National Institute on Drug Abuse RESEARCH MONOGRAPH SERIES Therapeutic Community: Advances in Research and Application U.S. Department of Health and Human Services1 • Public4 Health Service4 • National Institutes of Health Therapeutic Community: Advances in Research and Application Editors: Frank M. Tims, Ph.D. Division of Clinical Research National Institute on Drug Abuse George De Leon, Ph.D. Center for Therapeutic Community Research National Development and Research Institutes Nancy Jainchill, Ph.D. Center for Therapeutic Community Research National Development and Research Institutes NIDA Research Monograph 144 1994 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health National Institute on Drug Abuse 5600 Fishers Lane Rockville, MD 20857 ACKNOWLEDGMENT This monograph is based on the papers from a technical review on “Therapeutic Community: Advances in Research and Application” held on May 16-17, 1991. The review meeting was sponsored by the National Institute on Drug Abuse. COPYRIGHT STATUS The National Institute on Drug Abuse has obtained permission from the copyright holders to reproduce certain previously published material as noted in the text. Further reproduction of this copyrighted material is permitted only as part of a reprinting of the entire publication or chapter. For any other use, the copyright holder’s permission is required. All other material in this volume except quoted passages from copyrighted sources is in the public domain and may be used or reproduced without permission from the Institute or the authors. Citation of the source is appreciated. Opinions expressed in this volume are those of the authors and do not necessarily reflect the opinions or official policy of the National Institute on Drug Abuse or any other part of the U.S. Department of Health and Human Services. The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this publication are used only because they are considered essential in the context of the studies reported herein. National Institute on Drug Abuse NIH Publication No. 94-3633 Printed 1994 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of American Statistics Index, BioSciences Information Service, Chemical Abstracts, Current Contents Psychological Abstracts, and Psychopharmacology Abstracts. ii Contents Page Therapeutic Communities and Treatment Research . 1 Frank M. Tims, Nancy Jainchill, and George De Leon The Therapeutic Community: Toward a General Theory and Model . 16 George De Leon Socialization Into the Therapeutic Community Culture . 54 Lorand Szalay Client Outcomes From Therapeutic Communities . 80 Ward S. Condelli and Robert L. Hubbard Retention in Therapeutic Communities: Challenges for the Nineties . 99 Benjamin F. Lewis and Roy Ross Predictors of Retention in Therapeutic Communities . .117 Ward S. Condelli Adolescents in Therapeutic Communities: Retention and Posttreatment Outcome . 128 Kenneth F. Pompi Therapeutic Communities: Substance Abuse Treatment for Women . 162 Sally J. Stevens and Peggy J. Glider Therapeutic Communities in Prison . 181 Harry K. Wexler and Craig T. Love iii Co-Morbidity and Therapeutic Community Treatment . 209 Nancy Jainchill HIV and Therapeutic Communities . 232 Jane McCusker and James L. Sorensen Therapeutic Communities in Corrections and Work Release: Some Clinical and Policy Considerations . , . 259 James A. Inciardi, Dorothy Lockwood, and Steven S. Martin Clinical Issues in Therapeutic Communities . 268 Jerome F.X. Carroll Therapeutic Community Research and Practice: Recommendations . 280 Frank M. Tims, George De Leon, and Nancy Jainchill iv Therapeutic Communities and Treatment Research Frank M. Tims, Nancy Jainchill, and George De Leon INTRODUCTION Programs to treat drug abuse and addiction/dependence are a relatively recent innovation. Drug abuse programs emerged in an organized way in the 1960s as a response to this major social and public health problem in the United States. Mainstream organized health care was not prepared, either intellectually or organizationally, to respond to the drug abuse epidemic; thus, an alternative system developed. The growth of treatment facilities in the 1960s and 1970s reflected differing views of the nature of drug abuse and addiction and what was required to treat it effectively. Aside from detoxification units, which were intended to provide the first step in treatment but more commonly provided only a brief respite from the rigors of addiction, three modalities emerged as the dominant treatment types for drug abusers: drug-free outpatient programs; outpatient methadone maintenance programs; and long-term, drug-free residential programs called therapeutic communities (TCs). More recently, short-term residential programs using 12-step or other non-TC approaches have emerged (Institute of Medicine 1990). TREATING DRUG PROBLEMS This monograph grew out of a technical review meeting that took place in May 1991. The technical review was convened by the National Institute on Drug Abuse (NIDA) for the purpose of systematically examining the TC modality and the existing body of research on TC treatment, to review and consolidate knowledge about this modality, and to chart future directions in TC research. While the TC is a major modality that is unique in its view and application of treatment, research in this modality also has implications for other modalities; in fact, methods developed in TCs have been applied in other programs (De Leon et al. 1993). In addition to reviewing the TC research base to guide future lines of investigation, the goal of the technical review was to involve the TC movement’s practitioners to the greatest extent feasible. An essential 1 feature of research on treatment programs and modalities is the active cooperation of practitioners as partners in the research enterprise. These practitioners are in a position to facilitate the research, to offer insights during its planning and conceptualization, to provide guidance on critical issues and questions, and to provide feedback on analytic interpretations. As users of applied research, TC practitioners can help focus research so that it is truly useful. Thus, it was decided to invite the Therapeutic Communities of America (TCA) to attend the meeting, to form three panels (research, clinical, and administrative), and to report back to the group during the final phase of the meeting. Although the TCA reports are not contained in this monograph, they were useful in developing the recommendations contained in the final chapter. TC PROGRAMS TC programs reflect a view of the drug abuse client as having a social deficit and requiring social treatment. This social treatment may be characterized as an organized effort to resocialize the client, with the community as an agent of personal change. There has been much folklore and misinformation about TCs. They are viewed by some as isolated from the mainstream of drug abuse treatment, antagonistic toward medications in drug abuse treatment, and not generally receptive to research. Regarding the first point, TCs have evolved from a self-help perspective as a social movement. Because TCs utilize a social treatment approach, their leaders and practitioners have not tended to have medical credentials. Indeed, given their history and self-help perspective, TC staff (at all levels) have included ex-addicts, social activists, and health professionals. It should be noted that all drug abuse treatment modalities have evolved in a rather short span of time, and TCs are generally accepted by practitioners in other modalities as a legitimate treatment approach. Existing drug abuse treatment modalities evolved in response to a need that the mainstream health care system was not meeting, and the evolution of these modalities is in the direction of integration. While medications, notably methadone, are not generally part of TC treatment, some TCs permit appropriate use of psychotropic medications under medical supervision, as long as they do not pose a threat to the abstinence norms that are therapeutically important. It also is important to note that, 2 while many TCs may not have research departments, much of the existing research in the drug abuse literature was carried out in cooperation with TC programs. In fact, some of the early landmark studies on treatment effectiveness were carried out by TC researchers (Collier and Hijazi 1974; De Leon 1984). TCs tend to share a similar view of the client, an emphasis on structure and hierarchy within the program, a need to isolate the individual from competing influences during treatment, a need for a prolonged period of treatment that is phased and intensive, and clear norms regarding personal responsibility and behavior which form the core of treatment. Learning, accepting, and internalizing these norms is accomplished through a highly structured treatment process that requires active participation by the client in a context of confrontation (to address denial, false beliefs, and defense mechanisms), mutual self-help, and affirmation of program expectations. Thus, as De Leon points out in the following chapter, community is treatment. The therapeutic process involves the group (the community) constantly, but also must involve the individual. An aphorism of the TC movement is,“Only you can do it, but you can’t do it alone.” MAJOR AREAS OF FOCUS Not all residential drug