Do dimensions of therapeutic community treatment predict retention and outcomes?

The path of therapeutic community process experience to recovery capital and psychological well-being as mediated by group working alliance: the role of locus-of-hope

The therapeutic community (TC) is a social-learning treatment program for people with substance use disorders (PSUDs). Most studies focused on how the TC program facilitates positive recovery outcomes. Less emphasis was given to ethnically relevant patient dispositions that may influence the TC process from a collectivist context, especially from Asian developing countries like the Philippines. In this study, we tested the TC process experience's (TCPE) path to recovery capital (RC) and psychological well-being (PWB) as mediated by group working alliance (GWA). We also examined if PSUDs' locus-of-hope (LOH), or the person's goal-pursuit disposition involving external co-agencies like peers, family, and spirit, interact with this mechanism. A total of 451 male PSUDs from TC facilities in the Philippines were surveyed, with 406 participants included in the final analysis. Results showed that the participants' TCPE predicted RC and PWB. The direct pathways were mediated by GWA. There were no significant mediation effects among patients with high internal and external-peer LOH. Moreover, there were significant mediation effects among patients with high external-family and external-spirit LOH. The results suggest the contributions of PSUDs' LOH dispositions to the TC mechanism from a collectivist population, thus revealing nuances of the TC model applied in a vulnerable ethnic context.

The prison-based Therapeutic Community: Resident recommendations for program improvement

INTRODUCTION

The prison-based Therapeutic Community (TC) is widely used within correctional institutions to address substance use disorders (SUDs). While most evaluations of the prison-based TC find the program to be effective, recent mixed evidence and the continued surge of the opioid crisis call for deeper investigation into program operations, barriers to engagement, and sources of treatment effect heterogeneity. Notably lacking from prior evaluations, and critical to our understanding of variable program engagement, is first-hand experiences and perceptions from program participants.

METHODS

To assess prison-based TC resident perceptions of the program and their recommendations for improvement, we utilize data from the Therapeutic Community Prison Inmate Network Study (TC-PINS), a longitudinal data collection effort conducted in one prison-based TC unit within a Pennsylvania state prison. Specifically, we assess resident responses to the open-ended item "What can the TC do better?" Analyzing 470 responses to this question by 177 residents, two independent coders identified seven substantive categories of recommended changes or improvements to their TC program.

RESULTS

Residents provided tangible recommendations for improvement of their prison-based TC program based on their experiences and perceptions. Importantly, a number of their recommendations directly counter the intended model of the TC, which highlights imperative issues underlying the translation of the TC model within the prison environment. Resident suggestions include enhanced structure, increased individualization, expanded curriculum, stricter enforcement of rules, and improved or more experienced staff. Additionally, many question the coercive nature of TC program participation within this prison system.

CONCLUSIONS

Resident recommendations for program improvement unveil important sources of treatment effect heterogeneity and highlight tangible program changes that can be implemented to reduce barriers to treatment engagement. We provide suggested changes to this prison-based TC based on resident perceptions and discuss both the importance and relative ease of eliciting this critical participant feedback.

Eigenvector centrality defines hierarchy and predicts graduation in therapeutic community units

INTRODUCTION

Therapeutic communities (TCs) are mutual aid based residential programs for the treatment of substance abuse and criminal behavior. While it is expected that residents will provide feedback to peers, there has been no social network study of the hierarchy through which feedback flows.

METHODS

Data for this study was drawn from clinical records of peer corrections exchanged between TC residents in six units kept over periods of less than two to over eight years. Four of the units served men while two served women. Hierarchy position was measured using eigenvector centrality, on the assumption that residents who were more central in the network of corrections were lower in the hierarchy. It was hypothesized that residents would rise in the hierarchy over time. This was tested using Wilcoxon paired samples tests comparing the mean and maximum eigenvector centrality for time in treatment with those in the last month of treatment. It was also hypothesized that residents who rose higher in the hierarchy were more likely to graduate, the outcome of primary interest. Logistic regression was used to test hierarchy position as a predictor of graduation, controlling for age, race, risk of recidivism as measured by the Level of Services Inventory-Revised (LSI-R) and days spent in the program.

RESULTS

Residents averaged a statistically significantly lower eigenvector centrality in the last month in all units, indicating a rise in the hierarchy over time. Residents with lower maximum and average eigenvector centrality both over the length of treatment and in the last month of treatment were more likely to graduate in four of the six units, those with lower maximum and average eigenvector centrality in the last month but not over the length of treatment were more likely to graduate in one of the six units, while eigenvector centrality did not predict graduation in one unit. However, this last unit was much smaller than the others, which may have influenced the results.

CONCLUSION

These results suggest that TC residents move through a social network hierarchy and that movement through the hierarchy predicts successful graduation.

Network Integration within a Prison-Based Therapeutic Community

Prison-based therapeutic communities (TCs) are a widespread, effective way to help incarcerated individuals address substance abuse problems. The TC philosophy is grounded in an explicitly relational paradigm that entails building community and conditioning residents to increasingly take responsibility for leadership therein. Although TCs are based on cultivating a network that continuously integrates new residents, many common structural features can jeopardize TC goals and are hence discouraged (e.g., clustering, homophily). In light of this tension, analyzing the TC from a network perspective can offer new insights to its functioning, as well as to broader questions surrounding how networks integrate new members. In this study we examine a men's TC unit in a Pennsylvania prison over a 10-month span. Using data on residents' informal networks, we examine: (1) how well individuals integrate into the TC network across time, (2) what predicts how well residents integrate into the TC, and (3) how well the TC network structure adheres to theoretical ideals. Results suggest that individual integration is driven by a range of hypothesized factors and, with limited exceptions, the observed TC is able to foster a network structure and integrate residents consistent with TC principles. We discuss the implications of these results for evaluating TCs and for understanding the process of network integration.

Social and programmatic interactions in a therapeutic community for women: an exponential random graph model analysis

Purpose

To analyze networks of social interactions between the residents of a therapeutic community (TC) for women and the way, in which such interactions predict the discussion of issues that arise in treatment.

Design/methodology/approach

In total, 50 residents of a corrections-based TC for women were surveyed on the peers with whom they socialized informally, shared meals, shared letters from home and discussed issues that arose in treatment over a 12 h period. The data were analyzed using exponential random graph models (ERGM).

Findings

Reciprocity occurred in all networks while transitivity (a tendency of two residents who are connected to both connect to a third peer) occurred in all networks measuring informal social interactions. When controlling for reciprocity and transitivity, residents avoided spending social time or sharing meals with the same peers. There was no evidence of homophily by race, age or years of education. Homophily by entrance time and case manager occurred in social time. Case manager homophily occurred in the discussion of treatment issues but disappeared when controlling for social time and sharing letters from home.

Research limitations/implications

Social networks in this TC arise from factors endogenous to the TC itself. It should be possible to determine the characteristics of optimal social networks in TCs. External validity is limited.

Practical implications

It should be possible to intervene to optimize the social networks of TC residents.

Originality/value

This is the first ERGM analysis of both informal and formal interactions in a TC.

Pretreatment social network characteristics relate to increased risk of dropout and unfavorable outcomes among women in a residential treatment setting for substance use

Increased retention in residential treatment for substance use disorder (SUD) has been associated with more favorable clinical outcomes for residents. Yet SUD treatment dropout remains high. It is essential to uncover factors contributing to these high rates. Little is known about whether features of an individual's social network prior to treatment entry are related to number of days in treatment or to clinical status at treatment termination. To examine these relationships, we analyzed data from 241 women (58.5% Hispanic) entering an SUD residential treatment facility, who agreed to participate in a parent randomized control trial. We assessed characteristics of these women's social networks prior to treatment entry at baseline. We extracted clinician-determined progress at treatment termination and days in treatment two months after treatment entry from clinical records. Data-driven analyses using purposeful selection of predictors showed that the overall size of the social network was associated with increased likelihood of being classified as having achieved good clinical progress in treatment at termination and that number of drug users in the pretreatment social network was related to staying fewer days in treatment. Contrary to our hypothesis, we found no significant associations between other pretreatment social support network characteristics (i.e., social support) and treatment retention or clinical discharge status. Future research should examine how features of social networks change through treatment and how these changes relate to treatment outcomes.

Building the community: Endogenous network formation, homophily and prosocial sorting among therapeutic community residents

BACKGROUND

Researchers have begun to consider the ways in which social networks influence therapeutic community (TC) treatment outcomes. However, there are few studies of the way in which the social networks of TC residents develop over the course of treatment.

METHODOLOGY

We used a Temporal Exponential Random Graph Model (TERGM) to analyze changes in social networks totaling 320,387 peer affirmations exchanged between residents in three correctional TCs, one of which serves men and two of which serve both men and women. The networks were analyzed within weekly and monthly time-frames.

RESULTS

Within a weekly time-frame residents tended to close triads. Residents who were not previously connected tended not to affirm the same peers. Residents showed homophily by entry cohort. Other results were inconsistent across TC units. Within a monthly time-frame participants showed homophily by graduation status. They showed the same patterns of triadic closure when connected, tendency not to affirm the same peers when not connected and homophily by cohort entry time as in a weekly time frame.

CONCLUSIONS

TCs leverage three human tendencies to bring about change. The first is the tendency of cooperators to work together, in this case in seeking graduation. The second is the tendency of people to build clusters. The third is homophily, in this case by cohort entry time. Consistent with TC clinical theory, residents spread affirmations to a variety of peers when they have no previous connection. This suggests that residents balance network clustering with a concern for the community as a whole.

Treatment engagement in a prison-based Therapeutic Community: A mixed-methods approach

Given the high proportion of inmates with histories of substance use disorders in the era of mass incarceration, many correctional institutions have integrated the prison-based Therapeutic Community (TC) into their programming. While most evaluations provide evidence of lowered rates of relapse and recidivism, the majority of TC graduates still have negative outcomes post-release. Filling an important gap in the TC treatment literature, we analyze quantitative measures of treatment engagement alongside qualitative narratives from prison-based TC residents, providing an essential look into the black box of TC treatment mechanisms. Quantitative results show more between-person variation than within-person change, reflecting trivial increases in treatment engagement throughout time in the program. Qualitative results unpack these findings, pointing to processes of selection bias, heterogeneous treatment effects, and program fidelity lapses. In combination, our mixed data identify tangible modifications to program implementation that could strengthen desired post-release outcomes.

The recovery-oriented therapeutic community for addictions (ROTC): a response to contemporary substance use disorder treatments in the Philippines

Purpose

The Philippines’ nationwide campaign on drugs has been under the limelight due to its controversial approaches in dealing with the problem of addiction. Despite the government’s current efforts, substance use disorders continue to persist within the population. The purpose of this paper is to provide recommendations for addressing the issue of substance use disorder treatment through a modification of the therapeutic community (TC) in the Philippine context.

Design/methodology/approach

This conceptual paper reviews the existing facts about the Philippines’ campaign against drugs, the approaches implemented by the government, current state and research developments of TCs, and its resulting impact on contemporary evidence-based treatment for addiction in the country.

Findings

A treatment framework outlining a recovery-oriented therapeutic community (ROTC) is presented. The ROTC aims to address addiction as a chronic, relapsing disease. This alternative approach for addiction treatment in the Philippines is based on the concept of recovery, principles of effective substance use disorder treatment, and recent developments in TC best practices from the international community.

Originality/value

This paper discusses different recommendations for policy development, interventions and research, aimed at improving the odds of securing recovery for people suffering from addiction.

The alumni club: interpersonal contact and the exchange of recovery oriented helping in a sample of former residents of a therapeutic community for women

Purpose

Aftercare is an important predictor of outcomes following treatment for substance abuse. Despite this, there is evidence that the great majority of substance abusing clients choose not to participate in aftercare. Aftercare programs that are tied to specific residential treatment facilities, sometimes known as alumni groups or alumni clubs, might increase participation by offering former residents the opportunity to maintain treatment oriented social networks. Therapeutic communities (TCs), which emphasize mutual aid between residents, are ideal candidates for such programs. The paper aims to discuss these issues.

Design/methodology/approach

In total, 100 randomly chosen former TC residents were randomly surveyed regarding their contact with fellow alumni and their exchange of recovery oriented helping behaviors. A thirty day timeline follow-back methodology was used.

Findings

Contact was primarily through electronic means, particularly phone calls, texts and the alumni club Facebook page. Participants who reported more electronic contact also reported more days in which they offered and received recovery oriented help. Participants who were African American or had spent more time in TC treatment offered and received recovery oriented help on more days.

Research limitations/implications

While this is an exploratory study limited to one TC, this alumni club allows for the maintenance of a mutual aid network after termination. That network primarily consists of electronic forms of contact. A longer time spent in TC treatment may allow for the internalization of the practice of mutual aid. Further research on alumni clubs is warranted.

Originality/value

This is the first survey of TC alumni club members.

A Meta-Analysis of the Efficacy of Case Management for Substance Use Disorders: A Recovery Perspective

Background: Case management is a client-centered approach to improve the coordination and continuity of service delivery, especially for persons with substance use disorders (SUD) and multiple and complex support needs. This intervention supports individuals by helping them identify needed services, facilitate linkage with services, and promote participation and retention in services. However, it is questionable whether case management is equally effective in promoting recovery and aspects of personal functioning. The objective was to conduct an updated meta-analysis and to assess whether case management was more effective than treatment as usual (TAU) among persons with SUD for improving treatment-related (e.g., successful linkage with and retention in treatment) as well as personal functioning outcomes (e.g., substance use). Methods: This meta-analysis focuses on randomized controlled trials (RCTs) that included persons with alcohol or drug use disorders and compared case management with TAU. To be eligible, interventions had to meet core case management functions as defined in the literature. We conducted searches of the following databases to May 2017: the Cochrane Drugs and Alcohol Specialized Register, CENTRAL, PubMed, Embase, CINAHL, and Web of Science. Also, reference lists of retrieved publications were scanned for relevant (un)published studies. Results: The overall effect size for case management compared to TAU across all outcome categories and moments was small and positive (SMD = 0.18, 95% CI 0.07-0.28), but statistically significant. Effects were considerably larger for treatment tasks (SMD = 0.33, 95% CI 0.18-0.48) than for personal functioning outcomes (SMD = 0.06, 95% CI -0.02 to 0.15). The largest effect sizes were found for retention in substance abuse treatment and linkage with substance abuse services. Moderator effects of case management models and conditions were assessed, but no significant differences were observed. Conclusions: The primary results from earlier meta-analyses were supported: case management is more effective than TAU conditions for improving outcomes, but this effect is significantly larger for treatment-related tasks than for personal functioning outcomes. Case management can be an important supplement to available services for improving linkage and retention, although further research is needed to assess its potential for supporting recovery from a longitudinal perspective.

Completion rates and psychosocial intervention effectiveness in an Australian substance use therapeutic community

BACKGROUND

Program attrition is a major problem in substance use treatment. It is not clear which client and treatment variables are related to successful completion. This study aimed to identify client variables associated with Therapeutic Community (TC) completion. A secondary aim was to investigate changes in entry and exit scores on psychosocial outcome measures.

METHODS

Retrospective quantitative analysis of data collected from 193 Australian TC residents, over 3.5 years. Variables measured included: demographics; Depression, Anxiety, Stress Score (DASS-21) and World Health Organisation Quality of Life 8 questions (WHOQOL-8).

RESULTS

Completion rates were 30.6%. High Money WHOQOL-8 scores, suggestive of minimal financial stressors, positively predicted completion. Multivariate analyses showed that negative predictors of completion were: amphetamine being primary substance of concern, aggression, high Relationship WHOQOL-8 scores, suggestive of positive relationships, and younger or older age. Those in the program demonstrated clinically significant psychological improvement and significant improvement in all quality of life scores over time. The degree of psychometric improvement was most pronounced in those who completed the course, with the exception of depression, stress, and money problems.

CONCLUSION

The findings provide an understanding of specific predictors of program completion which may help to identify high-risk clients and inform program improvement. Early attrition rates may be reduced by monitoring and supporting high-risk clients. Overall, psychometric improvement occurred amongst both completers and non-completers overtime but is most prominent amongst course completers, with the exception of depression, stress, and money problems. Future research could potentially focus on amphetamine users and shortened TC programs, focusing on acute psychosocial intervention.

Traits associated with treatment retention in a therapeutic community for substance dependence

Purpose

The treatment of severe and chronic substance dependence is challenged by high rates of treatment attrition, highlighting the need to identify factors that hinder treatment retention. The paper aims to discuss this issue.

Design/methodology/approach

The present study examined certain neurocognitive and personality traits in relation to treatment retention in a sample of 46 residents of an Australian therapeutic community (TC). The traits examined were previously found to be associated with problematic substance use in non-clinical samples and were also previously shown to differentiate TC clients from social drinkers. The hypothesis was thus that traits that appear to be risk factors for addictions are also likely to impact on TC treatment retention.

Findings

Group comparisons of those retained for more than the recommended 90 days vs those who left treatment prematurely showed that after controlling for the influence of depression, those who left treatment prematurely reported significantly higher levels of trait impulsivity, punishment sensitivity and executive cognitive dysfunction. There was a very high rate of alexithymia in the sample (52 per cent), but alexithymia was unrelated to retention.

Research limitations/implications

The final sample size was less than planned but reflected the strict participation criteria and temporal limitations of this study. No statistical assumptions were violated and the reliability indices of the scales completed by clients ranged from acceptable to excellent. Another limitation was that dropout cannot be assumed to mean relapse, as the reasons for client dropout were not available.

Originality/value

Findings highlight the important roles of trait factors in TC treatment retention in addition to the motivational and interpersonal factors identified in previous work.

Generosity, fairness, trust and time: the performance of therapeutic community residents in economics experiments

Purpose

Therapeutic communities (TCs) assume that residents are capable of working together to overcome substance abuse and criminal behavior. Economic games allow us to study the potential of cooperative behavior in TC residents. The paper aims to discuss this issue.

Design/methodology/approach

The authors analyze results from a sample of 85 corrections-based TC residents and a comparison group of 45 individuals drawn from the general population who participated in five well-known economic experiments – the dictator game, the ultimatum game, the trust game, risk attitude elicitation and time preference elicitation.

Findings

TC residents keep less money in the dictator game and return more in the trust game, and prefer short-term rewards in the time preference elicitation. In the ultimatum game, nearly half of all residents refuse offers that are either too low or too high.

Research limitations/implications

While the study involves a sample from one TC and a comparison group, the results suggest that residents are at least comparable to the general public in generosity and appear willing on average to repay trust. A substantial minority may have difficulty accepting help.

Practical implications

Rapid peer feedback is of value. Residents will be willing to offer help to peers. The TC environment may explain residents’ tendency to return money in the trust game. Residents who refuse to accept offers that are either too low or too high in the ultimatum game may also have difficulty in accepting help from peers.

Social implications

Economic games may help to clarify guidelines for TC clinical practice.

Originality/value

This is the first use of economic games with TC residents.

Saving My Life: Dynamics of Peer and Staff Corrections Among Therapeutic Community Residents

BACKGROUND

Therapeutic communities (TCs) maintain order and encourage behavior change through a system of peer corrections. This study is the first quantitative analysis of the dynamics of the exchange of peer corrections at TCs.

OBJECTIVES

We applied longitudinal social network analysis to compare the reactions of TC residents to peer versus staff intervention, while analyzing dynamics of correction exchange among residents.

METHOD

The data consisted of a large database of staff and peer affirmations and corrections at four therapeutic community units that occurred between the years 2006 and 2008. We modeled the data as a directed temporal social event network, using a generalized linear mixed effects model to analyze predictors of corrections among residents.

RESULTS

Residents were more likely to send a correction following peer affirmations and corrections than following staff affirmations and corrections. Residents reciprocated corrections to individual peers. Autocorrelation was evident in both sending and receiving corrections and residents were more likely to send a correction after having sent an affirmation. Residents who arrived at roughly the same time were more likely to exchange corrections. Residents tended to send and receive more corrections in the middle 3 months of their treatment. European American residents and those with higher scores on the LSI-R were more likely to receive corrections than others.

CONCLUSIONS

TC residents respond more strongly and more positively to peer than to staff intervention. The pattern of exchange of peer corrections in TCs is complex. This suggests possible paths to improved outcomes.

Attachment, motivation, and clinical progress in a Filipino therapeutic community: a mediation analysis

Purpose

The therapeutic community (TC) is a widely used intervention program in treating substance use disorders. Despite its documented utility, researchers and practitioners are still perplexed on how it exactly works. The purpose of this paper is to suggest the role of attachment styles and treatment motivation in the TC process.

Design/methodology/approach

Applying an explanatory correlational research, this notion was tested by examining the responses of 200 patients with substance use disorder in a TC using mediation analysis.

Findings

The results revealed that attachment styles indirectly affect client’s clinical progress by the path of treatment motivation. Although the current study cannot conclude causality, the results provide empirical evidence suggesting that attachment activates motivation in treatment within the social dynamics of the TC, thus influencing clinical progress.

Originality/value

From these findings, recommendations for the modification of TCs along with considerations for further research, and socio-political implications are discussed.

A network of helping: Generalized reciprocity and cooperative behavior in response to peer and staff affirmations and corrections among therapeutic community residents

BACKGROUND

Clinical theory in therapeutic communities (TCs) for substance abuse treatment emphasizes the importance of peer interactions in bringing about change. This implies that residents will respond in a more prosocial manner to peer versus staff intervention and that residents will interact in such a way as to maintain cooperation.

METHOD

The data consist of electronic records of peer and staff affirmations and corrections at four corrections-based therapeutic community units. We treat the data as a directed social network of affirmations. We sampled 100 resident days from each unit (n = 400) and used a generalized linear mixed effects network time series model to analyze the predictors of sending and receiving affirmations and corrections. The model allowed us to control for characteristics of individuals as well as network-related dependencies.

RESULTS

Residents show generalized reciprocity following peer affirmations, but not following staff affirmations. Residents did not respond to peer corrections by increasing affirmations, but responded to staff corrections by decreasing affirmations. Residents directly reciprocated peer affirmations. Residents were more likely to affirm a peer whom they had recently corrected. Residents were homophilous with respect to race, age and program entry time.

CONCLUSION

This analysis demonstrates that TC residents react more prosocially to behavioral intervention by peers than by staff. Further, the community exhibits generalized and direct reciprocity, mechanisms known to foster cooperation in groups. Multiple forms of homophily influence resident interactions. These findings validate TC clinical theory while suggesting paths to improved outcomes.

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.

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).

The impact of a randomised trial on TC environments

Purpose

– The purpose of this paper is to investigate the possible impact of a randomised controlled trial on the therapeutic environment of participating therapeutic communities (TCs).

Design/methodology/approach

– The authors compared the environment in four democratic day TCs involved in a randomised trial (experimental TCs) with a similar democratic day TC not involved in the trial (the control TC) by administering the Community Oriented Environment Scale (COPES) to 28 TC members.

Findings

– TC members’ views of the real psychosocial environment at the experimental TC and control TC showed similar high levels for spontaneity, autonomy and personal problem orientation and similar intermediate levels for practical orientation and staff control. The TC members at the experimental TC rated significantly higher levels for order and organisation and clarity, while members at the control TC rated a significantly higher level for involvement.

Originality/value

– The study provided no evidence of a significant adverse impact on the culture of democratic day TCs due to participation in a randomised trial. This finding answers one of the most common arguments in the debate on the ethics of RCTs in TCs.

Factors associated with substance use treatment completion in residential facilities

PURPOSE

Individuals in residential treatment often face many challenges, which can include limited education, unstable housing, difficulty participating in the workforce, and severe substance use problems. We analyzed factors associated with substance use treatment completion. We focused on factors that can be influenced by health care system changes resulting from the Affordable Care Act (ACA).

DATA AND METHODS

We used the 2010 Treatment Episode Data Set - Discharges (TEDS-D), which is made available by the Substance Abuse and Mental Health Services Administration (SAMHSA). We analyzed factors associated with substance use treatment completion using logistic regression.

RESULTS

Individuals in residential treatment were often unemployed or not in the labor force, had prior substance use treatment episodes, used more than one substance, and were uninsured. Factors associated with treatment completion included older age, greater education, employment, criminal justice referral, not being homeless, and private insurance.

CONCLUSION

The expansion in private insurance coverage as a result of the ACA may result in more treatment completion in residential settings. Changes to the Medicaid program resulting from the ACA, including coverage of substance use treatment as an essential health benefit and greater support for housing, education, and employment, may also contribute to more residential discharges ending in treatment completion.

Improving the retention rate for residential treatment of substance abuse by sequential intervention for social anxiety

BACKGROUND

Residential drug rehabilitation is often seen as a treatment of last resort for people with severe substance abuse issues. These clients present with more severe symptoms, and frequent psychiatric comorbidities relative to outpatients. Given the complex nature of this client group, a high proportion of clients seeking treatment often do not enter treatment, and of those who do, many exit prematurely. Given the highly social nature of residential drug rehabilitation services, it has been argued that social anxieties might decrease the likelihood of an individual entering treatment, or increase the likelihood of them prematurely exiting treatment. The current paper reports on the protocol of a Randomised Control Trial which examined whether treatment of social anxiety prior to entry to treatment improves entry rates and retention in residential drug rehabilitation.

METHOD/DESIGN

A Randomised Control Trial comparing a social skills treatment with a treatment as usual control group was employed. The social skills training program was based on the principles of Cognitive Behaviour Therapy, and was adapted from Ron Rapee's social skills training program. A permutated block randomisation procedure was utilised. Participants are followed up at the completion of the program (or baseline plus six weeks for controls) and at three months following entry into residential rehabilitation (or six months post-baseline for participants who do not enter treatment).

DISCUSSION

The current study could potentially have implications for addressing social anxiety within residential drug treatment services in order to improve entry and retention in treatment. The results might suggest that the use of additional screening tools in intake assessments, a focus on coping with social anxieties in support groups for clients waiting to enter treatment, and greater awareness of social anxiety issues is warranted.

AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRY

Australian New Zealand Clinical Trials Registry (ACTRN) registration number: ACTRN12611000579998.

Short-Run Prosocial Behavior in Response to Receiving Corrections and Affirmations in Three Therapeutic Communities

Therapeutic communities (TC s) have a strong record of maintaining a high quality social climate on prison units. One possible reason for this is the system of mutual monitoring among TC residents, based on the assumption that peer affirmation of behavior in accord with TC norms and peer correction of behavior contrary to TC norms will lead to increased resident prosocial behavior. Laboratory experiments have demonstrated that such peer monitoring can lead to cooperation, but there has been no quantitative test of this hypothesis in an actual TC. In this article we test this assumption by using the affirmations that residents of three different TCs send as a measure of prosocial behavior following the reception of peer affirmations and corrections. At all three facilities residents send more affirmations following the reception of both affirmations and corrections, with this relationship being stronger and longer lasting after receiving affirmations. No other variable consistently predicts the number of affirmations that residents send to peers. These findings imply that mutual monitoring among TC residents can lead to increased levels of prosocial behavior within the facility, and that prosocial behavior in response to peer affirmations plays a key role.

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.