The Therapeutic Community Approach: Essential Elements and Adaptations for Special Populations and Settings. GEORGE DE LEON Ph.D. Center for Therapeutic Community NDRI Clinical Professor of Psychiatry; NYU School of Medicine Presented at FADAA/FCCMH ANNUAL CONFERENCE AUG 7-9, 2013, ORLANDO, FLORIDA

2 The TC: A Recovery Oriented Approach Emerged from the Substance Abusers themselves. TCs serve the most serious substance abusers; Severity of Substance abuse, psychological dysfunction and social deviancy). TCs address the disorder of the whole person and focus on recovery goals: changes in lifestyle and identities.

3 View of Disorder  Cognitive, behavioral, emotional, medical, social and spiritual problems Physical dependency must be seen within the context of the individual’s psychological status and life style Problem is the person, not the drug The Therapeutic Community Perspective Four Interrelated Views Drug abuse is a disorder of the whole person involving some or all the areas of functioning.

4 View of the Person  Rather than drug use patterns, individuals are distinguished along dimensions of psychological dysfunction and social deficits. The Therapeutic Community Perspective Some shared characteristics: Poor tolerance for frustration, discomfort, delay of gratification Low self-esteem Problems with authority Problems with responsibility Poor impulse control Unrealistic Difficulty coping with feelings Dishonesty, manipulation, self-deception Guilt (self, others, community) Deficits (reading, writing, attention, communication)

5 View of Recovery  The goals of treatment are global changes in lifestyle and identity. The Therapeutic Community Perspective Some assumptions about recovery: Recovery is developmental learning Self-help and mutual self-help Motivation Social learning Treatment is an episode in the recovery process

6 View of Right Living  Certain precepts, beliefs and values as essential to self-help recovery,, personal growth and healthy living.. The Therapeutic Community Perspective Some examples: Truth/Honesty (in Words and in Actions) Here and Now (Living in the present) Personal Responsibility for their recovery and life style Social Responsibility ("Brother's/Sister's Keeper") Work ethic (Economic self reliance, standards of excellence) Moral Code Concerning Right and Wrong Behavior Inner Person is "Good", but Behavior Can be "Bad"

7 The TC Approach: Community As Method  The purposive use of community to teach individuals to use the community to change themselves.

8 Community as Method Four interrelated components Community is the context of peer and staff relationships, and the daily regimen of activities. Community sets the expectations for individual’s participation. Community assesses the individual’s progress in meeting these expectations. Community responds to individual’s meeting expectations.

9 Community, the individual and the Process of Change  Individuals use the context and expectations of the community to learn and change. Meeting community expectations requires continual self change in behaviors, attitudes and emotional management. Avoidance of, or difficulties in, meeting community expectations also results in individual growth through continual self examination, re-motivation to engage in the trial and error learning and re-commitment to the change process.

10 Community, the individual and the Process of Change  Thus, in striving to meet community expectations for participation residents pursue their individual goals of socialization and psychological growth.  This process is summarized in the phrase: if you participate, then you will change.

11 Components of a Generic TC Program Community separateness A community environment Community activities Staff roles and functions Peers as role models A structured day Work as therapy and education Phase format TC concepts Peer encounter groups Awareness training Emotional growth training Planned duration of treatment Continuity of care * * *

12 TC: SPECIAL POPULATIONS TC APPROACH AND MODEL HAS BEEN ADAPTED AND MODIFIED FOR VARIOUS POPULATIONS.

13 Variants of TCs The extent to which the program is guided by TC perspective and approach (Communty as Method)  Standard TCs: Guided by perspective and method but may incorporate other evidence informed practices to enhance community as method.)  Modified TCs: Guided by TC perspective and method but adapted for special populations and settings. Incorporates special services ( eg., mental health, medicational, other health services).  TC Oriented; Not guided by TC perspective or community as method.Uses selected elements of the TC (eg. a community meeting, peer support group etc) but mainly services and practices not specific to the TC.

14 Current Modifications of the TC Model  Treatment Twelve-step components Mental health services Other Evidence Based Practices (CBT, MET, RPT, DBT) Contingency contracting Pharmacotherapy Family Therapies  Social and Health Services Family services approaches Primary health care and medical services Aftercare services Vocational, Educational, Housing

15 Current Applications for Special Populations and Settings Special Populations Adolescents, Juvenile Justice clients Addicted mothers and children Incarcerated substance abusers Mentally ill chemical abusers AIDS- and HIV-seropositive clients Elderly substance abusers Methadone maintained clients Special Settings Prisons, jails, Community Correctional facilities Hospitals, day treatment clinics, methadone clinics Homeless Shelters, Halfway Houses, Alternative schools

16 General Summary of Modifications of TC Practices and Program Elements for Special Populations and Settings  The treatment goals, planned duration of treatment, flexibility of the program structure and in the intensity of peer interactions all accommodate individual differences.  Successful implementation of TC program models within special settings requires accommodation to the goals, procedures, personnel, general practices, and restrictions of these settings.  Special services and interventions are integrated into the program as supplemental to the primary TC treatment (Community as method).

17 General Guidelines of Adaptations of the TC  Adhere to the perspective on recovery and right living and to the fundamental approach—community as method.  Retain basic components of the generic model including its social organization, work structure, daily schedule of meetings, groups, seminars and recreational activities and program phases.  Integrate the variety of staff conceptually in the TC perspective and approach through intensive and continuous cross training.

TC : An Evidence Based Approach The main findings and conclusions are summarized from multiple sources of research: Field outcome studies, controlled/comparison studies, meta-analytic surveys, cost benefit analyses and indirect evidence from outside of TCs

Evidence: Field Effectiveness Studies Main Conclusions  Who comes for treatment? Profiles of Admissions are the most severe.  What are the success rates? Individuals change during and following treatment.  Does Treatment “Dosage” relate to Outcomes? Retention consistently predicts outcomes.

Retention and Outcomes

BEHAVIORAL AND PSYCHOLOGICAL OUTCOMES: 5 YEARS AFTER TC TREATMENT MALE OPIATE ADDICTS: DROPOUTS (N=110)

Modified TCs for Special Populations Main Findings and Conclusions  Provide a positive cost benefit compared to traditional approaches in correctional settings, mental health facilities, shelters.  Improvements occur on both behavioral (drug use, criminality and employment) and mental health status (eg., symptoms, re-hospitalization, adherence to medications, health care).  Sources: TIPS 42, 44, De Leon, 2008

23 Indirect Evidence Evidence Based Principles within TCs  Although TCs emerged outside of mainstream social science and mental health, familiar social psychological principles are evident.  Evidence based learning principles in TCs: social role training, vicarious learning, behavior modification  These are naturalistically mediated through Community as method.

24 Indirect Evidence (TC practices and elements supported by research outside the TC)  Peer mentoring; Peer Role modeling, tutoring  CBT, RPT,TC concepts: Topics in Peer/staff Seminars  “Therapeutic Alliance”: The individual’s relationship with the community rather than with a specific therapist:  Motivational enhancement: Group process focus on problem identification and desire to change: Role Models who illustrate motivation in attitude and behaviors.  Goal Attainment: The TC Program Stages and Phases

25 TC is an Evidenced Based Treatment  “Weight” of the research evidence from all sources supports the conclusion that the TC is an effective and cost effective treatment for certain subgroups of substance abusers, particularly those with severe drug use, social and psychological problems.  Evidenced based social psychological principles and practices are embedded within Community as method. (Indirect Evidence)  Other Evidenced informed strategies can be incorporated to enhance, not substitute for, community as method, the primary approach.

26 Suggested References Books, Chapters, Articles De Leon, G. (2000). The Therapeutic Community: Theory, Model, and Method. New York: Springer Publishing Company. New York (English, Spanish, Portuguese, Norwegian, Polish) De Leon, G. (Ed.). (1997). Community as Method: Therapeutic Communities for special populations and special settings. Westport, CT: Greenwood Publishing Group, Inc. Now ABC-CLIO LLC. Santa Barbara. Ca. De Leon, G. (2008). Therapeutic communities. In M. Galanter, & H.D. Kleber (Eds.), The American Psychiatric Publishing textbook of substance abuse (4 th Edition, pp ). Washington, DC: American Psychiatric Publishing, Inc. De Leon, G.(2010) Is the Therapeutic Community an Evidenced Based Treatment? What the Evidence Says. International Journal of Therapeutic Communities 31, 2, summer

27 Suggested References Videos (De Leon) Stages of Recovery (2005). Center for Criminality and Addictions Research (CCARTA) University of California, San Diego UCSD The Therapeutic Community:(2005) Volume 1 The Therapeutic Community Perspective; The Therapeutic Community Training Series. Amity Foundation Psychotherapy.net. The Therapeutic Community:(2005) Volume 2. Community as Method; The Therapeutic Community Training Series. Amity Foundation. Psychotherapy.net The Therapeutic Community:(2005) Volume 3 Components of a Generic Therapeutic Community.The Therapeutic Community Training Series. Amity Foundation.Psychotherapy.net