By: Valerie J.
Slaymaker, Kirk J. Brower and Mike Crawford
‘‘Therapeutic community’’ (TC) is a term that was first applied in the United Kingdom in the early 1950s to describe a newly developed treatment method for psychiatric inpatients. As a form of substance abuse treatment, therapeutic communities (TCs) were developed independently by recovering individuals with substance use disorders as a mutual self-help alternative to traditional medical and psychiatric treatment approaches (De Leon, 2004).
‘‘Therapeutic community’’ (TC) is a term that was first applied in the United Kingdom in the early 1950s to describe a newly developed treatment method for psychiatric inpatients. As a form of substance abuse treatment, therapeutic communities (TCs) were developed independently by recovering individuals with substance use disorders as a mutual self-help alternative to traditional medical and psychiatric treatment approaches (De Leon, 2004).
TCs are highly structured hierarchical settings in which
members of the community progress through a series of stages characterized by their length
in treatment, motivation and commitment, status in the TC, and achievement of
specific goals.
Individuals in TCs are viewed as community members or residents, rather than
patients or clients. The TC is a self-operating, working environment in which cooking,
cleaning, and repairs
within its expertise are performed by member residents. Community status such as junior,
intermediate, or senior
peer resident is assigned according to length and progress in treatment. Junior
members perform the most basic or menial tasks
and advance through the ranks over
time to become senior members who serve as role models, conduct house meetings and lead peer encounter
groups, and provide support and confrontation to more junior members. Community
rules and expected conduct are
clearly defined. Contingency management is utilized such that adherence to
rules and treatment expectations are rewarded with an increase in
privileges and community
status, whereas rule violations are sanctioned by loss
of privileges and status which can be regained with appropriate behavior and therapeutic progress. Early in
treatment, motivation may be mostly external in origin, and members comply with the rules primarily to avoid
sanctions or discharge. Later in treatment, members may conform to community
rules because
they actively seek affiliation with the community. In the final stages of
treatment, members are ideally motivated by their commitment to enhance the
community and
provide leadership.
TCs are widely used in the USA over 500 member treatment
programs belong to Therapeutic Communities of America (TCA), a non-profit
association established in 1975 to represent therapeutic communities in the
United States
and Canada (TCA, 2005). The American Psychiatric Association’s Practice Guideline for the Treatment of
Patients with Substance Use Disorders,
2nd edn (APA, 2006, p. 15) notes the utility of TCs when patients with
opioid, cocaine or multiple substance use disorders do not benefit from less
intensive treatment
settings, but does not specifically recommend TCs for patients with only
alcohol use disorders.
The VA/DOD (2001) Clinical Practice
Guideline Summary for the Management of Substance Use Disorders does not mention therapeutic communities specifically, although it does specify
‘24-Hour Supervision’ as a housing option in which supervision is provided by
other patients,
volunteers, and paraprofessionals. It also specifies homelessness, lack of
social supports and an inability to maintain abstinence without supervision as
indications for
this level of care.
Therapeutic Communities for substance use disorders can be broadly categorized by chronology into ‘traditional’ and ‘modified’ TCs.
Traditional TCs
Traditional TCs emerged in the 1960s and refer to abstinence-based residential treatment programs of 15–24 months in duration (De Leon, 2004). The traditional TCs served mostly male heroin-dependent individuals without serious Axis I psychiatric disorders. As such, study findings of the effectiveness of traditional TCs may not generalize well to alcohol-dependent patients, but are included here for background information and because traditional TCs are better studied than modified TCs.
The evidence for the effectiveness of traditional TCs comes primarily from
naturalistic treatment outcome studies (DeLeon, 2004). As is generally
consistent with such studies, time in treatment is positively correlated
with good outcomes. DeLeon (2004)
cites ‘success rates’ (defined as a composite index of neither substance use nor criminal activity)
as 90% for patients who complete treatment, 50% for those who remain in treatment for
at least 1 year, and 25%
for those who stay less than 1 year. Unfortunately, retention rates at 1 year are about
20–35%. Therefore,
using an intent-to-treat computation, 10–18% of patients are successful.
Nevertheless, traditional TCs typically accept patients with high-severity substance
use disorders
that are characterized by criminality and Axis II psychopathology, all of which
portend poor outcomes.
Modified TCs
Beginning in the 1980s with the emergence of the crack cocaine epidemic in the USA, the addicted population shifted and included more individuals with cocaine dependence and poly-substance dependence, both of which are frequently associated with heavy alcohol consumption and alcohol-related problems. As programs became more integrated, individuals with severe, chronic, and treatment-resistant forms of alcohol dependence, who required global lifestyle changes, were also accepted into TCs even in the absence of other drug use disorders.
Around the same time, TCs were modified to make them more widely available by
reducing costs and accommodating special populations. Costs were reduced by
introducing TC concepts and treatment methods into shorter stay residential programs
(3–12 months) and non-residential outpatient programs (e.g. partial hospital and other
abstinence-based outpatient programs as well as methadone maintenance programs).
Recommended lengths of treatment in abstinence-based outpatient TCs range from
6 to 12
months (De Leon, 2004). Special populations have included incarcerated
individuals, addicted mothers and their children, individuals with co-occurring
psychiatric disorders,
and adolescents.
Outcomes of modified TCs were first published in the
late 1990s and also demonstrate effectiveness (Hubbard et
al., 1997; Simpson et
al., 1997), especially for patients with
lower problem severity in shorter stay programs (Melnick et
al., 2000).
References
Peter
Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in
Psychiatry, Cambridge University Press 2008.
No comments:
Post a Comment