employ a communityapproach and the principles ofmutual self-help. They can behelpful in preparing a person forentry into a residential programor may serve as a “step down”modality after the residentialphase is complete. Day treatmentTCs can also provide compre-hensive, self-contained treatmentfor those who may not need residential care.
In a study comparing a daytreatment TC with a traditionalresidential TC, the day treatmentTC produced outcomes com-parable to the traditional TC,including reduction in alcoholand drug use and improvementin many problem areas. Possibly
10NIDA RESEARCH REPORT SERIES
NIDA RESEARCH REPORT SERIES11because of poorer retentionrates, the day treatment programwas not as successful as the traditional TC with those whohad severe social and psychiatricproblems. The traditional residential TC also had betteroutcomes for employment, anarea heavily emphasized in most residential TC program.However, for those with lesssevere mental health and socialfunctioning problems, the daytreatment TC may be more cost-effective.
ResourcesNIDAGeneral Inquiries: NIDA Public Information Office, 301-443-1124
Inquiries about NIDA’s treatment research activities: ■ Division of Treatment Research and Development, 301-443-6173■ Division of Epidemiology, Services, and Prevention Research,
301-443-4060.www.drugabuse.gov
Center for Substance Abuse Treatment (CSAT)CSAT, a part of the Substance Abuse and Mental Health ServicesAdministration, supports treatment services through block grants, disseminates findings to the field, and promotes their adoption. CSAT also operates the National Treatment Referral Hotline (1-800-662-HELP).CSAT publications are available through the National Clearinghouse on Alcohol and Drug Information (1-800-729-6686). www.samhsa.gov/csat
National Clearinghouse on Alcohol and Drug Information(NCADI)NIDA educational resources on drug addiction treatment and publicationsfrom other Federal agencies are available from this source. Staff provides assistance in English and Spanish and has TDD capability; call 1-800-729-6686. www.health.org
National Institute of Justice (NIJ)NIJ supports research, evaluation, and demonstration programs on drug abuse in the contexts of crime and the criminal justice system. For information and publications, contact the National Criminal JusticeReference Service at 1-800-851-3420 or 301-519-5500.www.ojp.usdoj.gov/nij
Therapeutic Communities of America (TCA)TCA is an association of member organizations that advocate for and promote understanding of TCs. TCA increases knowledge of the TC philosophy and methodology; develops and promulgates standards of quality for TC programs and practitioners; provides members with information, networking, and forums to promote the TC methodology; and creates a supportive atmosphere for members in their individual effortsand national representation. For more information, call 202-296-3503.www.tcanet.org
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• International activities
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J.C.; Walker, J.R.; Pagan, E.S.; and Biafora, F.A. A program evaluation study of a nursing homeoperated as a modified therapeutic community forchemically dependent persons with AIDS. Journal ofSubstance Abuse Treatment 18:373-386, 2000.
Condelli, W.S., and Hubbard, R.L. Relationship betweentime spent in treatment and client outcomes fromtherapeutic communities. Journal of SubstanceAbuse Treatment 11:25-33, 1994.
Daley, M.; Argeriou, M.; McCarty, D.; Callahan, J.J.;Shepard, D.S.; and Williams, C.N. The costs of crime and the benefits of substance abuse treatment for pregnant women. Journal ofSubstance Abuse Treatment 19:445-458, 2000.
De Leon, G. The Therapeutic Community: Theory,Model, and Method. New York: Springer PublishingCompany, 2000.
De Leon, G.; Hawke, J.; Jainchill, N.; and Melnick, G.Therapeutic communities. Enhancing retention intreatment using ”Senior Professor“ staff. Journal ofSubstance Abuse Treatment 19:375-82, 2000.
De Leon, G.; Melnick, G.; Thomas, G.; Kressel, D.; and Wexler, H.K. Motivation for treatment in aprison-based therapeutic community. AmericanJournal of Drug and Alcohol Abuse 26:33-46, 2000.
De Leon, G.; Sacks, S.; Staines, G.; and McKendrick,K. Modified therapeutic community for homelessmentally ill chemical abusers: Treatment outcomes.American Journal of Drug and Alcohol Abuse,26(3):461-480, 2000.
Etheridge, R.M.; Hubbard, R.L.; Anderson, J.; Craddock,S.G.; and Flynn, P.M. Treatment structure and program services in the Drug Abuse TreatmentOutcome Study (DATOS). Psychology of AddictiveBehaviors 11:244-260, 1997.
French, M.T.; Sacks, S.; De Leon, G.; Staines, G.; andMcKendrick, K. Modified therapeutic community formentally ill chemical abusers: Outcomes and costs.Evaluation & the Health Professions 22:60-85,1999.
Grella, C.E.; Polinsky, M.L.; Hser, Y.-I.; and Perry, S.M.Characteristics of women-only and mixed-genderdrug abuse treatment programs. Journal ofSubstance Abuse Treatment 17:37-44, 1999.
Guydish, J.; Sorensen, J.L.; Werdegar, D.; Chan, M.;Bostron, A.; and Acampora, A. A randomized trialcomparing day and residential drug abuse treat-ment: 18-month outcomes. Journal of Consultingand Clinical Psychology 67:428-434, 1999.
Hiller, M.L.; Knight, K.; Broome, K.M.; and Simpson,D.D. Legal pressure and treatment retention in anational sample of long-term residential programs.Criminal Justice and Behavior 25:463-481, 1998.
Hser, Y.I.; Grella, C.E.; Hubbard, R.L.; Hsieh, S.C.;Fletcher, B.W.; Brown, B.S.; and Anglin, D. An evaluation of drug treatments for adolescents in 4 U.S. cities. Archives of General Psychiatry58:689-695, 2001.
Inciardi, J.A.; Martin, S.S.; and Surratt, H.L.Therapeutic Communities in Prisons and WorkRelease: Effective Modalities for Drug InvolvedOffenders. Therapeutic Communities for theTreatment of Drug Users. London: Jessica KingsleyPublishers, 241-256, 2001.
Jainchill, N. Therapeutic communities for adolescents:The same and not the same. In: DeLeon, G. (ed).Community as Method. Westport, CT: Praeger, 161-177, 1997.
Jainchill, N.; Hawke, J.; De Leon, G.; and Yagelka, J.Adolescents in TCs: One year post-treatment outcomes. Journal of Psychoactive Drugs32(1):81-94, 2000.
Liberty, H.J.; Johnson, B.D.; Jainchill, N.; Ryder, J.;Messina, M.; Reynolds, S.; and Hossain, M.Dynamic recovery: Comparative study of therapeutic communities in homeless shelters for men. Journal of Substance Abuse Treatment15:401-423, 1998.
Martin, S.S.; Butzin, C.A.; Saum, C.A.; and Inciardi,J.A. Three year outcomes of therapeutic communitytreatment for drug involved offenders in Delaware:From prison to work release to aftercare. The PrisonJournal 79(3):294-320, 1999.
McCusker, J.; Stoddard, A.M.; Hindin, R.N.; Garfield,F.B.; and Frost, R. Changes in HIV risk behavior following alternative residential programs of drugabuse treatment and AIDS education. Annals ofEpidemiology 6:119-125, 1996.
McGeary, K.A.; French, M.T.; Sacks, S.; McKendrick,K.; and De Leon, G. Service use and cost by mentally ill chemical abusers: Differences by retention in a therapeutic community. Journal ofSubstance Abuse 11(3):265-279, 2000.
McLellan, A.T.; Lewis, D.C.; O’Brien, C.P.; and KleberH.D. Drug dependence, a chronic medical illness.Implications for treatment, insurance, and out-comes evaluation. JAMA 284:1689-1695, 2000.
Mierlak, D.; Galanter, M.; Spivak, N.; Dermatis, H.;Jurewicz, E.; and De Leon, G. Modified therapeuticcommunity treatment for homeless dually diagnosedmen. Who completes treatment? Journal ofSubstance Abuse Treatment 15:117-121, 1998.
Morral, A.; Reti, M.; McCaffrey, D.; and Ridgeway, G.Phoenix Academy treatment outcomes: Preliminaryfindings from the adolescent outcomes study. NIDAResearch Monograph 182:111-112, 2001.
Nemes, S.; Wish, E.D.; and Messina, N. Comparing theimpact of standard and abbreviated treatment in atherapeutic community. Journal of Substance AbuseTreatment 17:339-347, 1999.
Sia, T.L.; Dansereau, D.F.; and Czuchry, M.L. Treatmentreadiness training and probationers’ evaluation ofsubstance abuse treatment in a criminal justice setting. Journal of Substance Abuse Treatment19:459-467, 2000.
Simpson, D.D.; Joe, G.W.; and Brown, B.S. Treatmentretention and follow-up outcomes in the Drug AbuseTreatment Outcome Study (DATOS). Psychology ofAddictive Behaviors 11:294-307, 1997.
Simpson, D.D.; Joe G.W.; Fletcher, B.W.; Hubbard,R.L.; and Anglin, M.D. A national evaluation oftreatment outcomes for cocaine dependence.Archives of General Psychiatry 56:507-514, 1999.
Wexler, H.K.; De Leon, G.; Thomas, G.; Kressel, D.;and Peters, J. The Amity prison TC evaluation.Criminal Justice and Behavior 26:147-167, 1999.
Wexler, H.K.; Melnick, G.; Lowe, L.; and Peters, J.Three-year reincarceration outcomes for Amity in-prison therapeutic community and aftercare inCalifornia. Prison Journal 79:321-336, 1999.
Woods, W.J.; Guydish, J.R.; Sorensen, J.L.; Coutts, A.;Bostrom, A.; and Acampora, A. Changes in HIV-related risk behaviors following drug abusetreatment. AIDS 13:2151-2155, 1999.
