1. Copyright Alcohol Medical Scholars Program1 The Therapeutic Community As Treatment in Substance Use Disorders Laura Pieri, MD Temple University School of Medicine

2. Copyright Alcohol Medical Scholars Program2 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

3. Copyright Alcohol Medical Scholars Program3 What the Therapeutic Community is:  Definitions  Demography  History

4. Copyright Alcohol Medical Scholars Program4 TC Philosophy and Perspectives  View of the “disorder”  View of the “person”  View of “recovery”  View of “healthy living”

5. Copyright Alcohol Medical Scholars Program5 View of the “Disorder” The “problem” is the individual not the drug Detox is a condition of entry The GOAL is abstinence

6. Copyright Alcohol Medical Scholars Program6 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

7. Copyright Alcohol Medical Scholars Program7 View of “Recovery”  Change in lifestyle and personal identity  Motivation: pressure(s) to change  Treatment is through staff and peers  Social learning

8. Copyright Alcohol Medical Scholars Program8 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

9. Copyright Alcohol Medical Scholars Program9 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?)

10. Copyright Alcohol Medical Scholars Program10 Usual Patient Characteristics  Social profiles  Psychological profiles  Psychiatric diagnoses  Criteria for treatment

11. Copyright Alcohol Medical Scholars Program11 Social Profiles  70-75% male  Most from broken homes/disrupted families  <33% were employed full-time  >66% have been arrested  30-40% have prior treatment

12. Copyright Alcohol Medical Scholars Program12 Psychological Profiles  High anxiety/depression  Poor socialization  IQ = dull (70-84) to normal (85-115)  Low self esteem  Disturbed thinking  Immature/antisocial

13. Copyright Alcohol Medical Scholars Program13 Psychiatric Diagnoses  >70% lifetime psychiatric symptoms  33% current serious mental disorder  Temporary, substance-induced conditions  Independent disorders: Antisocial personality disorder Bipolar disorder Anxiety disorders

14. Copyright Alcohol Medical Scholars Program14 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

15. Copyright Alcohol Medical Scholars Program15 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

16. Copyright Alcohol Medical Scholars Program16 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)

17. Copyright Alcohol Medical Scholars Program17 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

18. Copyright Alcohol Medical Scholars Program18 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

19. Copyright Alcohol Medical Scholars Program19 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

20. Copyright Alcohol Medical Scholars Program20 Variables  Client Variables Fixed (demography, history) Dynamic (self esteem, hopefulness)  Treatment Entry Variables Legal Involvement Significant Other(s) Pressure

21. Copyright Alcohol Medical Scholars Program21 Predictors of Drop-Out (DeLeon, 1999)  Severe Criminality  Severe Psychopathology  Perceived Legal Pressure

22. Copyright Alcohol Medical Scholars Program22 TIP and Outcomes NTC#TIP  Simpson (1979)7352490  Bale(1980)361350  DeLeon(1982)5251120-180  Hubbard(1989)73110190-365

23. Copyright Alcohol Medical Scholars Program23 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

24. Copyright Alcohol Medical Scholars Program24 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