1. THE RECOVERY MOVEMENT: WHAT CAN BE LEARNED FROM THERAPEUTIC COMMUNITIES FOR ADDICTIONS GEORGE DE LEON, Ph.D. RECOVERY ACADEMY, 2 nd ANNUAL CONFERENCE Edinburgh, Scotland, Sept.2011

2. PAST AS PROLOGUE “ Arguably, the therapeutic community for addictions (TC) is one of the first formal treatment approaches that is explicitly recovery oriented. Surely, AA and similar mutual self help approaches facilitate recovery but these represent themselves as support, not treatment. Pharmacological approaches, notably, methadone maintenance, have as their treatment goal the reduction or elimination of illicit opiate use. Evidence based behavioral approaches, such as cognitive behavioral therapy (CBT), contingency contracting, motivational enhancement (MET) focus upon reduction in targeted drug use. “

3. TC: PAST AS PROLOGUE “ In the TC perspective, however, the primary goal of treatment is recovery which is broadly defined as changes in lifestyle and identity. These changes involve abstinence from all non prescribed drug use, elimination of social deviance and development of pro social behaviors and values “ De Leon: (2010) The Therapeutic Community: A Recovery Oriented Treatment Pathway and The Emergence of a Recovery Oriented Integrated System. In ( R. Yates and M.Mallloch Editors) Tackling Addiction; Pathways to Recovery (pp.70-83) London, Jessica Kingsley Publishers

4. THE TC AND RECOVERY: KEY CONTRIBUTIONS  A Perspective and Definition of Recovery  A Research Literature - Documents The Fact of Recovery  A Recovery Stage Framework- A ten stage paradigm to illustrate the recovery process  A Recovery Oriented Integrated System (ROIS)- A systems model of treatment, social services and aftercare to promote recovery, rather than manage disease

5. TC PERSPECTIVE ON RECOVERY  RECOVERY: OVERCOMING A DISEASE; A “RETURN TO A HEALTH OR NORMALITY”  REHABILITATION: REBUIDLING A POSITIVE LIFESTYLE.  HABILITATION: BUILDING A POSTIVE LIFESTYLE (FOR THE FIRST TIME).

6. TC: PERSPECTIVE ON RECOVERY Some assumptions about the recovery process: Recovery is developmental learning Self-help and mutual self-help Motivation Social learning Treatment is an episode in the recovery process

7. TC RESEARCH: The FACT of RECOVERY  Natural History Studies described recovery changes in small followup samples.  TC field effectiveness studies( single program and multimodality) systematically documented multidimensional recovery changes in large samples followed 1-12 years post treatment

8. TC: Research Outcomes  The main findings and conclusions are summarized from multiple sources of outcome research in North America including multi- program field effectiveness studies, single program controlled studies, meta analytic statistical surveys and cost–benefit studies.  The weight of the research evidence from all sources is compelling in supporting the hypothesis that the TC is an effective and cost- effective treatment for certain subgroups of substance abusers. De Leon, G.(2010), Is the Therapeutic Community an evidenced based treatment? What the evidence says. Int. J. Therapeutic Communities, 31, 2, Summer 100-104

9. A Recovery Stage Framework TC outcome research and clinical experience provide an empirical basis for a descriptive framework of the long term recovery process.

10. A 10 Recovery Stage Paradigm  Early Recovery: Stages 1-3 1.Denial: Active abuse and/or associated problems, with no problem recognition or problem acceptance. 2. Ambivalence: Some problem recognition, but inconsistent acceptance of the consequences of continued use on self and others. 3.Extrinsic Motivation: Some recognition and acceptance of drug use and associated problems, but attributed to external influences and not seen as reasons for seeking change.

11. A Recovery Stage Paradigm  Early Recovery: Stages 4-6 4. Intrinsic motivation: Acceptance of drug use and associated problems, and an expressed desire to change based on positive and negative inner reasons. 5. Readiness for Change: Willingness to seek change options which are not treatment related. 6. Readiness for Treatment: Rejection of all other options for change except treatment.

12. A 10 Stage Paradigm  Middle Recovery (Stages 7-8) 7. De-Addiction: Detachment from active drug use; pharmacological, behavioral and social detoxification. 8. Abstinence: Stabilized drug freedom for a continuous period, usually beyond the individual’s longest period of drug freedom.  Later Recovery (9-10) 9. Continuance: Sobriety plus personal resolve to acquire or maintain the behavior, attitudes, and values associated with the drug free lifestyle. 10. Integration and Identity Change: Interrelation of treatment influences, recovery stage and broader life experiences, resulting in self perceived change in social and personal identity. De Leon, G. (1996). Integrative recovery: A stage paradigm. Substance Abuse, 17 (1), 51-63;

13. Beyond Treatment: A Recovery Oriented Integrated System  The Current System of Treatment and Aftercare Must be integrated to sustain the individual in the recovery process.  The TC program stage format, particularly, the re- entry stages guide the development of a recovery oriented integrated system.

14. (ROIS) A Recovery Oriented Integrated System  ROIS is a paradigm of a systems approach. It emphasizes partnership linkages among community providers to coordinate transitional and aftercare treatment and social services.

15. A RECOVERY ORIENTED INTEGRATED SYSTEM (ROIS) (cont’d).) Typical social service partners include those in education, employment, housing, family, mental health. For criminal justice clients additional partners may include: prison based treatment providers, parole/probation officers, judges, halfway houses.

16. A RECOVERY ORIENTED INTEGRATED SYSTEM (ROIS) (cont’d.) The integrative ingredient of the system is an overarching framework of recovery.

17. KEY ASSUMPTIONS OF ROIS (ROIS) consists of interrelated treatment interventions, surveillance and social services provided in a variety of settings, which is guided by a common perspective on the disorder and recovery.

18. KEY ASSUMPTIONS OF ROIS (cont’d.) In a ROIS, settings and modalities may change, but their purpose remains the same, to move the individual to the next stage in the process of recovery.

19. KEY ASSUMPTIONS OF ROIS (Cont’d ) Treatment services, social services and surveillance differ in their contribution to the recovery process.

20. KEY ASSUMPTIONS OF ROIS (Cont’d.) The optimal utilization of aftercare services in institutions, halfway houses, day treatment or outpatient setting depends upon the client’s stage of recovery.

21. SUMMARY OF KEY ELEMENTS OF ROIS  A Recovery Stage Framework  System-wide vernacular  System-wide assessment protocol  Coordinated procedures for referral and placement.