Modified therapeutic community for homeless mentally ill chemical abusers. Sociodemographic and psychological profiles

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.

Deconstructing the Concept of “Special Populations”

As part of the April 2001 “Common Ground, Common Language, Common Goals: Bringing Substance Abuse Practice and Research Together” conference, a panel of treatment provider experts was assembled to discuss the unique treatment needs of “special populations.” The “Special Populations” panel was initially guided by the assumption that clients with unique needs should be considered as distinct homogeneous groups, outside the mainstream. However, as panel members revealed, the heterogeneity of the substance abuse treatment client population suggests that the concept of “special populations” may be inappropriate and that alternative approaches to conceptualizing diversity within the substance abuse treatment client population are needed. The present paper provides background on the use of term “special populations” in the substance abuse field and summarizes discussions that occurred during the “Special Populations” panel regarding the application of this concept to clients in substance abuse treatment.

A systematic review of studies examining effectiveness of therapeutic communities

Purpose

– The purpose of this paper is to systematically review quantitative research since 2000 on the effectiveness of residential therapeutic communities (TCs) for the treatment of substance-use disorders with reference to substance-use, crime, mental health and social engagement outcomes.

Design/methodology/approach

– A systematic search with broad inclusion criteria resulted in the review of 11 studies. The studies investigated community-based TCs, as well as TCs modified for prisoners, prisoners transitioning to community living and TCs for individuals with co-occurring substance-use and mental health issues.

Findings

– Results were analysed by comparing the findings of the studies under investigation, of which three studies investigated within-subjects outcomes, four compared TC treatment with a no-treatment control condition and four compared TC treatment with another treatment condition. Conclusion: consistent with previous systematic reviews of TCs, outcomes varied across studies but indicated TCs are generally effective as a treatment intervention, with reductions in substance-use and criminal activity, and increased improvement in mental health and social engagement evident in a number of studies reviewed.

Research limitations/implications

– Variability in outcomes suggests further TC research and research syntheses focusing on a second key research question in the evaluation of complex interventions – how the intervention works – could play an important role in understanding TC effectiveness, and for whom it is effective and in what contexts.

Practical implications

– Although there is some variability in treatment populations included in this review, evidence reported in other studies suggests individuals with severe substance-use disorders, mental health issues, forensic involvement and trauma histories, will benefit from TC treatment. This is supported by the literature which has found a general relationship between severity of substance use and treatment intensity (Darke et al., 2012; De Leon et al., 2008) with outcomes further enhanced by self-selection into treatment and appropriate client-treatment matching (see De Leon, 2010; De Leon et al., 2000, 2008). The weight of evidence gleaned from multiple sources of research, including randomised control trials and field outcome studies (De Leon, 2010) suggests TCs are an important and effective treatment for clients in improving at least some aspects of their quality of life, specifically mental health and social engagement, and in reducing harmful behaviours, including substance-use and crime. Variability in treatment setting and populations reflect the real-world setting in which TC treatment is delivered, providing a multifaceted treatment modality to a complex population in variable circumstances.

Originality/value

– The strength of the current study is that it provided a broad evaluation of TC effectiveness across a range of outcomes (substance-use, criminal activity, mental health and social engagement), and is therefore valuable in updating the current literature and providing context for future research in this area. It aimed to address a key question in evaluating complex interventions: whether they are effective as they are delivered. Findings suggest that TC treatment is generally effective for the populations of concern in reducing substance use and criminal activity and contributing to some improvement in mental health and social engagement outcomes.

Personality disorders and retention in a therapeutic community for substance dependence

Although therapeutic community (TC) treatment is a promising intervention for substance use disorders, a primary obstacle to successful treatment is premature attrition. Because of their prevalence within substance use treatment facilities, personality disorder (PD) diagnoses have been examined as predictors of treatment completion. Prior research on TC outcomes has focused almost exclusively on antisocial personality disorder (ASPD), and the results have been mixed. This study extends previous research by examining the impact of the 10 Axis II PDs on early (first 30 days) attrition as well as overall time to dropout in a 9-month residential TC. Survival analyses indicated that borderline was the only PD negatively related to overall program retention. In contrast, ASPD, as well as histrionic PD, were related to very early attrition, but not to overall program retention. Early assessment and identification of at-risk individuals may improve treatment retention and outcome for TC treatment.

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.

Modified therapeutic communities and adherence to traditional elements

Traditional therapeutic communities (TCs) are characterized by confrontational group therapy, treatment phases, a tenure-based resident hierarchy, and long-term residential care. Many TCs have modified the structure and intensity of the traditional model, tailored services for specific client populations, and hired more professionally trained staff. This study examines the extent to which modified TCs are able to retain the underlying core technology of the TC. Using data from a nationally representative sample of 380 self-identified TCs, six traditional TC elements are identified. Results from a structural equation model indicate that offering services for specific populations and professionalization of staff has limited impact on the six TC elements. Modifications to structure and intensity of TC programming evidenced the strongest effect. Specifically, outpatient-only TCs showed significantly lower adherence to five of the six elements. Short-term residential programs showed a similar negative trend. Findings suggest selected modifications are possible without significantly impacting the TC model's core technology.

Counselor emotional exhaustion and turnover intention in therapeutic communities

Counselor turnover is a significant problem facing substance abuse treatment agencies. Understanding the role of organizational culture in predicting burnout and turnover intention may yield important information on how to address turnover in treatment organizations. Using data collected from 817 counselors employed in a national sample of 253 therapeutic communities (TCs), structural equation modeling was used to estimate the associations between emotional exhaustion, turnover intention, and three measures of organizational culture: centralized decision making, distributive justice, and procedural justice. The model controlled for counselor demographics, credentials, and earnings. Counselors' emotional exhaustion scores were higher in TCs with greater centralized decision making (p < .01) but lower in TCs where greater distributive justice (p < .05) and procedural justice (p < .001) were reported. Likewise, turnover intention was positively associated with centralized decision making (p < .05) and inversely associated with the workplace justice measures (p < .001). These data suggest that management practices in TCs and perhaps in other types of substance abuse treatment facilities likely play a substantial role in counselors' well-being and in their decisions to leave their jobs. Because these practices are not structural features of organizations, they may be targeted for intervention and change.

Alcohol use and other psychiatric disorders in the formerly homeless and never homeless: prevalence, age of onset, comorbidity, temporal sequencing, and service utilization

Interview survey data were collected on a large (n = 4730) general population sample of adults subsequently classified as "never homeless" (NH) or "formerly homeless" (FH), with the latter group consisting of persons who had past experience of at least a one-month period with no regular place to live. The objective was to analyze differences, as a function of this classification, in the prevalence, age of onset, comorbidity, temporal sequencing, and service utilization pertinent to alcohol-use and other psychiatric disorders. Almost half of the FH group were found to have a one-year DSM diagnosis, nearly twice the rate seen in the NH group. Moreover, at 15.1%, the prevalence of alcohol-use disorder (AUD) comorbid with one or more other psychiatric disorders was five times that reported by NH participants. Subsequent analyses addressed differences betweenthe FH (n = 167) and NH (n = 1031) groups within the subset who met criteria for one or more psychiatric diagnoses. Focusing on drinking behavior, we found that among the FH, dual-diagnosis was associated with elevated rates of alcohol-use problem symptoms and with greater alcohol consumption than were evident in the FH with AUD alone. Also, among the FH with comorbid AUD, as well as among those with two or more psychiatric disorders unrelated to alcohol, there was an earlier onset of psychiatric disorders than in the NH. This earlier onset may have placed these individuals at greater risk for later homelessness and AUD, and may also be indicative of a more severe course of illness. Differences between the FH and the NH suggest the importance of devoting special attention to this unique sample.

Improved psychological status in a modified therapeutic community for homeless MICA men

An adaptation of the drug-free therapeutic community (TC) model to homeless men with comorbid mental illness and chemical addiction (MICA) was evaluated with respect to change in psychological status over the course of a six-month residential treatment. Psychological status was assessed by: the Symptom Checklist-90-R (SCL90-R), Beck Depression Inventory (BDI), Shortened Manifest Anxiety Scale (SMAS), and Tennessee Self-Concept Scale (TSCS). A total of 52 out of an original study cohort of 124 residents were followed in longitudinal analyses to treatment midpoint, with a subset of 34 assessed through treatment completion. Significant, widespread psychological improvements were found during both the first and second half of treatment; it would appear that distress reduction was ongoing throughout treatment, with intrapersonal preceding interpersonal relief. The premise of applying a socially-based treatment to this population is discussed in light of these findings.

Co-occurring mental and substance use disorders: promising approaches and research issues

This paper surveys the mental health and drug user treatment literature, identifying promising approaches and research issues in the treatment of co-occurring mental illness and substance use disorders. The prevalence and classification of co-occurring disorders are briefly reviewed, and selected treatment models currently in use are described. Three models are cited as representing particularly promising approaches--comprehensive integrated treatment, assertive community treatment, and the modified therapeutic community--and best practices are summarized. This paper proposes a research agenda focused on relevant emerging treatment issues.

Modified therapeutic community for homeless mentally ill chemical abusers: treatment outcomes

This study compared homeless mentally ill chemical abuser (MICA) clients (n = 342), male and female, sequentially assigned to either of two modified therapeutic community programs (TC1 and TC2) and to a treatment-as-usual (TAU) control group. Follow-up interviews were obtained at 12 months postbaseline and at time F (on average more than 2 years postbaseline) on a retrieved sample of 232 (68%) clients and 281 (82%) clients, respectively. Outcome measures assessed five domains: drug use, crime, HIV risk behavior, psychological symptoms, and employment. Individuals in both modified TC groups showed significantly greater behavioral improvement than TAU at 12 months and time F, and the modified TC2, with lower demands and more staff guidance, was superior to modified TC1. Completers of both TC programs showed significantly greater improvement than dropouts and a subgroup of TAU clients with high exposure (i.e., more than 8 months) to other treatment protocols. The present findings support the effectiveness and longer term stability of effects of a modified TC program for treating homeless MICA clients.

A program evaluation study of a nursing home operated as a modified therapeutic community for chemically dependent persons with AIDS. Project Samaritan AIDS Services, Inc.'s Residential Health Care Facility, Highbridge Section, Bronx, NY

An interagency evaluation of the treatment effectiveness of a speciality nursing home (NH) run as a therapeutic community (TC) for residents diagnosed with acquired immunodeficiency syndrome (AIDS) and substance abuse/dependence (SA/D) was conducted. A total of 79 chemically dependent men and women with AIDS were: (a) administered the Tennessee Self-Concept Scale (TSCS; Roid & Fitts, 1991) at initial testing (T(1)) and 8 months after their initial testing (T(2)); and (b) assessed on specific physical health indicators (i.e. , weight, CD-4 count, and viral load) and other treatment outcomes (e.g., abstinence) over the same two time periods. The TSCS results identified a valid and invalid TSCS test group and further distinguished among three subgroups of invalid responders. Significant improvements were observed from T(1) testing to T(2) testing on the TSCS, on the physical health indicators, and on other treatment outcomes. The need for additional and continued mental health services for this population was noted.

Modified therapeutic community for homeless mentally ill chemical abusers: emerging subtypes

This paper is one of a series reporting on a clinical field trial evaluating the efficacy of the modified therapeutic community (TC) approach for the treatment of homeless mentally ill chemical abusers (MICAs). The social and psychological characteristics of the treatment sample were described in an earlier paper; the purpose of the present report was to categorize subtypes of homeless MICA clients to predict with greater accuracy their treatability in modified TCs. An index that consistently correlated with treatment-relevant variables was identified for each of three dimensions; Homelessness (residential instability), Mental Illness (current severity), and Substance Abuse (current substance abuse/dependence diagnosis). These indices yielded distributions that captured the variability in the sample with respect to a number of variables, including drug use, criminality, human immunodeficiency virus (HIV) risk (sexual behavior), psychological status, and motivation. Bivariate and multivariate analyses showed that the indices were not strongly related to demographic variables such as race/ethnicity, age, or gender, but were significantly associated with baseline drug use, criminal activity, HIV risk (sexual behavior), psychological symptoms, and motivation and readiness. These findings indicate that, even among those admitted to residential treatment for substance abuse, homeless MICA clients are not homogeneous; rather, subgroup differences emerge among the indices of homelessness, mental illness, and substance abuse. The efficacy of treatment in modified TCs for these subgroups will be assessed in subsequent papers examining the relationships among the three indices, client retention, and outcomes during and subsequent to residential treatment.

Modified therapeutic community for mentally ill chemical abusers: outcomes and costs

Several studies have established that the personal and social consequences of substance abuse are extensive and costly. These consequences are frequently compounded by mental illness. Although interventions that target mentally ill chemical abusers (MICAs) present several challenges, the potential benefits of successful interventions are significant. This article presents outcomes and costs of a modified therapeutic community (TC) intervention for homeless MICAs. Outcomes at follow-up are compared with those for a control group of homeless MICAs receiving standard services in a "treatment-as-usual" (TAU) condition. Annual economic costs for the modified TC and the average weekly cost of treating a single client are estimated. Treatment and other health service costs at 12 months postbaseline are compared for modified TC and TAU clients. The results of this study indicate that, suitably modified, the TC approach is an effective treatment alternative for homeless MICAs, with the potential to be highly cost-effective relative to standard services.