Благотворительный фонд "Старый Свет"

CHAPTER 26
THERAPEUTIC COMMUNITIES
George De Leon

 

THERAPEUTIC COMMUNITIES: THEORY, RESEARCH, AND APPLICATIONS

Therapeutic communities (TCs) for addictions derive from Synanon, founded in 1958 by Charles Dederich with other recovering alcoholics and drug addicts. Although the immediate antecedents of the addiction TC is Alcoholics Anonymous, ancient prototypes exist in all forms of communal healing and mutual self-help. The contemporary therapeutic community for addictions has matured into a sophisticated human services modality in the past 35 years, evident in the broad range of programs that subscribe to the basic TC perspective and approach, serving an estimated 80,000 admissions yearly in the United States (Therapeutic Communities of America, 1993). These comprise a wide diversity of clients who use an expanded cafeteria of drugs and present complex social-psychological problems in addition to their chem¬ical abuse.

THE THERAPEUTIC COMMUNITY MODALITY

The therapeutic community is a drug-free modality that utilizes a social-psychological, self-help approach to the treatment of drug abuse. The characteristic setting for its
programs is a community-based residence in urban and nonurban locales. However, TC programs have been implemented in a variety of other settings, residential and nonresidential (e.g., hospitals, jails, schools, halfway houses, day treatment clinics and ambulatory clinics). TCs offer a wide variety of services including social, psycho¬logical, educational, medical, legal, and social/advocacy. However, these services are coordinated in accordance with the TC's basic self-help model.

The Traditional Residential TC

Much of what is known about the therapeutic community approach and its effectiveness is based on the long-term residential model, also termed the "traditional" TC. Traditional TCs are similar in planned duration of stay (15-24 months), structure, staffing pattern, perspective, and rehabilitative regime, although they differ in size (30-600 beds) and client demography. Staff are composed of TC-trained clinicians and other human service profes¬sionals. Primary clinical staff are usually former substance abusers who themselves were rehabilitated in TC pro¬grams. Other staff consists of professionals providing, medical, mental health, vocational, educational, family counseling, fiscal, administrative and legal services.
TCs accommodate a broad spectrum of drug abusers. Although they originally attracted narcotic addicts, the majority of their client populations are nonopioid abusers. Thus, this modality has responded to the changing trend in drug use patterns; treating clients with substance and psy¬chological disorders, problems of varying severity, differ¬ent lifestyles, and various social, economic, and ethnic/cultural backgrounds.
The TC views drug abuse as a deviant behavior, reflect¬ing impeded personality development or chronic deficits in social, educational, and economic skills. Its antecedents lie in socioeconomic disadvantage, in poor family effective¬ness, and in psychological factors. Thus the principal aim of the therapeutic community is a global change in lifestyle: abstinence from illicit substances, elimination of antisocial activity, development of employability, and prosocial attitudes and values. The rehabilitative approach requires multidimensional influence and training, which for most can only occur in a 24-hour residential setting.

Admission Criteria

Traditional TCs maintain an "open-door" policy with respect to admission to residential treatment. However, there are two major guidelines for excluding clients: suit¬ability and community risk. Suitability refers to the degree to which the client can meet the demands of the TC regime and integrate with others. This includes participation in groups, fulfilling work assignments, and living with mini¬mal privacy in an open community, usually under dormi¬tory conditions. Risk refers to the extent to which clients present a management burden to the staff or pose a threat to the security and/or health of others in the community.
Specific exclusionary criteria most often include histories of arson, suicide attempts, and serious psychiatric disorder. Psychiatric exclusion is usually based on documented his¬tory of psychiatric hospitalizations or prima facie evidence of psychotic symptoms on interview (e.g., frank delusions, thought disorder, hallucinations, confused orientation, or signs of serious affective disorder). Generally, clients on reg¬ular psychotropic regimes will be excluded because use of these usually correlates with chronic or severe psychiatric disorder. Clients requiring medication for medical conditions are acceptable in TCs, as are clients with disabilities or those who require prosthetics, providing they can meet the partici¬patory demands of the program.
A full medical history is obtained during the admission evaluation, which includes questions concerning current medication regimes (e.g., asthma, diabetes, hypertension)) and the necessity for prosthetics. As discussed later in this chapter, policy and practices concerning testing for HIV status and management of AIDS (acquired immune defi¬ciency syndrome), or AIDS-related complex (ARC) have recently been implemented by most TCs.

The Residential Client

Suitability for long-term treatment in TCs is based on several indicators that can be summarized across five main areas:
1. Health and Social Risk Status: The individual's experi¬ence of chronic or acute stress concerning physical, psychological, and social problems associated with drug use. Some indicators are
o out-of-control behavior with respect to drug use, criminality, or sexuality;
o suicidal potential threat through overdose; threat of injury or death through other drug-related means;
o anxiety or fear concerning violence, jail, illness, or death; and extent of personal losses (e.g., financial, relationships, employment).
2. Abstinence Potential: The individual's ability to main¬tain complete abstinence in a nonresidential treatment setting. Some indicators are
o previous treatment experiences (number, type, and outcomes);
o previous self-initiated attempts at abstinence (fre¬quency and longest duration);
o current active drug use versus current abstinence.
3. Social and Interpersonal Function: The individual's current capability to function in a responsible way. Some indicators are
o involvement in the drug lifestyle (friends, places, activities);
o impaired ability to maintain employment or school responsibility or to maintain social relations and respon¬sibilities (e.g., parental spouse, filial, friendships).
4. Antisocial Involvement: The extent to which the indi¬vidual' drug use is embedded in an antisocial lifestyle. Some indicators are
o active and past criminal history in term of type and frequency of illegal activities; frequency and dura¬tion of incarceration;
o existing legal pressures for treatment;
o long-term pattern of antisocial behavior, including juvenile contact with the criminal justice system and early school problems.
5. Perceived Suitability for the TC: Individual motivation, readiness and suitability for TC treatment. Some indi¬cators are
o acceptance of the severity of drug problem;
o acceptance for the need for treatment ("can't do it alone");
o willingness to sever ties with family, friends, and current lifestyle while in treatment;
o willingness to surrender a private life meeting the expectations of a structured community.

Health and Social Risk Status

Most abusers who seek treatment in the TC experience acute stress. They may be in family or legal crisis or at sig¬nificant risk to harm themselves or others such that a period of residential stay is indicated. However, the clients suitable for long-term residential treatment reveal a more chronic pattern of stress that induces treatment seeking, and when relieved, usually results in premature dropout. They require longer term residential treatment because they are a constant risk threat and they must move beyond relief seeking to initiate a genuine recovery process.

Abstinence Potential

In the TC's view of substance abuse as a disorder of the whole person, abstinence is a prerequisite for recovery. Among chronic users the risk of repeated relapse can sub¬vert any treatment effort regardless of the modality. Thus, the residential TC is needed to interrupt out-of-control drug use and to stabilize an extended period of abstinence in order to facilitate a long-term recovery process.

Social and Interpersonal Function

Inadequate social and interpersonal function not only results from drug use but often reveals a more general picture of immaturity or an impeded developmental history. Thus a setting such as the TC, which focuses upon the broad social¬ization and/or habilitation of the individual, is needed.

Antisocial Involvement

In the TC view, the term "antisocial" also suggests charac¬teristics that are highly correlated with drug use. These include behaviors such as exploitation, abuse and violence, attitudes of mainstream disaffiliation, and the rejection or absence of prosocial values. Modification of these characteristics requires the intensive resocialization approach of the TC setting.¬

Perceived Suitability for the TC

A number of those seeking admission to the TC may not be motivated to change, ready for treatment in general, or suitable for the demands of a long-term residential regime. Assessment of these factors at admission provides a basis for treatment planning in the TC or sometimes appropriate referral. Although motivation, readiness, and suitability are not criteri;t for admission to the TC, the importance of these factors often emerges after entry to treatment; not identifying and addressing them is related to early dropout.

ESSENTIAL ELEMENTS OF THE TC

The TC can be distinguished from other major drug treat¬ment modalities in two fundamental ways. First, the TC offers a systematic treatment approach that is guided by an explicit perspective on the drug use disorder, the person, recovery, and right living. Second, the primary "therapist" and teacher in the TC is the community itself, which con¬sists of the social environment, peers, and staff who, as role models of successful personal change, serve as guides in the recovery process. Thus the community is both context in which change occurs and method for facilitating change.

Therapeutic Community Perspective

Although expressed in a social/psychological idiom, this perspective evolved directly from the experience of recov¬ering participants in TCs and is organized in terms of four interrelated views of the substance disorder, the person, recovery, and right living. Table 26.1 outlines each of these views. Substance abuse is a disorder of the whole person. The fundamental problem is the person-not the drug. Recovery is a self-help process of incremental learning toward a stable change in behavior, attitudes, and values of right living that are associated with maintaining abstinence.

Elements of Community as Method

The quintessential element of the TC approach may be termed "community as method" (De Leon, 1995a, 1995b). What distinguishes the TC from other treatment approaches (and other communities) is the purposive use of the peer community to facilitate social and psychological change in individuals. Thus in a therapeutic community all activities are designed to produce therapeutic and educational change in individual participants and all participants are mediators of these therapeutic and educational changes. Table 26.2 sum¬marizes the fundamental elements of community as method.

Components of a Generic TC Program Model

The TC perspective on the disorder, the person, recovery, and right living and its distinctive approach, the use of community as method, provide the conceptual basis for defining a generic TC program model in terms of its basic components. The following is a list of these components, which are adapted in different ways depending on the set¬ting and the populations served.
 

Table 26.1 The Therapeutic Community Perspective: Four Interrelated Views

View of the Disorder Drug abuse is a disorder of the whole person involving some or all the areas of functioning:
o Cognitive, behavioral, emotional, medical, social, and spiritual problems
o Physical dependency must be seen in the context of the individual psychological status and lifestyle
o The problem is the person, not the drugo 
View of the Person Rather than drug use patterns, individuals are distinguished along dimensions of psychological distinguished along dimensions of psychological and social deficits. Some shared characteristics:
o Poor tolerance for frustration/discomfort/delay of gratification
o Low self-esteem
o Problems with authority
o Poor impulse control
o Unrealistic
o Coping with feelings
o Dishonesty/manipulation/self-deception
o Guilt (self, others, community)
o Deficits (reading, writing, attention, communication)
View of Recovery The goals of treatment are global changes in lifestyle and identity. Some assumptions about recovery:
o Recovery is a developmental learning
o Self-help and mutual self-help
o Motivation
o Social learning
o Treatment is an episode in the recovery process
View of Right Living Certain precepts, beliefs, and values as essential to self-help recovery, social learning, personal growth and healthy living. Some examples:
o Truth/honesty
o Here and now
o Personal responsibility for destiny
o Social responsibility ("brother's/sister's keeper")
o Moral code concerning right and wrong behavior
o Work ethic
o Inner person is "good," but behavior can be "bad"
o Change is the only certainty
o Learning to learn
o Economic self-reliance
o Community involvement
o Good citizenry
Source: "Therapeutic Comunities for Addictions: A Theoretical Framework" by G. DeLeon, 1995, International Journal of Addictions. pp. 1603-1645.

Table 26.2 Community as Method: Nine Essential Concepts

Use of Participant Roles
 Individuals contribute directly to all activities of the daily life in the TC, which provides learning opportunities through engaging in a variety of social roles (e.g. peer, friend, coordinator, tutor). Thus the individual is an active participant in the process of changing themselves and others rather than spectator.
Use of Membership Feedback
 The primary source of instruction and support for individual change is the peer membership. Providing observations and authentic reactions to the individual is the shared responsibility of all participants.
Use of the Membership as Role Models Each participant strives to be a role model of the change process. Along with their responsibility to provide feedback to others as to what they must change, members must also provide examples of how they can change.
Use of Collective Formats for Guiding Individual Change
 The individual engages in the process of change primarily with peers. Education, training, and therapeutic activities occur in groups, meetings, seminars, job functions, and recreation. Thus the learning and healing experiences essential to recovery and personal growth unfold in a social context and through social intercourse.
Use of Shared Norms and Values Rules, regulations, and social norms protect the physical and psychological safety of the community. However, there are beliefs and values that serve as explicit guidelines for self-help recovery and teaching right living. These are expressed in the vernacular and the culture of each TC and are mutually reinforced by the membership.
Use of Structure and Systems The organization of work, (e.g., the varied job functions, chores and management roles) needed to maintain the daily operations of the facility is a main vehicle for teaching self-development. Learning occurs not only through specific skills training, but in adhering to the orderliness of procedures and systems, in accepting and respecting supervision, and in behaving as a responsible member of the community on whom others are dependent.
Use of Open Communication The public nature of shared experiences in the community is used for therapeutic purposes. The private inner life of the individual, feelings and thoughts, are matters of importance to the recovery and change process, not only for the individual but for other members. Thus all personal disclosure is eventually
publicly shared.
Use of Relationships Friendships with particular individuals, peers and staff, are essential to encourage the individual to engage and remain in the change process. And relationships developed in treatment are the basis for the social network needed to sustain recovery beyond treatment.
Use of Language The argot, is the special vocabulary used by residents to reflect elements of its sub culture, particularly, its recovery and right living teachings. As with any special language. TC argot represents individual integration into the peer community. However, it also mirrors the individual's clinical progress. The gradual shift in attitudes, behaviors and values consonant with recovery and right living is reflected how well residents learn, understand and use the terms of the glossary and the argot in general. Thus, resident use of the argot of the TC is an explicit measure of their affiliation and socialization in the TC community.

Community Separateness

TC-oriented programs have their own names, often innovated by the clients and are housed in a space or locale that is sep¬arated from other agency or institutional programs, units, or generally from the drug-related environment. In the residen¬tial settings, clients remain away from outside influences 24 hours a day for several months before earning short-term day¬out privileges. In the nonresidential "day treatment" settings, the individual is in the TC environment for 4-8 hours and then monitored by peers and family. Even in the least restric¬tive outpatient settings, TC-oriented programs and compo¬nents are in place. Members gradually detach from old networks and relate to the drug-free peers in the program.

A Community Environment

The inner environment of a TC facility contains communal space to promote a sense of commonality and collective activities such as groups and meetings. The walls display signs that state in simple terms the philosophy of the pro¬gram, the messages of right living and recovery. Corkboards and blackboards identify all participants by name, seniority level, and job function in the program and daily schedules are posted. These visuals display an orga¬nizational picture of the program that the individual can relate to and comprehend, factors that promote affiliation.

Community Activities

To be effectively utilized, treatment or educational ser¬vices must be provided within a context of the peer com¬munity. Thus, with the exception of individual counseling, all activities are programmed in collective formats. These include at least one daily meal prepared, served, and shared by all members; a daily schedule of groups, meet¬ings, and seminars; team job functions; and organized recreational/leisure time, ceremony, and rituals (e.g., birth¬days, phase/progress graduations, and so on).

Staff Roles and Functions

The staff are a mix of self-help recovered professionals and other traditional professionals (e.g., medical, legal, mental health, and educational) who must be integrated through cross-training that is grounded in the basic con¬cepts of the TC perspective and community approach. Professional skills define the function of staff (e.g., nurse, physician, lawyer, teacher, administrator, case worker, clinical counselor). Regardless of professional discipline or function, however, the generic role of all staff is that of community member who are rational authorities, facilita¬tors and guides in the self help community method, rather than providers and treaters.

Peers as Role Models

Members who demonstrate the expected behaviors and reflect the values and teachings of the community are viewed as role models. Indeed, the strength of the commu¬nity as a context for social learning relates to the number and quality of its role models. All members of the com¬munity are expected to be role models-roommates; older and younger residents; junior, senior, and directorial staff. TCs require these multiple role models to maintain the integrity of the community and assure the spread of social learning effects.

A Structured Day

The structure of the program relates to the TC perspective, particularly the view of the client and recovery. Ordered, routine activities counter the characteristically disordered lives of these clients and distract from negative thinking and bore¬dom, which are factors that predispose drug use. Also, struc¬tured activities of the community facilitate learning self-structure for the individual in time management, plan¬ning, setting and meeting goals, and in general accountabil¬ity. Thus, regardless of its length, the day has a formal schedule of varied therapeutic and educational activities with prescribed formats, fixed times, and routine procedures.
¬
Work as Therapy and Education

Consistent with the TC's self-help approach, all clients are responsible for the daily management of the facility (e.g.. cleaning, activities, meal preparation and service, mainte¬nance, purchasing, security, coordinating schedules. preparatory chores for groups, meetings, seminars activities. and so on). In the TC, the various work roles mediate essen¬tial educational and therapeutic effects. Job functions strengthen affiliation with the program through participa¬tion, provide opportunities for skill development, and foster self examination and personal growth through performance challenge and program responsibility. The scope and depth of client work functions depend on the program setting (e.g.. institutional vs. free-standing facilities) and client resources (levels of psychological function, social and life skills).

Phase Format

The treatment protocol, or plan of therapeutic and educa¬tional activities, is organized into phases that reflect a developmental view of the change process. Emphasis is on incremental learning at each phase, which moves the indi¬vidual to the next stage of recovery.

TC Concepts

There is a formal and informal curriculum focused on teaching the TC perspective, particularly its self-help recovery concepts and view of right living. The concepts, messages, and lessons of the curriculum are repeated in the various groups, meetings, seminars, and peer conversa¬tions, as well as in readings, signs, and personal writings.

Peer Encounter Groups

The main community or therapeutic group is the encounter, although other forms of therapeutic, educational and support groups are utilized as needed. The minimal objective of the peer encounter is similar in TC-oriented programs¬ to heighten individual awareness of specific attitudes or behavioral patterns that should be modified. However, the encounter process may differ in degree of staff direction and intensity, depending on the client subgroups (e.g., ado¬lescents, prison inmates, the dually disordered).

Awareness Training

All therapeutic and educational interventions involve raising the individuals' consciousness of the impact of their conduct and attitudes on themselves and the social environment; and conversely the impact of the behaviors and attitudes of oth¬ers on themselves and the social environment.

Emotional Growth Training

Achieving the goals of personal growth and socialization involves teaching individuals how to identify feelings, express feelings appropriately, and manage feelings con¬structively through the interpersonal and social demands of communal life.

Planned Duration of Treatment

The optimal length of time for full program involvement must be consistent with TC goals of recovery and its developmental view of the change process. How long the individual must be program-involved depends on their phase of recovery, although a minimum period of inten¬sive involvement is required to assure internalization of the TC teachings.

Continuity of Care

Completion of primary treatment is a stage in the recovery
process. Aftercare services are an essential component in the TC model. Whether implemented within the bound¬aries of the main program or separately as in residential or nonresidential halfway houses or ambulatory settings, the perspective and approach guiding aftercare programming must be continuous with that of primary treatment in the TC. Thus the views of right living and self-help recovery and the use of a peer network are essential to enhance the appropriate use of vocational, educational, mental health, social and other typical aftercare or reentry services (De Leon, 1995a).

THE TC TREATMENT PROCESS

Understanding the process of change in the TC reflects its perspective and approach. A disorder of the whole person means that change is multidimensional. Thus change must be viewed along several dimensions of behavior, percep¬tions, and experiences. The main approach for facilitating change is the use of the community as method which con¬sists of multiple interventions. Recovery unfolds as devel¬opmental learning which can be described in terms of characteristic stages of change. Details of these process elements are provided elsewhere (e.g., De Leon, 1995a, 1995b; De Leon, in press).

Interventions

In the TC all of the activities are designed to produce ther¬apeutic or educational effects. These activities, singly and in various combinations, constitute interventions that directly and indirectly impact the individual in the change process. Indeed, it is this element of using every activity for teaching or healing that illustrates the meaning of com¬munity as method. The diverse activities of community that are basic to the TC model can be organized into three main classes of interventions: therapeutic/educative (e.g., individual counseling, groups, seminars), community enhancement (e.g., various communitywide meetings, cer¬emonies, rituals), community and clinical management (e.g., privileges, disciplinary sanctions).

Dimensions

Partitioning the "whole" individual into separate dimensions is a somewhat artificial device analogous to attempt¬ing to classify the TC milieu into separate interventions. Thus a complete description of change in the whole person includes both the objective behavioral dimensions as well as subjective changes reflected in self perceptions and experiences. These are separately discussed for purposes of clarity. Behavioral change is described along four broad dimensions that reflect the TC perspective. The dimen¬sions of community/member and socialization refer to the social development of the individual specifically as a member in the TC community and generally as a prosocial participant in the larger society. The developmental and psychological dimensions refer to the evolution of the individual as a unique person in terms of his or her basic psychological function, personal growth, and identity. Each dimension pictures the same individual from differ¬ent aspects in terms of observable behavioral indicators.
Subjective dimensions of change consist of essential client perceptions and experiences. How clients perceive their problems, their progress, peers, staff, the program environment, treatment demands, and the pushes and pulls from outside of the program compel contemplation and redecision to continue in the process, almost on a daily basis. These perceptions may be grouped under five domains: circumstances, motivation, readiness, suitability,and critical perceptions of self-change.
As with perceptions, a limited array of experiences are underscored that appear as necessary to the change process within the TC. These can be conceptualized under two dimensions: healing and learning. Healing refers to the various emotional experiences related to the others, such as nurturance-sustenance, physical and psychological safety, and social relatedness. Subjective learning experi¬ences refer to subjective outcomes on the theme of self¬efficacy and self-esteem that may occur.
Both healing and subjective learning experiences are interrelated in the process of individual change. Healing experiences are essential for engaging, affiliating and sus¬taining the individual in the peer community. Subjective outcomes are the basis of achieving internalized learning, that is, behavior change that is maintained by fewer exter¬nal consequences and is more under self-control.

Stages of Change

Stages and phases are definable points in the process. These can be described from two different but interrelated perspectives of change-program stages and treatment stages. Program stages refer to change in the four behav¬ioral dimensions described earlier, which picture the indi¬vidual's movement according to specific goals of the program. Three main program stages and several phases within each stage have been delineated for the traditional long-term process of TC: stage 1, induction/orientation; stage 2, primary treatment, 2-12 months; and stage 3, reentry, 13-24 months. For TCs with shorter planned dura¬tion of treatments, the length of each stage is correspond¬ingly shorter but the goals remain the same.
The treatment stages perspective more closely captures the evolving relationship between the individual and com¬munity. This evolution can be characterized in terms of levels of internalization-how much or completely the individual accepts, practices, and applies the behaviors, attitudes, values of the TC's teachings.
The mark of each stage of internalization is the trans¬fer of the influences on new learning from the external (objective) consequences to the internal (subjective) out¬come experiences of the individual. Internalized learning can be characterized as more stable and self-initiated ("inner directed") than as peer influenced ("outer directed") learning. Thus, as residents move through the program stages, four stages of internalization can be delin¬eated: compliance, conformity, commitment, and integra¬tion. Each stage reflects the gradual transfer from outer- to more inner-directed influences.
For TCs the importance of internalization is especially salient because the power of its community method can readily modify observable behaviors and attitudes in the program setting. However, these changes may not endure once the individual separates from the omnipresent influ¬ence of the peer community. Practically all residents in TCs display drug-free behavior during their residential stay. That relapse occurs among a number of the dropouts and some of the graduates, however, underscores the rele¬vance of internalization in the change process.

THERAPEUTIC COMMUNITY RESEARCH

328
SECTION V: TREATMENT

A considerable research literature on the TC has evolved since its inception some 30 years ago. Most studies have focused on description of the social and psychological pro¬files of TC admissions and evaluations of treatment effectiveness, through assessment of posttreatment outcomes. A smaller number of studies have been concerned with treat¬ment retention and treatment process. This section briefly summarizes the key findings and conclusions in each of these research areas.

Social Profiles

Clients in programs are usually male (70%-75%) but female admissions are increasing in recent years. Most com¬munity-based TCs are integrated across gender, race/ethnic¬ity and age, although the demographic proportions differ by geographic regions and in certain programs. In general, Hispanics, native Americans, and clients under 21 of age represent smaller proportions of admissions to TCs.
The majority of entries have histories of multiple drug use including marijuana, opiates, alcohol, and pills, although in recent years most report cocaine or crack as their primary drug of abuse. Most have poor work histories and have engaged in criminal activities at some time in their lives. Less than a third have had full-time jobs for more than 5 months and more than two thirds have been arrested (e.g., De Leon 1984; Hubbard, Valley-Rachal, Craddock, & Cavanaugh, 1984; Simpson & Sells 1982).
About a third of TC admissions are adolescents, although some programs serve adolescents exclusively. Over 70% have dropped out of school and more than 70% have been arrested at least once or involved with the crim¬inal justice system. Compared to adults, more adolescents have histories of family deviance; more have had treatment for psychological problems; and more are legally referred to TC treatment (De Leon & Deitch 1985; Holland & Griffen, 1984; Jainchill, Battacharya, & Yagelka, 1995; Pompi, 1994). These social profiles of admissions to tradi¬tional TC programs are similar regardless of drug prefer¬ence. They do not differ significantly from client profiles in special TC facilities implemented exclusively for cer¬tain populations such adolescents, females, ethnic minori¬ties, and criminal justice referrals.

Psychological Profiles

Clients differ in demography, socioeconomic background, and drug-use patterns but psychological profiles obtained with standard instruments appear remarkably uniform, as evident in a number of TC studies (e.g., Barr & Antes, 1981; Biase, Sullivan, & Wheeler, 1986; Brook & Whitehead, 1980; De Leon, 1989; De Leon, Skodol, & Rosenthal, 1973; Holland, 1986; Jainchill, 1994; Kennard & Wilson, 1979; Zuckerman, Sola, Masterson, & Angelone, 1975).
The psychological profiles reveal drug abuse as the prominent element in a picture that mirrors features of both psychiatric and criminal populations. For example, the character disorder characteristics and poor self-concept of delinquent and repeated offenders are present, along with the dysphoria, depression, anxiety, and confused thinking of emotionally unstable or psychiatric populations.

Psychiatric Diagnoses

There are a few recently completed diagnostic studies of admissions to the therapeutic community utilizing the diagnostic interview schedule (DIS). In these, over 70% of the admission sample revealed a lifetime nondrug psychi¬atric disorder in addition to substance abuse or dependence. A third had a current or continuing history of men¬tal disorder in addition to their drug abuse. The most fre¬quent non-drug diagnoses were phobias, generalized anxiety, psychosexual dysfunction, and antisocial person¬ality. There were only a few cases of schizophrenia but lifetime affective disorders occurred in over a third of those studied (De Leon, 1989; Jainchill, 1994; Jainchill, De Leon, & Pinkham 1986). Studies utilizing a structured diagnostic interview schedule for children (DICA) reveal comparable percentages of dual disorder among adoles¬cent admissions to TCs (Jainchill et al., 1995).
The psychological profiles vary little across age, sex, race, primary drug, or admission year and are not signifi¬cantly different from drug abusers in other treatment modalities. Thus, in addition to their substance abuse and social deviance, the drug abusers who enter TCs reveal a considerable degree of psychological disability a conclu¬sion confirmed in the diagnostic studies. Despite the TC's policy concerning psychiatric exclusion, the large majority of adult and adolescent admissions meet the criteria for coexisting substance abuse and other psychiatric disorders.

Treatment Effectiveness

A substantial evaluation literature documents the effec¬tiveness of the TC approach in rehabilitating drug abusers (e.g., Anglin & Hser, 1991; Condelli & Hubbard, 1994; De Leon, 1984, 1985; Hubbard et al., 1984; Institute of Medicine Report, 1990; McCusker et al., 1995; Simpson & Sells, 1982, 1990; Tirns, De Leon, & Jainchill, 1994; Tims & Ludford, 1984). The main findings on short- and long-term posttreatment followOup status from single-pro¬gram and multiprogram studies are reviewed.
Significant improvements occur on separate outcome variables (drug use, criminality, and employment) and on composite indices for measuring individual success. Maximum to moderately favorable outcomes (based on opioid, nonopioid and alcohol use; arrest rates; retreat¬ment; and employment) occur for more than half of the sample of completed clients and drop-outs (De Leon, 1984; Hubbard et al., 1989; Simpson & Sells, 1982).
There is a consistent positive relationship between time spent in residential treatment and posttreatment outcome status. For example, in long-term TCs, success rates (on composite indices of no drug use and no criminality) at 2¬years posttreatment approximate 90%, 50%, and 25%, respectively, for graduates/completers and dropouts who remain more than and less than one year in residential treatment, and improvement rates over pretreatment status approximate 100%, 70% and 40% respectively (De Leon, Jainchill, & Wexler, 1982).
In a few studies that investigated psychological out¬comes, results uniformly showed significant improvement at follow-up (e.g., Biase et aI., 1986; De Leon, 1984; Holland, 1983). A direct relationship has been demon¬strated between posttreatment behavioral success and psy¬chological adjustment (De Leon, 1984; De Leon & Jainchill, 1981-1982).
The outcome studies reported were completed on an earlier generation of chemical abusers, primarily opioid addicts. Since the early 1980s, however, most admissions to residential TCs have been multiple drug abusers, pri¬marily involving cocaine, crack, and alcohol, with rela¬tively few primary heroin users (e.g., De Leon, 1989). New studies are needed to evaluate the effectiveness of the TC for this recent generation of abusers. In this regard two large-scale evaluation efforts funded by the National Institute on Drug Abuse are underway: the Drug Abuse Treatment Outcome Study (DATOS) and the multisite pro¬gram of research carried out in a recently established Center for Therapeutic Community Research (CTCR).

Retention

Drop-out is the rule for all drug treatment modalities. For therapeutic communities, retention is of particular impor¬tance because research has established a firm relationship between time spent in treatment and successful outcome. However, most admissions to therapeutic community pro¬grams leave residency, many before treatment influences are presumed to be effectively rendered.
Research on retention in TCs has been increasing in recent years. Reviews of the TC retention research are con¬tained in the literature (e.g., De Leon, 1985, 1991; Lewis & Ross, 1994). Studies focus on several questions, reten¬tion rates, client predictors of dropout, and attempts to enhance retention in treatment.

Retention Rates

Dropout is highest (30% to 40%) in the first 30 days of admission, but declines sharply thereafter (De Leon, 1985). This temporal pattern of dropout is uniform across TC programs (and other modalities). In long-term residen¬tial TCs, completion rates average 10% to 20% of all admissions. One-year retention rates range from 15% to 30%, although more recent trends suggest gradual increases in annual retention compared to the period before 1980 (De Leon, 1991).

Predictors of Dropout

There are no reliable client characteristics that predict retention, with the exception of severe criminality andlo:r severe psychopathology, which are correlated with earlieJr dropout. Recent studies point to the importance of dynamic factors in predicting retention in treatment, such as perceived legal pressure, motivation and readiness for treatment (e.g., Condelli & De Leon, 1993; De Leon. 1988; De Leon, Melnick, Kressel, & Jainchill, 1994; Hubbard, Collins, Valley-Rachal, & Cavanaugh, 1988).

Enhancing Retention in TCs

Some experimental attempts to enhance retention in TCs have utilized supportive individual counseling, improved orientation to treatment by experienced staff ("Senior Professors") and family alliance strategies to reduce early dropout (e.g., De Leon, 1988, 1991). Other efforts provide special facilities and programming for mothers and chil¬dren (Hughes et al., 1992; Stevens, Arbiter, & Glider, 1989; Stevens & Glider, 1994) and curriculum-based relapse prevention methods (Lewis, McCusker, Hindin. Frost, & Garfield, 1993) to sustain retention throughout residential treatment. Though results are promising, these efforts require replication in multiple sites.
Although it is a legitimate concern, retention should not be confused with treatment effectiveness. Therapeutic communities are effective for those who remain long enough for treatment influences to occur. Obviously, how¬ever, a critical issue for TCs is maximizing holding power to benefit more clients.

Treatment Process

The area of TC treatment process is still relatively under¬investigated. Research in progress grounded in the above theoretical framework conceptualizes process as the inter¬action between TC elements and client factors to produce change in treatment. Studies to date have focused on two areas: empirical specification of the essential elements of the TC and assessment of client motivational and readiness factors. The main findings from these studies are briefly summarized.

Essential Elements

The extent to which the current diversity of programs actu¬ally incorporates the essential elements of the TC model and method is not completely known. However, the Center for Therapeutic Community Research (CTCR) in collaboration with Therapeutic Communities of America (TCA) have recently assessed this important question with a national survey of member programs in TCA. Information was obtained with the Survey of Essential Elements Questionnaire (SEEQ) an instrument based on the previ¬ously described theoretical framework. Approximately 60 program directors representing 80% of the member pro¬grams rated the "essentiality" ofTC elements. Results show extremely high consensus rates on all elements providing impressive empirical validation for the theoretical frame¬work (CTCR Newsletter, 1996; Melnick & De Leon, 1992). Clarification of the diversity of TCs has broad implications for treatment, policy, and research such as in the areas of staff training, client matching, quality assurance, and man¬aged care, as well as in evaluating the comparative effec¬tiveness and cost benefits of TC-oriented programs.

Motivation and Readiness

 

Unlike fixed client characteristics such as social back¬ground or demography, dynamic variables such as client perceptions continually interact with the treatment and nontreatment influences in the change process. Studies to date have been based upon an instrument measuring client perceptions in terms of four dimensions: circumstances (external pressures), motivation (intrinsic pressures), readiness for treatment, and suitability for TC approach (CMRS). Results show that CMRS scores are the most consistent predictors of early dropout in both adults and adolescents admissions to TCs (e.g., De Leon et al., 1994; Melnick, De Leon, Hawke, Jainchill, & Kressel, 1996).

MODIFICATIONS AND ADAPTATIONS OF THE TC MODEL AND APPROACH

Currently an increasing diversity of programs view them¬selves as TCs. Today the TC modality consists of a wide range of programs serving a diversity of clients who use a variety of drugs and present complex social-psychological problems in addition to their chemical abuse. Client differ¬ences, as well as clinical requirements and funding realities, have encouraged the development of modified residential TCs with shorter planned duration of stay (3, 6, and 12 months) as well as TC-oriented day treatment and outpatient ambulatory models. Correctional, medical, and mental hospi¬tals, community residence and shelter settings, overwhelmed with alcohol and illicit drug abuse problems, have imple¬mented TC programs within their institutional boundaries. The following sections summarize the main modifications of the TC approach and applications to special populations.

Current Modifications of the TC Model

Most community-based traditional TCs have expanded their social services or incorporated new interventions to address the needs of diverse admissions. In some cases these addi¬tions enhance but do not alter the basic TC regime; in oth¬ers they significantly modify the TC model itself.

Family Services Approaches

The participation of families or significant others has been a notable development in TCs for both adolescents and adults. Some TCs offer programs in individual and multi¬ple family therapy as components of their adolescent pro¬grams, nonresidential, and (more recently) short-term residential modalities. However, most traditional TCs do not provide a regular family therapy service because the client in residence is viewed as the primary target of treat¬ment rather than the family unit.
Experience has shown that beneficial effects can occur with forms of significant-other participation other than family therapy. Seminars, support groups, open house, and other special events focus on how significant others can affect the client's stay in treatment; they teach the TC per¬spective on recovery and provide a setting for sharing common concerns and strategies for coping with the client's future re-entry into the larger community. Thus family participation activities enhance the TC's rehabilita¬tive process for the residential client by establishing an alliance between significant others and the program.

Primary Health Care and Medical Services

331
Although funding for health care services remains insuffi¬cient for TCs, these agencies have expanded services for the growing number of residential clients with sexually trans¬mitted and immune-compromising conditions including HIV seropositivity, AIDS, syphilis, hepatitis B, and recently tuberculosis. Screening, treatment, and increased health education have been sophisticated, both on site and through linkages with community primary health care agencies.

Aftercare Services

Currently, most long-term TCs have linkages with other service providers and 12-step groups for their graduates. However, TCs with shorter term residential components have instituted well-defined aftercare programs both within their systems and through linkages with other non¬TC agencies. There are limits and issues concerning these aftercare efforts concerning discontinuities between the perspectives of the TC and other service agencies. These are outlined in the last section of this chapter and are dis¬cussed in other writings (De Leon, 1990-1991).

Relapse Prevention Training (RPT)
Based on its approach to recovery, the traditional TC has always focused on the key issues of relapse prevention. The 24-hour TC communal life fosters a process of learn¬ing how to resist drug taking and negative behavior. In its social learning setting the individual engages many of the social, emotional, and circumstantial cues for, and influ¬ences on, drug use that exist in the larger macrosociety. This broad context of social learning essentially provides a continual relapse-prevention training (De Leon, 1991).
Currently, however, a number of TCs include special workshops on relapse prevention training (RPT) utilizing the curriculum, expert trainers and formats developed out¬side the TC area (e.g., Marlatt & Gordon, 1985). These workshops are offered as formal additions to the existing TC protocol, usually in the re-entry stage of treatment. However, some programs incorporate RPT workshops in earlier treatment stages, and in a few others RPT is central to the primary treatment protocol (e.g., Lewis et al., 1993). Clinical impressions supported by preliminary data of the efficacy of RPT within the TC setting are favorable, although rigorous evaluation studies are still in progress (Lewis et al., 1993; McCuskor et al., 1995).

12-Step Components

Historically TC graduates were not easily integrated into AA meetings for a variety reasons (De Leon, 1990--1991). In recent years, however, there has been a gradual inte¬gration of AA/NAICA meetings during and following TC treatment, given the wide diversity of users socially and demographically and the prominence of alcohol use regardless of the primary drug. The common genealogi¬cal roots found in TCs and the 12-step groups are evident to most participants of these, and the similarities in the self-help view of recovery far outweigh the differences in specific orientation. Today, 12-step groups may be intro¬duced at any stage in residential TCs, but are considered mandatory in the re-entry stages of treatment: in the aftercare or continuance stages of recovery after leaving residential setting.

Mental Health Services

Among those seeking admission to TCs, increasing num¬bers reveal documented psychiatric histories (e.g., Jainchill, 1994; Jainchill et al., 1986; Jainchill, De Leon, & Yagelka, unpublished manuscript). Certain subgroups of these clients are treated within the traditional TC model and regime, which requires some modification in services and staffing. For example, psychopharmacological adjuncts and individual psychotherapy are utilized for selected clients at appropriate stages in treatment. Nevertheless, the tradi¬tional community-based TC models still cannot accommo¬date the substance abuser with serious psychiatric disorder. As described later in the section on mentally ill chemical abusers, the primary psychiatric substance abuser requires specially adapted forms of the TC model.

The Multimodal TC and Client-Treatment Matching

Traditional TCs are highly effective for a certain segmen1 of the drug abuse population. However, those who seek assistance in TC settings represent a broad spectrum of clients, many of whom may not be suitable for long-tern:: residential stay. Improved diagnostic capability and assessment of individual differences has clarified the need for options other than long-term residential treatment.
Many TC agencies are multimodality treatment centers that offer services in their residential and nonresidential programs, depending on the clinical status and situation needs of the individual. Modalities include short (under 90 days), medium (6-12 months), and long-term (1-2 years I residential components, drug-free outpatient services (6¬-12 months). Some operate drug-free day treatment and methadone maintenance programs. Admission assessment attempts to match the client to the appropriate modality within the agency. For example, the spread of drug abuse in the workplace, particularly in cocaine use, has prompted the TC to develop short-term residential and ambulatory models for employed, more socialized clients.
As yet, the effectiveness of TC-oriented multimodality programs has not been systematically evaluated, although several relevant studies are currently under way. Of partic¬ular interest is the comparative effectiveness and cost ben¬efits of long- and short-term residential treatment. To date however, there is no convincing evidence supporting the effectiveness of short-term treatment in any modality, res¬idential or ambulatory.
Given what is known about the complexity of the recovery process in addiction and the importance of length of stay in treatment, there is little likelihood that shorter term residential treatment alone will be sufficient to yield stable positive outcomes. In the multimodal TCs, combi¬nations of residential and outpatient services are needed to provide a long-term treatment involvement and impact.

Current Applications of Residential TCs for Special Populations

The evolution of the TC is most evident in its application to special populations and special settings. It is much beyond the purview of this chapter to detail the modifica¬tions of these adapted TC models. In the main examples of these, the mutual self-help focus is retained along with basic elements of the community approach, meetings, groups, work structure, and perspective on recovery and right living. This section highlights some of the key appli¬cations of the TC treatment approach for different client populations in different settings.

TCs for Adolescents

The prominence of youth drug abuse and the unique needs of the adolescent has led to adaptations of the traditional TC approach that appear more appropriate for these clients. These include age-segregated facilities with considerable emphasis on management and supervision, educational needs, family involvement, and individual counseling. More extensive accounts of the treatment of adolescents in TCs and effectiveness are contained in other writings (e.g., De Leon & Deitch, 1985; Jainchill et al., 1995; Pompi, 1994).

Addicted Mothers and Children

Several TCs have adapted the model for chemically depen¬dent mothers with their children. The profile of the addicted mother in residence is generally not different from other abusers, although it reflects more social disad¬vantage, poor socialization, and a predominance of crack/cocaine abuse. Most evident is that these women need a lifestyle change and an opportunity for personal maturation. Thus, within the context of the basic TC regime, additional services and modifications are provided that address their specific needs and those of their recov¬ery. These include family unit housing for mothers and children, medical and psychological care, parental train¬ing, and child care. Further accounts of clinical issues in TC programs for females in general and addicted mothers in particular are contained in other writings (e.g., Jainchill & De Leon, 1992; Hughes et aI., 1992; Stevens et aI., 1989; Stevens & Glider, 1994).

TCs for Incarcerated Substance Abusers

In recent years TC models have been adapted for incarcer¬ated substance abusers in prison settings. This develop¬ment has been fostered by overcrowded prisons, the influx of drug offenders, and the documented success of an early TC prison model in reducing recidivism to crime and relapse to drug use (Lockwood & Inciardi, 1993; Wexler & Williams, 1986). Modifications of the TC model are shaped by the unique features of the correctional institu¬tion, for example, its focus on security, its goal of early release, its limited physical and social space, and the prison culture itself.
Nevertheless, a peer-managed community for social learning is established for the inmates who volunteer for the program. A prominent feature of the modified prison model is the mutual involvement of correctional officers and prison administrators and mental health and TC treat¬ment paraprofessionals. For inmates who leave these prison TCs, models for continuance of recovery have recently been established outside the walls in TC-oriented halfway houses.

TCs for Mentally Ill Chemical Abusers

Special TC-adapted models have been developed to exclu¬sively treat the more seriously disturbed mentally ill chem¬ical abusers (i.e., MICA clients). Several of these have been developed by community-based TC agencies as spe¬cial programs in separate facilities; others have been implemented as innovative research demonstration pro¬jects in mental hospitals (e.g., Galanter, Franco, Kim, Jamner-Metzger, & De Leon, 1993), and in community residence settings for the homeless mentally ill chemical abuser (e.g., De Leon, 1993; Rahav et aI., 1994; Sacks, De Leon, Bernhardt & Sacks, in press).
In these models for the dually disordered the basic peer orientation and elements of the daily regime are retained, although there is more focus on individual differences that is evident in a greater flexibility in planned duration of stay, the structure, and phase format. Specific modifica¬tions include the standard psychotropic medication regime, moderated intensity of groups, a less demanding work structure, significant use of individual psychother¬apy, case management, and skills training.

TCs and HIV

Therapeutic communities have evolved a sophisticated response to the HIV/AIDS epidemic since its identifica¬tion in the early and mid 1980s. Special AIDS/HIV-ori¬ented programs are now the rule in most well-managed TCs. These integrate AIDS and HIV seropositive clients into the regular daily regime; they address the special issues of HIV, including education, pretest and posttest counseling for HIV testing, confidentiality concerning dis¬closure, and support through medical crises. These special programs are directed to the target residential client as well as significant others. Programs include individual and group formats for counseling on sexual practices and on drug and alcohol use behavior and for contact notification. Some TCs have innovated special residential models serv¬ing AIDS clients exclusively.
The effectiveness of the TC for special populations has not yet been sufficiently evaluated. Currently, however, multisite studies of adolescents are under way in various adaptations of the community-based TC (Etheridge, 1994; Jainchill et al., 1995); inmates in prison TCs (Knight, Simpson, Chatham, & Camacho, unpublished manuscript; Lockwood & Inciardi, 1993; Wexler & Graham, 1994); mentally ill chemical abusers (Rahav et aI, 1994; Sacks et al., in press); addicted mothers with their children (Stevens
& Arbiter, 1995; Hughes et al., 1992); and though not described, methadone clients in a day treatment TC model (De Leon et aI., 1994).
The modifications of the traditional residential model and its adaptation for special populations and settings are redefining the TC modality within mainstream human and mental health services. However, changes in clients, services and staffing along with conservative funding policies have also uncovered complex issues for TCs that relate to the TC's drug-free philosophy and its self help perspective. These issues represent ongoing challenges to the integrity of the TC approach itself. However, the advances in program adapta¬tion, theory, research and training demonstrate the flexibility and maturity of the TC in meeting these challenges.

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