copyright alcohol medical scholars program1 the therapeutic community as treatment in substance use...

Copyright Alcohol Medical Scholars Program 1

The Therapeutic CommunityAs Treatment in Substance Use Disorders

Laura Pieri, MD

Temple University

School of Medicine


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


What the Therapeutic Community is:

Definitions

Demography

History


TC Philosophy and Perspectives

View of the “disorder”

View of the “person”

View of “recovery”

View of “healthy living”


View of the “Disorder”

• The “problem” is the individual not the drug

• Detox is a condition of entry

• The GOAL is abstinence


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


View of “Recovery”

Change in lifestyle and personal identity

Motivation: pressure(s) to change

Treatment is through staff and peers

Social learning


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


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?)


Usual Patient Characteristics

Social profiles

Psychological profiles

Psychiatric diagnoses

Criteria for treatment


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


Psychological Profiles

High anxiety/depression Poor socialization IQ = dull (70-84) to normal (85-115) Low self esteem Disturbed thinking Immature/antisocial


Psychiatric Diagnoses

>70% lifetime psychiatric symptoms 33% current serious mental disorder Temporary, substance-induced conditions Independent disorders:

• Antisocial personality disorder

• Bipolar disorder

• Anxiety disorders


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


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


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)


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


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


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


Variables

Client Variables• Fixed (demography, history)

• Dynamic (self esteem, hopefulness)

Treatment Entry Variables• Legal Involvement

• Significant Other(s) Pressure


Predictors of Drop-Out (DeLeon, 1999)

Severe Criminality

Severe Psychopathology

Perceived Legal Pressure


TIP and Outcomes

N TC# TIP

Simpson (1979) 735 24 90

Bale(1980) 361 3 50

DeLeon(1982) 525 1 120-180

Hubbard(1989) 731 10 190-365


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


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 program1 the therapeutic community as treatment in substance use...

Documents

prior treatment slide

abstinence slide

disorder view

substance use disorder

treatment structure

treatment process

peers social learning

patients treatment tools