Modified therapeutic communities and adherence to traditional elements

The therapist, the group and I: how therapeutic alliance moderates the effect of group cohesion on outcomes

Purpose

This study aims to investigate whether the influence of group cohesion on the outcomes depended on the levels of the therapeutic alliance.

Design/methodology/approach

Sixteen individuals with a substance use disorder who were undergoing treatment in a therapeutic community responded to therapeutic alliance, group cohesion, craving and outcomes measures after every therapeutic small group session for a period of six weeks. Data analysis was performed using hierarchical linear modeling.

Findings

Results indicate that the effect of group cohesion is stronger when there is a high therapeutic alliance between resident and therapist.

Originality/value

Even on group interventions, to enhance group cohesion effects on outcomes, therapists must foster higher therapeutic alliance levels. The findings point out the importance of studying the effect of common factors on outcomes.

Prison Addiction Program and the Role of Integrative Treatment and Program Completion on Recidivism

This study examines whether there is variability between the effects of three different drug rehabilitation programs operating in the Israeli Prison Service (IPS) on completers' recidivism. By performing comparative analysis, this study attempts to address the problem of assessing the role of participants' motivation. The study uses a rich administrative data obtained from the IPS system to develop a propensity score matching (PSM) approach where the treatment groups consist of only those who completed the programs, and the comparison groups consist of drug-addicted prisoners who have not taken part in any drug rehabilitation program. After matching, prisoners in the treatment and comparison groups are found to be similar on all known characteristics. Findings show that the only rehabilitation program that promised significant and positive outcomes for its completers was the more comprehensive one operating at Hermon Prison. Prisoners who completed the treatment were incarcerated and arrested less than their comparison group. The "golden strategy" for rehabilitating drug-using prisoners, then, will be twofold. The program should be based on the promising components of rehabilitation, that is, cognitive behavioral therapy, therapeutic community, long duration, intensity, and positive social climate. The program should also succeed in retaining its participants through completion.

Factors Predicting Patient's Allocation to Short- and Long-Term Therapeutic Community Treatments in the Italian VOECT Cohort Study

The Evaluation of Therapeutic Community Treatments and Outcomes (VOECT) study was conducted in 131 Italian Therapeutic Communities (TCs) in 2008/2009. All of the patients entering residential treatment for drug or alcohol dependence were invited to participate. Data regarding patient socio-demographic characteristics, drug and alcohol consumption, health and psychopathological status, prior treatments and outcomes, and their motivation score were collected upon enrolment onto the study. The aim of this work was to identify the factors associated with allocation to short- versus long-term programmes in drug or alcohol dependent patients entering TCs in Italy. Of the 2470 patients included in the analysis, 30.8% were allocated to short-term treatment and 69.2% to long-term treatment. Several factors were significantly associated with the allocation to short- and long-term treatments: unstable living conditions; entering the TC when not detoxified; a high Symptom Checklist-90 somatization score; prior cessation episodes; previous in-patient detoxification treatments; psychosocial treatments; entering the TC by oneself; and a low motivation score.

Toward the Identification of a Specific Psychopathology of Substance Use Disorders

Addiction is a mental illness in which psychiatric conditions imply a prominent burden. Psychopathological symptoms in substance use disorder (SUD) patients are usually viewed as being assignable to the sphere of a personality trait or of comorbidity, leaving doubts about the presence of a specific psychopathology that could only be related to the toxicomanic process. Our research group at the University of Pisa has shed light on the possible definition of a specific psychopathological dimension in SUDs. In heroin use disorder patients, performing an exploratory principal component factor analysis (PCA) on all the 90 items included in the SCL-90 questionnaire led to a five-factor solution. The first factor accounted for a depressive "worthlessness and being trapped" dimension; the second factor picked out a "somatic symptoms" dimension; the third identified a "sensitivity-psychoticism" dimension; the fourth a "panic-anxiety" dimension; and the fifth a "violence-suicide" dimension. These same results were replicated by applying the PCA to another Italian sample of 1,195 heroin addicts entering a Therapeutic Community Treatment. Further analyses confirmed the clusters of symptoms, independently of demographic and clinical characteristics, active heroin use, lifetime psychiatric problems, kind of treatment received, and, especially, other substances used by the patient such as alcohol or cocaine. Moreover, these clusters were able to discriminate patients affected by addiction from those affected by psychiatric diseases such as major depressive disorder. Our studies seem to suggest the trait-dependent, rather than the state-dependent, nature of the introduced psychopathology dimensions of SUDs.

Drug use patterns and demographic correlations of residents of Saudi therapeutic communities for addiction

Objectives

This study describes the characteristics of residents in Saudi therapeutic communities (TCs), their patterns of drug use, and the correlations between these variables.

Methods

This retrospective study examined all Saudi TC residents admitted since the establishment of the first TC in 2000 until mid-2014. The TCs include three governmental and two non-governmental enterprises: two TCs in Dammam and one each in Riyadh, Jeddah, and Taif, with a total population of 2023 residents.

Results

All TC residents were adult males; 85.6% were Saudis, and almost all remaining residents were from the Gulf Cooperation Council countries. The mean age of residents was 33.9 years (±8.8 years), and their educational levels were mostly high school or lower; 25% were married, and 70.8% were jobless. The pattern of drug use indicated that 35.8% used opioids, 15% used hash, 11.9% used both hash and amphetamine, 11.1% used amphetamine, 7.9% used alcohol, and 10.9% used 3 or more drugs simultaneously. Amphetamine and hash dependencies were more prevalent among younger residents in comparison to opioids and alcohol, which were more common among older residents. Opioids were more used by the western region residents, while northern and southern regions residents preferred amphetamine.

Conclusion

This study showed that the residents' drug use patterns are similar to those in other inpatient treatment services. However, opioid dependency is overrepresented. Furthermore, the type of drug used differs according to the residence region, which may warrant consideration when planning services for these regions.

Adolescent therapeutic community treatment – an Australian perspective

Purpose

The purpose of this paper is to provide an overview of the adolescent therapeutic community (ATC) literature – drawing on studies primarily from the USA with consideration made to the Australian context.

Design/methodology/approach

A review of the efficacy research for ATCs is considered, and the characteristics of Australians accessing ATC treatment are discussed in the context of developmental needs.

Findings

Similarities are found in what precipitates and perpetuates adolescent substance use in the USA and Australia, and therefore, what appears to facilitate effective treatment utilising the therapeutic community model.

Originality/value

The paper provides a valuable perspective for Australian services, and explores the application of the ATC model within the Australian treatment context.

Developing a standard for youth modified therapeutic communities

Purpose

The purpose of this paper is to explore the applicability of the Australasian Therapeutic Communities Association (ATCA) Standard to Australian youth-specific modified therapeutic communities (MTCs). An Interpretive Guide for Youth MTCs and Residential Rehabilitation (RR) Services was developed and a pilot trial conducted with three Australian youth MTC services.

Design/methodology/approach

Using a mixed-methods design, this study included three components: a consultation process with residential youth MTCs (N=15), which informed the development of the ATCA Standard Interpretive Guide for Youth MTCs and RR Services; a pilot trial of the materials with three Australian youth MTCs (N=53); and an evaluation of the interpretive guide and assessment of applicability of the ATCA standard to youth MTCs through pre- (N=32) and post- (N=19) pilot trial administrations of the Survey of Essential Elements Questionnaires (SEEQ), and post-pilot trial focus groups (N=21).

Findings

Results indicate that the ATCA Standard is applicable to youth MTC settings when applied with the Interpretive Guide, although no significant differences were found between the pre- and post-pilot trial administrations of the SEEQ.

Practical implications

Future research is recommended to explore active mechanisms of youth-specific MTCs, differences between adults and youth MTCs, and the development of TC-specific training.

Originality/value

To date, no standard for youth residential substance use services in Australia has been developed, and this is the first study of its kind internationally to explore the efficacy of standards in a youth MTC.

Considering the Contemporary Issues and Unresolved Challenges Facing Therapeutic Communities for Clients with Alcohol and Substance Abuse

Alcohol and substance abuse remain significant public health problems in many parts of the occidental world. Some facilities that provide treatment for such abuse often refer to themselves as "Therapeutic Communities" (TCs). However, fundamental compositional differences in TCs present unresolved issues and as such, create significant implications for research, practice, education, and substance/alcohol care policy. Accordingly, this paper examines the heterogeneity and efficacy of TCs; the treatment approaches of harm reduction and abstinence; the training of TC staff and workers; and the recommended length of stay for individuals seeking recovery.

Saudi addiction therapeutic communities:Are they implementing the essential elements of addiction therapeutic communities

Objective:

To investigate whether Saudi therapeutic communities (TCs) implement essential elements of TCs.

Methods:

This is a cross sectional study where the author visited all of the Saudi addiction TCs between September and December 2014. At least one week was spent in each TC, attending many therapeutic activities, reviewing patient files and program documents, and interviewing directors, treating teams and residents. At the end of each visit, a short version of the Survey of Essential Elements Questionnaire (SEEQ) was conducted, which is a reliable tool to evaluate the essential elements of TCs.

Results:

In 2014, there were only 5 TCs in Saudi Arabia. All of them were traditional TCs for adult male residents. The average total score was 3.72 out of 5 on the SEEQ. Regarding the 6 dimensions of the SEEQ, the TCs scored 4.15 on the TC perspective, 3.72 on the agency treatment approach and structure, 4.40 on community as therapeutic agent, 2.60 on educational and work activities, 3.50 on formal therapeutic elements, and 4.3 on process. There were no significant differences in dimensions scores among the 5 Saudi TCs.

Conclusion:

In general, all of the Saudi TCs scored fairly high on the SEEQ, which may reflect a sufficient implementation of the TC as a therapeutic model. Educational and work activities lagged behind the other dimensions and should be improved and re-evaluated.

Knowledge displays: Soliciting clients to fill knowledge gaps and to reconcile knowledge discrepancies in therapeutic interaction

OBJECTIVE

To examine knowledge displays (KDs), a practice by which Therapeutic Community (TC) professionals exhibit previous knowledge about their clients' circumstances and experiences.

METHODS

Conversation analysis is used to examine 12 staff-led meetings recorded in Italy (8 in a drug addiction TC; 4 in a mental health TC).

RESULTS

The TC professionals use KDs within broader sequences of talk where they solicit their clients to share personal information and where the clients provide insufficient or inconsistent responses. In these circumstances, the staff members employ KDs to pursue responses that redress emerging knowledge gaps and discrepancies regarding the clients' experiences or circumstances.

CONCLUSION

KDs allow the staff members to achieve a balance between respecting their clients' right to report their own experiences and influencing the ways in which they report them. KDs help to reinforce the culture of openness that is central to many forms of therapeutic interaction, to forward the therapeutic agenda and to expand the staff members' knowledge of the clients' experiences and circumstances.

PRACTICE IMPLICATIONS

KDs can be used to solicit clients to share personal information. This paper illustrates core features that underlie the function of KDs (where they are used and how they are constructed).

Examining the pathways for young people with drug and alcohol dependence: a mixed-method design to examine the role of a treatment programme

INTRODUCTION

Young people with drug and alcohol problems are likely to have poorer health and other psychosocial outcomes than other young people. Residential treatment programmes have been shown to lead to improved health and related outcomes for young people in the short term. There is very little robust research showing longer term outcomes or benefits of such programmes. This paper describes an innovative protocol to examine the longer term outcomes and experiences of young people referred to a residential life management and treatment programme in Australia designed to address alcohol and drug issues in a holistic manner.

METHODS AND ANALYSIS

This is a mixed-methods study that will retrospectively and prospectively examine young people's pathways into and out of a residential life management programme. The study involves 3 components: (1) retrospective data linkage of programme data to health and criminal justice administrative data sets, (2) prospective cohort (using existing programme baseline data and a follow-up survey) and (3) qualitative in-depth interviews with a subsample of the prospective cohort. The study will compare findings among young people who are referred and (a) stay 30 days or more in the programme (including those who go on to continuing care and those who do not); (b) start, but stay fewer than 30 days in the programme; (c) are assessed, but do not start the programme.

ETHICS AND DISSEMINATION

Ethics approval has been sought from several ethics committees including a university ethics committee, state health departments and an Aboriginal-specific ethics committee. The results of the study will be published in peer-reviewed journals, presented at research conferences, disseminated via a report for the general public and through Facebook communications. The study will inform the field more broadly about the value of different methods in evaluating programmes and examining the pathways and trajectories of vulnerable young people.

Psychopathological symptoms of patients with heroin addiction entering opioid agonist or therapeutic community treatment

BACKGROUND

The relationship between substance use disorders and psychiatric pathology is still an open question. The main aim of the present study was to verify whether the five psychopathological dimensions identified through the SCL-90 tool in a previous study carried out on patients with heroin addiction entering an outpatient opioid agonist treatment (OAT) were also observable in those entering a residential treatment community (TC). Further aims were to look at differences in the psychopathological profiles of patients entering a TC versus an OAT treatment and at the correlation between gender and the observed psychopathology.

METHODS

A confirmatory factor analysis was performed on the results of SCL-90 filled by 1,195 patients with heroin dependence entering TC treatment. It replicates the extraction method previously used on 1,055 OAT patients with heroin addiction by using a principal component factor analysis (PCA). The association between the kind of treatment received (TC or OAT), gender, and the psychopathological dimensions was assessed through logistic regression and general linear model (GLM) analysis.

RESULTS

The PCA carried out on the SCL-90 results of patients entering a TC yielded a five-factor solution, confirming the same dimensions observed in patients entering an OAT: 'worthlessness and being trapped', 'somatization', 'sensitivity-psychoticism', 'panic anxiety', and 'violence-suicide'. The logistic regression analysis showed a statistically significant association between 'somatization' and 'violence-suicide' severity score and OAT. GLM analysis showed that psychopathological factorial scores for 'worthlessness-being trapped', 'somatic symptoms', and 'panic anxiety' dimensions were more severe in OAT vs TC male patients and in TC vs OAT female ones. 'Violence suicide' followed the same severity pattern for males, but did not differ in TC vs OAT females, while 'sensitivity-psychoticism' did not differ in OAT vs TC patients. The five dimensions did not differ in OAT males vs females.

CONCLUSIONS

Our research appears to confirm the existence of a specific aggregation of psychological/psychiatric features within the category of individuals with heroin addiction. It also shows a correlation between the dominant psychopathological subgroup and the assignment to TC versus OAT. Further research is needed to clarify the differences between the five psychopathological subgroups and their determinants.

The Impact of Acculturation, Motivation and the Therapeutic Alliance on Treatment Retention and Outcomes for Hispanic Drug Involved Probationers

Factors associated with retention and outcomes for Hispanic offenders mandated to treatment for substance use disorders have been overlooked in the literature resulting in an impediment to providing evidence-based, culturally relevant treatment services. This project examined the roles of motivational factors, the therapeutic relationship, and acculturation in predicting treatment retention and recidivism among Hispanic male probationers mandated to residential treatment. By following a treatment cohort over one hundred and twenty days, this research identifies factors that may be targeted to improve interventions and policies. The following conclusions are supported: among Hispanic offenders, the number of days in treatment is positively related to motivation to change and level of acculturation.

Sustainment of smoking cessation programs in substance use disorder treatment organizations

INTRODUCTION

The majority of individuals who enter substance use disorder (SUD) treatment also use tobacco. Integrating smoking cessation services into SUD treatment may have substantial public health benefits, but few studies have examined whether organizations offering counseling-based smoking cessation programs sustain them over time.

METHODS

This study examines sustainment of smoking cessation programs using 2 waves of data collected from 150 SUD treatment organizations. Data were collected in 2006-2008 and 2009-2010 using face-to-face interviews, telephone interviews, and mailed surveys. Logistic regression models of sustainment were estimated with administrators' attitudes toward smoking cessation and organizational barriers as covariates.

RESULTS

About 60.2% of these SUD treatment organizations sustained their counseling-based smoking cessation programs at follow-up. Sustainment was significantly more likely when administrators' baseline attitudes about the impact of smoking cessation on recovery were more supportive (odds ratio, OR = 1.84; 95% confidence interval, CI = 1.13-3.01; p =.015) and when programs were accredited (OR = 3.95, 95% CI = 1.65-9.50, p =.002). Worsening over time of barriers encompassing staff interest, staff skills, and competing treatment demands were negatively associated with sustainment (OR = 0.58, 95% CI = 0.42-0.81, p =.001).

CONCLUSIONS

These findings provided empirical support for theoretical perspectives regarding the importance of leadership and staff expertise in promoting sustainment of innovations over time. Although the majority of SUD treatment organizations sustained their smoking cessation programs, the 40% rate of discontinuation is concerning and highlights the ongoing challenges faced by tobacco control efforts in substance abuse treatment.

Educating Staff and Volunteers at a Therapeutic Community for Homeless Persons with Co-Morbid Disorders: Support for Therapeutic Community Curriculum

In Autumn 2011, 12 participants at a newly-formed therapeutic community in western Canada completed 54 hours of Therapeutic Community Curriculum (TCC). Participants completed a shortened version of the Survey of Essential Elements Questionnaire (SEEQ) before and after the training (De Leon & Melnick, 1993b). A paired sample t-test of the SEEQ items revealed a moderate-strong effect size (Cohen's d = .68) and the positive effect of 11 items, at least 1 each from the 6 conceptual domains of the SEEQ. Following training, a focus group found that participants had a better understanding of TC theory and the concepts and believed training would help them in their roles in the community. However, some volunteers felt overwhelmed by the amount of detail covered during training and both staff and volunteers suggested that the experiential exercises could be enhanced.

The availability of integrated care in a national sample of therapeutic communities

Therapeutic communities (TCs) for substance abusers are oriented toward changing the entire person as a means for facilitating a drug-free future. This vision parallels ideas such as integrated care for the treatment of co-occurring substance abuse and psychiatric conditions. The extent to which integrated services are available in TCs has not been documented. Using data from a national sample of 345 TCs, this paper examines the availability of integrated care in TCs and the structural and cultural characteristics of TCs that offer integrated care. The results indicate that a substantial portion of TCs in this sample admit clients with co-occurring disorders (70.7%), and as many as half of the TCs offer integrated care. TCs that offer integrated care show increased use of professional staff, individual psychotherapy, and a less confrontational milieu, but notably, retain many of the "essential elements" of the traditional TC model.

Essential elements of treatment: a comparative study between European and American therapeutic communities for addiction

The purpose of this study was to investigate whether European and American therapeutic communities (TCs) for addiction, both traditional and modified, share a common perspective on what is essential in treatment using the Survey of Essential Elements Questionnaire (SEEQ). The European sample (N = 19) was gathered in 2009. For the American sample (N = 19), we used previously published research data. Despite comparable perspectives, European traditional TCs (N = 11) scored significantly higher than their American predecessors (N = 11) on four SEEQ domains. Cluster differences were more pronounced in Europe than in America.