Transcript The Therapeutic Community As Treatment in Substance Use

The Therapeutic Community
As Treatment in Substance Use
Disorders
Laura Pieri, MD
Temple University
School of Medicine
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Overview
 Definition of the Therapeutic Community
(TC)
 TC philosophy and its perspective on:
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Substance Use Disorders
The patient
The recovery process
Healthy living
 Component parts and design
 Success rates
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What the Therapeutic
Community is:
 Definitions
 Demography
 History
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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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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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Usual Patient Characteristics
 Social profiles
 Psychological profiles
 Psychiatric diagnoses
 Criteria for treatment
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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
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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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Psychiatric Diagnoses
 >70% lifetime psychiatric symptoms
 33% current serious mental disorder
 Temporary, substance-induced conditions
 Independent disorders:
• Antisocial personality disorder
• Bipolar disorder
• Anxiety disorders
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Criteria for Treatment
 Exclusionary criteria
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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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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
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Work as therapy
Mutual self-help
Peers as role models
Staff as rationale authorities
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The Recovery Process
 Typical Daily Regimen
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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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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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Predictors of Drop-Out
(DeLeon, 1999)
 Severe Criminality
 Severe Psychopathology
 Perceived Legal Pressure
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TIP and Outcomes
 Simpson (1979)
N
735
TC# TIP
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90
 Bale(1980)
361
3
50
 DeLeon(1982)
525
1
120-180
 Hubbard(1989)
731
10
190-365
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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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