The Therapeutic Community as Treatment in Substance Use Disorders[1]

The Therapeutic Community As Treatment in Substance Use Disorders Laura Pieri, MD Temple University School of Medicine Copyright Alcohol Medical Scholars Program 1 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 Copyright Alcohol Medical Scholars Program 2 What the Therapeutic Community is:  Definitions  Demography  History Copyright Alcohol Medical Scholars Program 3 TC Philosophy and Perspectives  View of the “disorder”  View of the “person”  View of “recovery”  View of “healthy living” Copyright Alcohol Medical Scholars Program 4 View of the “Disorder” • The “problem” is the individual not the drug • Detox is a condition of entry • The GOAL is abstinence Copyright Alcohol Medical Scholars Program 5 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 Copyright Alcohol Medical Scholars Program 6 View of “Recovery”  Change in lifestyle and personal identity  Motivation: pressure(s) to change  Treatment is through staff and peers  Social learning Copyright Alcohol Medical Scholars Program 7 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 Copyright Alcohol Medical Scholars Program 8 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?) Copyright Alcohol Medical Scholars Program 9 Usual Patient Characteristics  Social profiles  Psychological profiles  Psychiatric diagnoses  Criteria for treatment Copyright Alcohol Medical Scholars Program 10 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 Copyright Alcohol Medical Scholars Program 11 Psychological Profiles  High anxiety/depression  Poor socialization  IQ = dull (70-84) to normal (85-115)  Low self esteem  Disturbed thinking  Immature/antisocial Copyright Alcohol Medical Scholars Program 12 Psychiatric Diagnoses  >70% lifetime psychiatric symptoms  33% current serious mental disorder  Temporary, substance-induced conditions  Independent disorders: • Antisocial personality disorder • Bipolar disorder • Anxiety disorders Copyright Alcohol Medical Scholars Program 13 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 Copyright Alcohol Medical Scholars Program 14 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 Copyright Alcohol Medical Scholars Program 15 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) Copyright Alcohol Medical Scholars Program 16 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 Copyright Alcohol Medical Scholars Program 17 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 Copyright Alcohol Medical Scholars Program 18 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 Copyright Alcohol Medical Scholars Program 19 Variables  Client Variables • Fixed (demography, history) • Dynamic (self esteem, hopefulness)  Treatment Entry Variables • Legal Involvement • Significant Other(s) Pressure Copyright Alcohol Medical Scholars Program 20 Predictors of Drop-Out (DeLeon, 1999)  Severe Criminality  Severe Psychopathology  Perceived Legal Pressure Copyright Alcohol Medical Scholars Program 21 TIP and Outcomes  Simpson (1979)  Bale(1980)  DeLeon(1982)  Hubbard(1989) N 735 TC# TIP 24 90 361 525 731 3 1 10 50 120-180 190-365 Copyright Alcohol Medical Scholars Program 22 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 Copyright Alcohol Medical Scholars Program 23 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 Copyright Alcohol Medical Scholars Program 24