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Monday, September 04, 2006

What is a Therapeutic Community?

What is a therapeutic community?
Therapeutic communities provide long-term residential treatment for substance abuse in a secure, drug-free environment. The first therapeutic community, Synanon, was formed in 1958 (by an early member of Alcoholics Anonymous) to provide a safe environment in which users of alcohol and other substances could work together to help themselves and each other recover from their addictions and rebuild their lives. Since then, therapeutic communities have become the best-known and most common type of long-term residential program for substance-use recovery (Hubbard et al., 1989).

The primary goal of treatment in a therapeutic community is not simply to treat the addiction but to help a person in recovery achieve personal growth by learning new behaviors, coping skills, and attitudes that will help him or her to pursue a drug-free lifestyle. (De Leon and Rosenthal, 1989.) Social and vocational skills are also taught. Fellow residents and counselors (who are themselves usually former residents who have successfully recovered) help persons in recovery by serving as role models and setting a good example of how to handle stress without resorting to substance abuse. Peer pressure is also an important aspect of therapeutic community-based treatment.

What does therapeutic community-based treatment involve?
In a therapeutic community, treatment includes both individual and group counseling. Persons in recovery are counseled (sometimes in a confrontational manner) by their peers to (APA, 2000):

· overcome denial and accept their substance abuse problem
· understand the role of substance use in their lives
· identify unhealthy behaviors and ways of coping
· learn healthy ways to handle stress and depression
· develop attitudes and beliefs that are incompatible with continued substance use.
Therapy community programs often involve three key stages of treatment (Kooyman, 1993):
· induction (preparing persons in recovery for admission to the program)
· primary treatment (helping residents to recover and become stronger)
· reentry preparation (preparing residents for independent, substance-free living and reintegration
into society)

What is it like to live in a therapeutic community?
The therapeutic community environment is highly structured, with rules and schedules. Both penalties and rewards are used to encourage recovery and personal growth (Kerr, 1986). Newcomers to therapeutic communities are given very few privileges to start with; they are considered “low on the totem pole” and are given the least desirable work chores. As residents demonstrate that they can remain drug-free and follow community rules, they earn increasing privileges, status, and opportunities for leadership (APA, 2000).

Residents in a therapeutic community are considered “members,” not patients, and are expected from the beginning to take responsibility for themselves and to participate actively in all aspects of the community, including counseling of fellow members, community decision-making, and chores. Honesty, trust, and self-help are stressed. Members play an active role in all decisions affecting them, including admission and discharge of fellow residents, assignment of domestic tasks, and penalties for rule-breaking (Kennard, 1998).

How effective are therapeutic communities for drug addition recovery?
In order for therapeutic community-based treatment to be effective, the person in recovery must remain in treatment for an appropriate length of time. Unfortunately, only 15% to 25% of patients who are voluntarily admitted to a therapeutic community program remain in the program for a sufficient period of time (see below) (APA, 2000).

Therapeutic community-based programs may be more effective than outpatient programs in helping persons in recovery. Research suggests that one year after treatment, patients who have completed therapeutic programs are less likely to have started using drugs again than those that have undergone outpatient treatment (De Leon, 1984).

Three to five years after program completion, persons in recovery who have participated in a therapeutic community show less criminal activity and increased full-time employment (O’Brien and Biase, 1992).

Who is best suited for therapeutic community-based treatment?
Therapeutic community-based treatment may be most appropriate for people who are seeking a highly structured setting to begin their recovery. People who seek support and strong encouragement of peers who have “been there” and know what it takes to recover will do well in this treatment setting. This form of treatment may be especially appropriate for people for whom other forms of treatment have not been effective (APA, 2000).

There are two basic types of therapeutic communities for adults. The short-term type of therapeutic community, where treatment lasts an average of three to six months, is appropriate for persons in recovery who have a stable social and family environment, and focuses mainly on developing a drug-free lifestyle. For persons in recovery who do not have strong family and social support, the longer-term type of therapeutic community may be more appropriate. In this type of therapeutic community, treatment lasts an average of six to nine months; goals include both attainment of a drug-free state and development of practical living skills and social skills (Singer, 1992).

Therapeutic community-based treatment may not be appropriate for all persons in recovery. Studies have shown that people with low self-esteem, poor self-definition, and a tendency to criticize themselves heavily and overemphasize negative features are more likely to drop out of therapeutic community programs before treatment is complete (O’Brien & Biase, 1992). The confrontational style of counseling that sometimes occurs in the therapeutic community setting may be too intense for those that are highly sensitive to criticism (Singer, 1992).

What about therapeutic communities for adolescents?
Juvenile persons in recovery can also benefit from therapeutic-community based treatment. There are special adolescent therapeutic communities that have been modified to be appropriate for youths; these programs include the following features (Mullen, Arbiter, and Glider, 1991):
· shorter treatment periods
· less confrontational style
· increased supervision
· more recreational activities
· greater family involvement
· emphasis on education, including actual schoolwork
· increased staff-to-youth ratio
· separation of boys and girls (except for occasional program activities)

How long does therapeutic community-based treatment last?
Studies have shown that patients who remain in treatment for at least three months show improvement, but the greatest recovery benefits are achieved when treatment lasts from 6 to 12 months (APA, 2000), which is a typical length of stay. Treatment can last for as long as 18 to 24 months.

How much does therapeutic community-based treatment cost?
Treatment in a therapeutic community tends to be highly cost-effective. Treatment costs are lower than in clinical treatment settings, because former residents (rather than licensed professionals) serve as counselors and because residents work cooperatively to operate and maintain the residence. Costs for treatment in a therapeutic community vary depend on facility, but are approximately $55 to $60 per day for standard adult care. Treatment costs are slightly higher for adolescents, pregnant women, and other special populations (Wolf Jones, 2000). Government assistance is often available for those with limited incomes.

References

American Psychiatric Association (2000). Practice Guideline For The Treatment Of Patients With Substance Use Disorders Alcohol, Cocaine, Opioids. III: General Treatment Principles and Alternatives. (On-line: http://www.psych.org/psych/htdocs/clin_res/pg_substance_3.html)

De Leon G. (1984). The Therapeutic Community: Study of Effectiveness. NIDA Treatment Research Monograph Series, DHHS Publication (ADM) 85-1286. Rockville, Md, National Institute on Drug Abuse, 1984.

De Leon G, Rosenthal MS (1989). Treatment in residential therapeutic communities, in Treatments of Psychiatric Disorders: A Task Force Report of the American Psychiatric Association, Vol 2. Washington, DC, APA.

Hubbard, R. L., Marsden, M. E., Rachal, J. V., Harwood, H. J., Cavanaugh, E. R., & Ginzburg, H. M. (1989). Drug Abuse Treatment: A National Study of Effectiveness. Chapel Hill, N.C. and London: The University of North Carolina Press.

Kennard, D. (1998). Introduction to Therapeutic Communities. London: Jessica Kingsley Publishers.

Kerr, D. H. (1986). The therapeutic community: A codified concept for training and upgrading staffmembers working in a residential setting. In: De Leon & Ziegenfuss (eds.), Therapeutic Communities for Addiction, pp. 55-63. Springfield, IL: Charles C. Thomas.

Kooyman, Martien (1993). The Therapeutic Community for Addicts. Amsterdam: Swets & Zeitlinger.

Mullen, R., Arbiter, N., & Glider, P. (1991). A comprehensive therapeutic community approach for chronic substance-abusing juvenile offenders: The Amity model. In T.L. Armstrong (Ed.), Intensive interventions with high-risk youths: Promising approaches in juvenile probation and parole. Monsey, NY: Criminal Justice Press, a Division of Willow Tree Press, Inc.

O’Brien, W.B. & Biase, D.V. (1992). Therapeutic community: A coming of age. In: Lowinson, J.H., Ruiz, P., Millman, R.B., Langrod, J.G. (Eds.), Substance Abuse: A Comprehensive Textbook (2nd ed.). Baltimore: Williams and Wilkins.

Singer, A. (1992). Effective treatment for drug-involved offenders: A review and synthesis for judges and other court personnel. Newton, MA: Education Development Center, Inc.

Wolf Jones, L. R. (Executive Director, Therapeutic Communities of America). Personal communication, 11/13/2000.

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