Therapeutic communities: diversity in treatment elements

Attachment Patterns in Subjects Diagnosed With a Substance Use Disorder: A Comparison of Patients in Outpatient Treatment and Patients in Therapeutic Communities

The purpose of the present study is to analyze the quality of attachment in substance abuse patients in outpatient treatment vs. patients in therapeutic communities in order to identify the role of attachment insecurity in choosing a care system. The sample consisted of 127 subjects (107 males and 20 females); 97 were outpatients (83 males) and 30 therapeutic community patients (24 males). Attachment with respect to current, significant relationships was assessed using the Relationship Questionnaire. In the outpatient subgroup, the prevailing attachment style was preoccupied; for the therapeutic community patients, the prevailing attachment style was dismissive. The dimensions of care (how the caregiver is perceived as loving and caring) and overprotection (how the caregiver is perceived as intrusive and interfering)-evaluated by means of the Parent Bonding Instrument-were higher in the outpatient subgroup. Scores were higher with respect to maternal subscales regardless of treatment modality. No differences emerged with respect to self-perceived symptoms (SCL-90-R) between the subgroups; however, fearful-avoidant and dismissive-avoidant individuals reported higher self-perceived symptom regardless of treatment modality. Understanding the distribution of different attachment patterns with respect to the treatment modality may improve efficacious interventions, attuning them to the individual and his or her developmental environment.

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.

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.

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

Purpose

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

Design/methodology/approach

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

Findings

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

Research limitations/implications

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

Originality/value

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

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.

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.

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.

The Therapeutic Community for Addictions: An Evolving Knowledge Base

The therapeutic community (TC) has become an established treatment approach serving thousands of substance abusers in community, institutional, and other settings. This article summarizes the research that contributed to the acceptance and growth of TCs and laid the groundwork for the establishment of TCs for substance abusers in correctional settings. The TC knowledge base has contributed to the revival of a rehabilitation philosophy in correctional policy, which is described in the second section. The reflections of the authors who have collaborated for about 40 years are provided at the end of the paper.

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.

Dynamic effects among patients' treatment needs, beliefs, and utilization: a prospective study of adolescents in drug treatment

OBJECTIVE

To document the prospective, reciprocal relationships among substance use problems, utilization of drug treatment, and predisposing beliefs thought to increase treatment utilization.

DATA SOURCE

Persistent Effects of Treatment Study-Adolescent (PETS-A), conducted by the Center on Substance Abuse Treatment. This was a longitudinal study of youths originally participating in one of two CSAT studies; one sample included 476 youths receiving residential drug treatment, and the other included 519 youths receiving outpatient treatment.

STUDY DESIGN

This study uses five waves of data collected over a 12-month period to examine the temporal relationships among four variables: treatment dose, substance use problems, drug resistance self-efficacy, and perceived need for treatment (PNT). Data from this longitudinal study were analyzed using cross-lagged panel models, and structural equation modeling techniques were used to estimate the prospective, reciprocal relationships among these four variables in each of the two samples, while controlling for several covariates.

PRINCIPAL FINDINGS

Both PNT and low drug resistance self-efficacy led to higher levels of subsequent treatment. However, low self-efficacy presaged increases in drug problems while PNT predicted decreases.

CONCLUSIONS

Understanding the role of psychological variables in the utilization of health services is complicated for psychological disorders because beliefs that affect treatment can also influence the disorder itself. Efforts to keep adolescents in drug treatment should focus on convincing youth that treatment can help them with their problems, rather than convincing them that they cannot resist drugs on their own. While both messages increase treatment utilization, the latter belief undermines the effects of treatment.

Retention of court-referred youths in residential treatment programs: client characteristics and treatment process effects

The juvenile justice system relies heavily on residential treatment services for adolescents. Because treatment dropout limits the likely effectiveness of these services, in this study we examine the client and program characteristics associated with program retention among a sample of adolescent probationers referred to residential rehabilitation by the Juvenile Court in Los Angeles. Participants in the present study (n = 291) are a subset of those in the Adolescent Outcomes Project, conducted within RAND's Drug Policy Research Center, to examine the outcomes of youths entering treatment at seven residential treatment programs. Three months after a preadmission interview, youths were asked about their perceptions of counselors at the program, other residents, and their feelings of safety in the program. In addition, they were asked whether they needed and had received various services (e.g., job training, legal advice, family counseling). Results of a multivariate survival analysis revealed that pretreatment characteristics including motivation and substance use severity, as well as treatment program factors including safety, and perceived over- and underprovision of services, contribute significantly to the prediction of retention. Pretreatment environmental risk factors and ratings of program counselor and resident support were marginally significant. These results imply that changes in adolescent residential program delivery may serve to increase retention rates, thus improving long-term outcomes.