Measuring changes in client-level treatment process in the therapeutic community (TC) with the Dimensions of Change Instrument (DCI)

Examining Treatment Climate Across Prison-Based Substance Abuse Treatment Groups

BACKGROUND

With notable exceptions, few studies have looked critically at the role and effects of factors other than individual or programmatic differences that contribute to the climate within substance abuse treatment programs. De Leon's work on the therapeutic community, however, indicates that factors beyond the individual and program can contribute to the overall functioning of similarly situated communities.

OBJECTIVES

In this study, we introduce and examine the concept of the "treatment group," the level of aggregation between the individual who participates in treatment and the organization that provides it. The treatment group refers to the social context and dynamics that operate among treatment participants, and we sought to study differences in treatment climate across 12 prison-based treatment groups within a single prison.

METHODS

Using data from 604 participants who were assigned at random to one of the 12 groups, we analyzed differences on seven treatment climate indicators from one month and six months into the program across the treatment groups.

RESULTS

No differences were found among the treatment groups at after one month; however, after 6 months, significant differences emerged across the groups on three treatment climate variables: program structure, counselor rapport, and counselor competence.

CONCLUSIONS/IMPORTANCE

This study is among the first of its kind to conceptualize and examine treatment climate across otherwise similar groups and find that differences emerge on several indicators of climate. As such, we argue that the treatment group may be important to consider in both the delivery and evaluation of substance abuse treatment.

Encouraging the Disuse of Illicit Drugs Among At-Risk Youth

Youth at risk of illicit drug abuse and other delinquent acts are the target of social work services. Preventing or discouraging the use of illicit drugs among at-risk youth is a long-standing practical and research concern. For this reason, the preventive function of courage is a research gap the present study seeks to fill. The study collected data from 169 at-risk youths and their social workers with two-wave panel surveys. Results show that courage in Wave 1 presented a strong negative effect on illicit drug use in Wave 2 in the youth, controlling for illicit drug use in Wave 1 and background characteristics. Moreover, the negative effect was stronger when Wave 1 drug use was more likely. These results imply the helpfulness of encouraging at-risk youth to gather courage to resist the temptation to use illicit drugs.

Reducing Deviance Through Youths' Mutual Aid Group Dynamics

The mutual aid group, as supported by the social worker, emerges to play a vital role in helping group members reduce their deviance or behavioral problem. However, how the collaboration of the group and social worker accomplishes the reduction has remained uncharted. Based on social capital theory, mutual aid and cohesion within the group and social workers' specific aid for the group are likely responsible for the reduction. The test of such hypotheses relies on a two-wave panel survey of the members of 60 mutual aid groups who had deviant behavioral problems, located in Hong Kong, China. These groups had 241 youths completing both initial and 1-year follow-up surveys. Results manifested the direct or unconditional contributions of mutual aid, group cohesion, and social workers' specific aid to reducing deviance. Hence, social workers can enhance the effectiveness of the mutual aid group in reducing youths' deviance.

Core characteristics, treatment process and retention in therapeutic communities for addictions: a summary of four studies

Purpose

– The purpose of this paper is to summarize the main findings and conclusions of four separate studies on treatment in therapeutic communities (TCs) for addictions.

Design/methodology/approach

– The first two studies address the core characteristics of the TC approach: a study on the workable and destructive elements of the Synanon model; and a comparative study on the essential elements of TCs for addictions in Europe and in the USA. The final two studies highlight clients’ perceptions of the TC treatment process in relation to retention: a study on clients’ first month perceptions of the TC treatment process and the influence of fixed and dynamic client factors; and a longitudinal study on changes in clients’ perception of the TC treatment process and the impact of motivation, psychological distress and cluster B personality traits.

Findings

– The first study showed that Synanon’s therapeutic and pedagogical methods are still highly valued despite its negative reputation. The results of the second study suggest that while traditional TCs operate as concept-based TCs in Europe, modified TCs might differ in the extent to which they apply the core principles and elements of the TC approach. The third study provides evidence that suitability for treatment is a very important predictor for clients’ first month perceptions of the community environment. The fourth study shows that with time in treatment clients develop more profound perceptions regarding the essence of TC treatment.

Research limitations/implications

– Finally, implications for clinical practice, general limitations and some concrete recommendations for future research are presented in this paper.

Originality/value

– The PhD summary study contributes to the existing literature on TC treatment.

Verbal feedback in therapeutic communities: pull-ups and reciprocated pull-ups as predictors of graduation

The most important proximal outcomes for residents of therapeutic communities (TCs) are retention and successful completion of the program. At this point there has been no quantitative analysis of the relationship between the exchange of corrective reminders, or pull-ups, between peers in TCs and graduation. This study draws on a database of pull-ups exchanged between 5464 residents of three midwestern TCs. Residents who send more pull-ups to peers and who reciprocate pull-ups with a larger percentage of peers are more likely to graduate. Residents who receive more pull-ups from peers and staff and a larger percentage of whose peers reciprocate pull-ups that they send are less likely to graduate. Implications of these findings for program theory and program improvement are discussed.

Fixed and dynamic predictors of treatment process in therapeutic communities for substance abusers in Belgium

Background

Research on substance abuse treatment services in general reflects substantial attention to the notion of treatment process. Despite the growing popularity of process studies, only a few researchers have used instruments specifically tailored to measure the therapeutic community (TC) treatment process, and even fewer have investigated client attributes in relation to early TC treatment process experiences. The aim of the current study is to address this gap by exploring clients’ early in-treatment experiences and to determine the predictors that are related to the treatment process, using a TC-specific multidimensional instrument.

Methods

Data was gathered among 157 adults in five TCs in Flanders (Belgium). Descriptive statistics were used to explore clients’ early in-treatment experiences and multiple linear regressions were conducted to determine the fixed and dynamic predictors of Community Environment and Personal Development and Change (two indicators of TC treatment process).

Results

Clients reveal a more positive first-month response to TC social processes than to personal-development processes that require self-reflection and insight. The variance in clients’ ratings of Community Environment was primarily due to dynamic client factors, while the variance in clients’ ratings of Personal Development and Change was only related to fixed client factors. Suitability for treatment was the strongest predictor of Community Environment ratings, whereas a judicial referral more strongly predicted Personal Development and Change scores.

Conclusions

Special attention should be devoted to suitability for treatment as part of motivational assessment as this seems to be a very strong predictor of how clients react to the initiation stage of TC treatment. To help improve clients’ (meta-)cognitive skills needed to achieve insight and self-reflection and perhaps speed up the process of recovery, the authors suggest the introduction of (meta-)cognitive training strategies in the pre-program and/or the induction stage of a TC program.

Subjective prior distributions for modeling longitudinal continuous outcomes with non-ignorable dropout

Substance abuse treatment research is complicated by the pervasive problem of non-ignorable missing data-i.e. the occurrence of the missing data is related to the unobserved outcomes. Missing data frequently arise due to early client departure from treatment. Pattern-mixture models (PMMs) are often employed in such situations to jointly model the outcome and the missing data mechanism. PMMs require non-testable assumptions to identify model parameters. Several approaches to parameter identification have therefore been explored for longitudinal modeling of continuous outcomes, and informative priors have been developed in other contexts. In this paper, we describe an expert interview conducted with five substance abuse treatment clinical experts who have familiarity with the therapeutic community modality of substance abuse treatment and with treatment process scores collected using the Dimensions of Change Instrument. The goal of the interviews was to obtain expert opinion about the rate of change in continuous client-level treatment process scores for clients who leave before completing two assessments and whose rate of change (slope) in treatment process scores is unidentified by the data. We find that the experts' opinions differed dramatically from widely utilized assumptions used to identify parameters in the PMM. Further, subjective prior assessment allows one to properly address the uncertainty inherent in the subjective decisions required to identify parameters in the PMM and to measure their effect on conclusions drawn from the analysis.

Do dimensions of therapeutic community treatment predict retention and outcomes?

First-week Dimensions of Change Instrument (DCI) assessments from a cohort of 519 adults entering six therapeutic communities (TCs) were used to predict treatment retention and outcomes. A more positive first-week response to TC social processes (Community Responsibility; Resident Sharing, Support, and Enthusiasm; Group Process; and Clarity and Safety) and to one TC personal-development process (Positive Self-Attitude and Commitment to Abstinence) predicted retention for the first month. Improvement in Clarity and Safety and Resident Sharing, Support, and Enthusiasm scores at 30 days predicted retention in treatment for 3, 6, and 9 months. In multivariate analyses available to a subset of the entry cohort, a longer tenure in treatment was a robust predictor of posttreatment outcomes. First-week DCI scores on the community process scales predicted posttreatment alcohol-and-other-drug abstinence and functioning.

The relationship between the Dimensions of Change Instrument and retention in therapeutic community treatment: the moderating influence of time in treatment

OBJECTIVES

The Dimensions of Change Instrument (DCI) (1) assesses aspects of the therapeutic community treatment process. More positive scores on two of the eight dimensions of treatment process assessed at the beginning of treatment, Clarity and Safety, and Resident Support, Sharing and Enthusiasm predict retention in treatment at 30, 90, 180, and 270 days as well as overall length of stay. This study explored whether these process subscales assessed at different phases predicted retention at the next phase, and of treatment.

METHODS

Five-hundred nineteen individuals, aged 18 to 62, undergoing therapeutic community treatment completed the DCI at baseline, one, three, six, and nine months of the therapeutic community treatment.

RESULTS

DCI scale scores at each stage of treatment predicted dropout in the subsequent period. In the early stages of treatment, higher scores predicted a higher probability of retention in the subsequent stage of treatment. In later stages, lower DCI scores predicted a higher probability of retention.

CONCLUSIONS

We conclude that predictions about retention made using the DCI scale scores are treatment stage dependent--the DCI predicts retention at the next stage but the direction of the scale prediction varies as a function of client tenure in treatment. This suggests that treatment processes that influence clients to remain early in treatment may change their valence for clients more advanced in treatment.