copyright alcohol medical scholars program1 the therapeutic community as treatment in substance use...
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Copyright Alcohol Medical Scholars Program 1
The Therapeutic CommunityAs 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:• 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• 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 • Work as therapy
• Mutual self-help
• Peers as role models
• Staff as rationale authorities
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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)
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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
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
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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