1. The Therapeutic Community As Treatment in Substance Use Disorders
Dr. Mohamed El-Hamady
Ass. Prof. of Psychiatry
Benha Faculty of Medicine
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Overview
Definition of the Therapeutic Community (TC)
TC philosophy and its perspective on:
Substance Use Disorders
The patient
The recovery process
Healthy living
Component parts and design
Success rates
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3. What the Therapeutic Community is:
Definitions
Demography
History
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4. TC Philosophy and Perspectives
View of the “disorder”
View of the “person”
View of “recovery”
View of “healthy living”
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View of the “Disorder”
The “problem” is the individual not the drug
Detox is a condition of entry
The GOAL is abstinence
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View of the “Person”
Dimensions of:
Psychological dysfunction
Social deficits
Vocational/educational deficits
Habilitative vs. rehabilitative needs
Personality disturbances either as a cause or result of the substance use disorder
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View of “Recovery”
Change in lifestyle and personal identity
Motivation: pressure(s) to change
Treatment is through staff and peers
Social learning
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8. View of “Healthy Living”
Clear “moral” positions are held
Right and wrong behaviors are identified
Specific values are stressed
Guilt (as a central issue in recovery) is addressed
Focus is on“here and now”
The past is explored only to illustrate current patterns and attitudes
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The Prototypical TC
Who comes for treatment?
How is “treatment” implemented or provided (Who is doing the treating?)?
What is the treatment “process?” (What does the patient experience as treatment?)
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10. Usual Patient Characteristics
Social profiles
Psychological profiles
Psychiatric diagnoses
Criteria for treatment
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Social Profiles
90-95% male
Most from broken homes/disrupted families
<33% were employed full-time
>66% have been arrested
30-40% have prior treatment
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12. Psychological Profiles
High anxiety/depression
Poor socialization
IQ = dull (70-84) to normal (85-115)
Low self esteem
Disturbed thinking
Immature/antisocial
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13. Psychiatric Diagnoses
>70% lifetime psychiatric symptoms
33% current serious mental disorder
Temporary, substance-induced conditions
Independent disorders:
Antisocial personality disorder
Bipolar disorder
Schizophrenia and other psychotic disorders
Anxiety disorders
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14. Criteria for Treatment
Exclusionary criteria
H/O arson
H/O suicide attempts
Serious psychiatric disorders
Patients on daily psychotropic medications
“Open-door” policy
Modified TCs for dual diagnosis
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15. The TC Approach to Treatment
Structure and social organization of the TC
Role of staff
Role of the patient(s)
Treatment tools used via the social structure
Work as therapy
Mutual self-help
Peers as role models
Staff as rationale authorities
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The Recovery Process
Typical Daily Regimen
Community meeting
Work time
Groups
Recreational activities
Individual counseling
Program stages
I: Orientation (0-60 days)
II: Primary treatment (2-12 months)
III: Advanced treatment and aftercare (13-24 months)
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17. Effectiveness of the TC Approach
Success reflected in improvements in several variables
Post-treatment outcomes most influenced by “time in program” (TIP)
Retention rates: predictors of this are important
Drop-out is expected, but there are some predictors of this
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Success Rates
Substantial improvements in (NIDA, 2001):
40-60% reduction in drug use
Up to 40% in decreased arrest rates
Up to 40% in employment gains
TIP and outcomes (success = no drug use or criminality):
90% for program graduates
50% for drop-outs after 1 year of treatment
25% for drop-outs prior to 1 year of treatment
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Retention
Completion rate: 10-25% of all admissions
Dropout rates highest first 30 days (30-40%)
Retention very weakly predicted by client variables
Treatment entry variables stronger, more consistent predictors of retention
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Variables
Client Variables
Fixed (demography, history)
Dynamic (self esteem, hopefulness)
Treatment Entry Variables
Legal Involvement
Significant Other(s) Pressure
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21. Predictors of Drop-Out (DeLeon, 1999)
Severe Criminality
Severe Psychopathology
Perceived Legal Pressure
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TIP and Outcomes
N TC# TIP
Simpson (1979)
Bale(1980)
DeLeon(1982)
Hubbard(1989)
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23. Future Directions (Lees, 1999)
Qualitative and quantitative studies on improvements in mental health/functioning
Effectiveness of TC for personality disorders
More research needed to identify ways of reducing drop-out rates
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Summary
TC is a “consciously-designed social environment and program” for Substance Use Disordered patients
How the disorder, patient, recovery and healthy living are viewed in the TC model
How the structure and design of the TC is the method of treatment
The TC is an effective treatment method
Further research is needed
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