Modern Therapeutic Communities for Addiction
Contrary to what readers may have thought, TCs remain widely utilized, especially for certain populations of substance misusers. Developed as alternatives to traditional treatments, maligned in the past for demeaning and punitive interventions, Dr. George DeLeon argues that modern therapeutic communities, with flexible treatments and lengths of stay, are exactly right for promoting “right living” and producing positive outcomes with respect to reduction in substance misuse, fewer legal problems, improvements in employment status and overall psychosocial status….Dr. Richard Juman
Over the past 50 years, the Therapeutic Community (TC) for addiction has evolved from a modality which played a marginal role in the treatment world to one that is now considered to be one of the core components of the substance misuse treatment continuum. Over this period of time, the nature of the treatment and services provided by TCs has also evolved. My guess is that a number of readers have a perception of TCs that is based on some interventions and practices that occurred decades ago and doesn’t reflect the evolution of the “TC Model.”
Modern TCs serve a wide diversity of clients and problems; they have new staffing compositions, have reduced the typical duration of residential treatment, have reconsidered their treatment goals and, to a considerable extent, have adapted and modified the therapeutic approach itself. Unfortunately, although TCs have evolved, the view of them among the public, policymakers and other members of the treatment community has not necessarily kept pace, and so the role of contemporary therapeutic communities in the spectrum of addiction treatments remains unclear.
In the absence of an informed view of the TC, historical perceptions and misperceptions of this significant treatment modality tend to persist, to everybody’s detriment. It is imperative that addiction professionals educate themselves about the advances and applications of the contemporary TC in serving special populations in various settings. Additionally, it’s critical that greater linkages are forged between TCs and the broader field of addiction psychology. The Therapeutic Community is a unique social-psychological approach to treating addiction (”community as method”) that addresses the whole person. This includes focusing on the complex psychological injuries that are associated with addiction and launching a recovery process defined by identity change.
TC programs have been implemented worldwide for over five decades; globally, it is conservatively estimated that there are over 3,000 TCs operating in hospitals, prisons, juvenile centers, outpatient programs and other community-based settings. TC programs have been implemented in Europe, Asia, Africa, Latin America, and the Middle East. And despite the ethnic, social-political, and religious differences that are encountered across these various cultures, TCs retain their essential elements and effectiveness in a way that is universal.
Community as Method: a unique psychosocial treatment
Therapeutic communities are commonly understood to be long-term residential programs with peer support and confrontation as their hallmark therapeutic strategies. This understanding, however, does not capture the actuality of the TC’s unique social-psychological approach to treating substance misuse and its related problems, summarized in the phrase “community as method” (De Leon 1997, 2000). Theoretical writings offer a definition of community as method as the purposive use of the community to teach individuals to utilize the community to change themselves. The fundamental assumption underlying the TC approach is that individuals obtain maximum therapeutic and educational impact when they engage in and learn to use all of the activities, elements and relationships of the community as tools for self-change.
Thus, community as method means that the community itself is the context and mediator of social and psychological change. Members establish the expectations or standards of participation in community activities, they continually assess how individuals are meeting these expectations; and they respond to individuals with strategies that promote continued participation.
Although the TC emerged a-theoretically, embedded in its social learning approach are familiar elements and practices supported by abundant evidence in the behavioral and social–psychological literature. Examples include: peer tutoring (mutual self-help grounded in peers as role models and mentors), motivational enhancement (various forms of group process focusing on problem identification and encouraging desire to change), behavior modification (a system of informal verbal corrections and affirmations delivered by peers and formal privileges and disciplinary consequences delivered by staff), goal attainment (the TC stage-phase format designed to facilitate incremental positive outcomes leading to program completion), and therapeutic alliance (the concept that participation and change depend upon a positive affiliative relationship between the individual and the community).
Similarly, a variety of proven behavioral and social learning principles and mechanisms of change underlie TC programming and practices—examples would be self-efficacy (trial and error) training, social role training and vicarious learning. Rather than formal guidelines, these social learning principles naturalistically mediate practices within the context and structure of community living. Thus, although the TC emerged as an alternative to conventional mental health and medical treatment, its relationship to contemporary behavioral and psycho-social addiction treatments can be appreciated in its perspective theory, model and method. (see De Leon 2000)
TC Applications: Special Populations and Special Settings
The most impressive sign of the evolution of the TC is its wide application to special populations and special settings. The effectiveness and cost benefits of modified TCs have been documented for adolescents and juvenile justice clients, addicted mothers and children, individuals with co-occurring mental illness, homeless substance misusers, AIDS- and HIV-seropositive clients, elderly substance misusers and methadone-maintained clients. This adaptability has allowed TC-oriented programs to be developed and to thrive in special settings such as correctional facilities, shelters, halfway houses, psychiatric hospitals and alternative schools.
To serve such a diversity of clients and problems, contemporary therapeutic communities utilize a variety of strategies, many of which are not specific to the TC modality. These include 12-step groups and many varieties of mental health services including cognitive behavioral therapy, motivational enhancement therapy, relapse prevention therapy and dialectical behavior therapy. Additionally, TCs may offer the range of available pharmacotherapies, including psychotropics, methadone, buprenorphine and naltrexone, plus family therapies and primary health care. Finally, TCs often provide vocational and educational programming in addition to housing services.
It is important to be aware of the fact that the staff composition of contemporary TCs has diversified to address the complexity of client profiles and issues, now usually consisting of medical, mental health and educational professionals along with non-traditional recovered para-professionals. While incorporating these changes in staffing and practices, modified TC programs retain the essential elements of community as method (Dye et al 2009).
In contrast to what many in the treatment community believe, all TCs do not operate based on a long-term residential model. Many TC organizations are multimodality treatment centers, and like all good treatment the level of care recommended for any individual client is based on the clinical status, social stability and situational needs of the individual as revealed upon thorough clinical assessment. For example, planned durations of residential treatment may be short-term (less than 90 days), medium-term (3-6 months) or longer-term (9-12 months) and may be combined with outpatient services following the clients’ discharge from residential care.
Some TC agencies offer intensive day treatment, methadone-to-abstinence residential treatment and day-treatment methadone maintenance programs. The idea is to match the patient to the appropriate modality within the agency, so for example, more stable and socialized patients would be offered shorter-term residential treatment followed by an ambulatory TC model. Studies indicate better retention rates are achieved for patients who are matched to TC-oriented residential and outpatient settings on the basis of multiple domains of functioning, including drug use severity, and social maturation and psychological functioning (Melnick et al. 2000, 2001).
There is a wide spectrum of TC programs available, depending on the strictness of adherence to the TC perspective, with certain TCs utilizing the standard approach while some significantly modify the structure and others use TC-oriented concepts in a non-TC format. These designations (standard, modified or TC-oriented) are based upon the extent to which a program is guided by the essential TC perspective: that addiction is a disorder of the whole person and that the goals of treatment are recovery and “right living.” Additionally, programs differ to the extent to which they adhere to the TC model’s primary approach (community as method) and retain other essential components of the model, such as resident-managed social structure, and a variety of clinical, tutorial and community meetings.
A Word on TC Effectiveness
Thousands of individuals admitted to TC programs have been evaluated prospectively in outcome studies conducted over four decades. The main findings reveal a consistent relationship between retention in TC treatment and positive post-treatment outcomes. Those who complete treatment show the best outcomes, and among non-completers there is a positive relationship between length of stay and positive post-treatment outcomes (see Vanderplasschen, et al, 2013). Although there have been relatively few randomized controlled studies involving TC programs, conclusions concerning effectiveness are based upon multiple sources of research including the multimodality survey studies (e.g., DATOS), single program controlled studies, meta-analytic statistical surveys and cost–benefit studies. The weight of this evidence is compelling in supporting the hypothesis that the TC is an effective and cost-effective treatment for certain subgroups of substance abusers, particularly those who may be described as severe with respect to drug use, social deviance and psychological problems.
TCs in the Spectrum
In many ways the ongoing evolution of TCs reflects the maturation of the addiction field in general. Advances in addiction research are well-documented in an impressive and growing biomedical, socio-behavioral, genetic and neuroscience knowledge base. The trajectory of treatment policy has moved across perspectives such as chronic disease management, harm reduction and currently a resurgent recovery orientation. The latter development is evident not only among grassroots movement organizations (e.g., Faces and Voices of Recovery) but also in federal and state funding agencies, as witnessed by the fact that the National Institute on Alcohol Abuse and Alcoholism (NIAAA) renamed its Division of Treatment as the Division of Treatment and Recovery Research.
Contemporary addiction treatments offer various recovery pathways that hold differing views on the significance of abstinence in a recovery orientation. In the Therapeutic Community perspective, however, the primary goal of treatment is recovery, which is broadly defined as changes in lifestyle and identity. These changes involve abstinence from all non-prescribed drugs, elimination of social deviance and development of pro-social behaviors and values. This recovery perspective is the fundamental rationale for the TC program model, its unique approach, community as method, and its longer planned duration of treatment. Multi-dimensional (“Whole Person”) change requires a multi-interventional approach implemented for a sufficient period of time. Thus, across the diversity of clients within the current spectrum of treatment options, the TC offers an effective pathway—particularly for those whose recovery involves learning right living.
George De Leon is the leading authority on treatment and research in therapeutic communities. He is a founding member and former president of the APA Division 50 on Addictions, Clinical Professor of Psychiatry at New York University School of Medicine and Science Director of the NIDA funded Behavioral Science Training Program at NDRI, NY.