The University of Georgia Therapeutic Communities in the USA: A Dynamic Present and a Challenging Future Paul M. Roman, Ph.D. The University of Georgia This research is supported by the National Institute on Drug Abuse (R01-DA-14976)

The University of Georgia TCs in the American Treatment System Our key research questions: –What are the characteristics of programs across the United States that identify themselves as TCs? –What are the distinctions between those that follow the traditional residential model vs. modified TCs? –To what extent do these TCs endorse the ideological components of the classic TC model? –What major issues face American TCs in the future?

The University of Georgia Overview Features TCs are a growing sector of American treatment They are becoming increasingly integrated They have a unique model of treatment that should be recognized as a “evidence based practice”

The University of Georgia Challenges The issue of continuing strength of organizations of TCs promoting the integrity and importance of the TC model Adjusting funding to a comprehensive, “whole person” model Maintaining the core technology of TCs while adapting realistically to change.

The University of Georgia Project Design Features This study is a nationally representative sample of community-based self-identified therapeutic communities in the US The panel longitudinal design has several elements –Initial wave of on-site interviews with program administrators –Data also collected via:  Mailback questionnaires with program administrators  Mailback questionnaires with counselors  Follow-up telephone interviews at 6, 12, and 18 months to track changes in service delivery –Follow-up wave of data collection from program administrative staff to be completed in Fall 2006 –Follow-up data collection about 70 percent complete

The University of Georgia Research Design: Sample Construction Constructing a nationally representative sample of TCs was achieved using a two-stage design: –Creation of 10 strata of US counties based on population –Random sampling of US counties to be representative of the US population –Identification of all possible substance abuse treatment centers in those counties using SAMHSA’s national directory of substance abuse facilities and directories provided by all 50 state substance abuse directors –Centers were randomly selected from the 10 strata for telephone screening

The University of Georgia Research Design: Screening for Eligibility Telephone screening collected information about center’s eligibility for the study All TCs were required to be community-based Central criterion for inclusion was that the program self-identified as a therapeutic community –This allows for measurement of the range of programs that identify as TCs –On-site interview contains measures to examine the extent to which these organizations fit DeLeon’s model of TCs –Centers removed if identity as TC was in error

The University of Georgia Diversity of TCs in the Sample The independent units of the larger multi-site TC organizations were included in the sampling frame There is 57 units of these multi-site organizations in the sample This represents 15 percent of the sample; 85 percent are not part of large multi-site systems

The University of Georgia Distribution of TC Age

The University of Georgia A Look at TC Ownership Government Owned 8.5% Hospital <1% Individual 6.6% Religious Order 4.0% University <1% Private Foundation 29.4% Board of Directors 26.0% 503(c) non-profit corporations 24.4%

The University of Georgia Organizational Size in FTEs

The University of Georgia Services Offered at National Sample of 380 TCs Residential (90% offer some form) Long-term (>180 Days) 44.5 Six-month 36.8% Three-month 30.3% Short-term (< 30 days) 18.4%

The University of Georgia Services Offered at National Sample of 380 TCs (cont’d) Outpatient –Partial Hospitalization (at least 20 hours/week) 11.6% –Intensive Outpatient (9-20 hours/week) 27.9% –Outpatient (<9 hours/week) 40.5% Aftercare 48.7%

The University of Georgia Availability of Residential Care The vast majority of TCs (90.0%) offer some form of residential care –The average residential TC has about 51.9 beds About 10.0% (n=31) do not offer any form of residential care

The University of Georgia Availability of Adolescent Residential Programs Among TCs offering residential care (n = 278), the availability of four types of adolescent programs was examined Residential programs for adolescents were relatively rare, with only 10.7% of TCs offering any type of adolescent residential programming

The University of Georgia Outpatient Services in Residential TCs In TCs that offer residential care, there is some evidence of service diversification with regard to the availability of outpatient programming However, 60.4% of residential TCs have no PHP, IOP, or OP levels of care

The University of Georgia Cultural Aspects of the Classic TC Model The classic TC model involves a unique cultural approach to: –The goals and stages of treatment –The roles of peers and staff –The importance of hierarchy within the community –The use of work in the treatment process Using measures developed by DeLeon and his colleagues, we examined the similarities between our sample and these classic elements of TCs

The University of Georgia TC Culture: Treatment Goals “A main goal of the primary treatment stage is building a sense of ownership or belonging in the community.” –0 = no extent –5 = very great extent Residential-only and Mixed programs strongly endorse this measure, while non-residential programs report significantly lower agreement

The University of Georgia TC Culture: The Role of Clients “Clients confront the negative behavior and attitudes of each other and the community.” –0 = no extent –5 = very great extent Residential-only and Mixed programs are similar in their response, but non-residential programs report less agreement with this measure

The University of Georgia TC Culture: Hierarchy in the TC “Clients are stratified by levels of responsibility and clinical status, such as Junior, Intermediate, and Senior.” –0 = no extent –5 = very great extent Non-Residential TCs report less agreement with this measure than Residential-Only and Mixed TCs

The University of Georgia TC Culture: The Use of Work “Work is utilized as part of the therapeutic program (i.e. to build self-esteem and social responsibility).” –0 = no extent –5 = very great extent Although Residential-Only and Mixed TCs are similar, Non-Residential TCs are less likely to use work as part of the treatment process

The University of Georgia Comparing TCA and Non-TCA Members There should be differences between those TC organizations that commit themselves to a national membership organization and those which do not There should be differences between those TC organizations that have structured opportunities to interact intensely with TC peers at national meetings, and those which do not There should be differences between those TC organizations that have daily opportunities for networking and information-gathering from peers vs. those who do not

The University of Georgia Comparing TCA and Non-TCA Members Slightly less than a quarter of TCs in our sample (23.9%) are members of TCA Keep in mind that we define our units as having significant local administrative decision-making, so these figures offer multiple counts of established TC networks

The University of Georgia Comparing TCA and Non-TCA Members: Treatment Ideology Looking at 14 different dimensions of TC treatment ideology derived from DeLeon and colleagues’ work, there are significant differences between the overall groups of TCA members and non-TCA members on 8 of the dimensions

The University of Georgia Comparing TCA and Non-TCA Members TCA member organizations are significantly more likely to endorse: –Right living involves positive social values, such as work ethic social productivity, and community responsibility –The most important role of the clinical staff is to facilitate the clients’ commitment to the shared community values

The University of Georgia Comparing TCA and Non-TCA Members Clients are stratified by levels of responsibility and clinical status, such as Junior, Intermediate and Senior*** Clients are aware of the therapeutic goals of fellow residents and try to assist them in achieving these goals*** Peer feedback occurs more frequently than staff counseling

The University of Georgia Comparing TCA and Non-TCA Members Clients confront the negative behaviors and attitudes of each other and the community*** Encounter groups are used to confront negative behaviors and attitudes*** There are periodic “house runs” or thorough inspection of the premises

The University of Georgia Treatment of Dually Diagnosed Clients by Setting Of the total sample of TCs, 69.2% report that they treat clients that have been dually diagnosed There is variation in the treatment of dually diagnosed clients across the three types of settings

The University of Georgia Educational Attainment by Setting We examined the percentage of counselors with at least a Master’s-level degree –The average TC reported that 30.4% of their counseling staff had attained at least a Master’s-level degree Non-residential TCs reported significantly higher percentages of MA-level counselors than the two types of residential programs

The University of Georgia Recovery Status by Setting We examined the percentage of counselors that were personally in recovery –The average TC reported that 56.5% of their counseling staff were personally in recovery Residential-only TCs had significantly more counselors in recovery than the other two types –The difference between mixed and non- residential TCs was not significant

The University of Georgia Innovation Adoption

The University of Georgia Challenges The issue of continuing strength of organizations of TCs promoting the integrity and importance of the TC model Adjusting funding to a comprehensive, “whole person” model Maintaining the core technology of TCs while adapting realistically to change.