Can therapeutic communities
treat populations with
Research shows that those with special or complex needs can be treated in TCs. For example, individuals with co-occurring mental illness and substance abuse may be treated in TC-oriented programs based in shelters, community
residences, day treatment clinics, partial hospitalization settings, or on hospital wards. Community-based TC programs provide effective treatment for clients with criminal involvement, but successful TC programs for drug-involved offenders have also been established in correctional settings. Other special populations with substance abuse problems that may benefit from TC-oriented programs include adolescents, women and their children, persons with HIV/AIDS, and homeless people.
Specialized treatment strategies and services are often incorporated as part of the TC for these populations. Support may include child care services for mothers; programs aimed at normalizing the developmental process for adolescents; access to mental health and social services for individuals with co-occurring mental illness and substance abuse; attention to changing criminal thinking and behavior for the criminal offender; and links to medical and social services for those with HIV/AIDS. Individualized treatment, including lengths of stay tailored to the person's needs, is especially important due to the complexity of possible problems. In addition, TC clinical and management activities may need to be modified in terms of disciplinary sanctions, peer interactions, and degree of confrontation in groups.
Women who enter drug abuse treatment often have many serious problems. Many suffer from low self-esteem, depression, or other mental health disorders; are in abusive relationships; have little access to medical, mental health, and social services; lack marketable job skills; and have child custody concerns.
Both women-only programs and mixed-gender programs can be helpful in treating the drug problems of women. As might be expected, women-only programs and programs that serve higher percentages of women usually provide more services that women need. The evidence suggests that these services can contribute to significantly longer lengths of stay in treatment, which is related to better treatment outcomes.
Newer TC approaches for treating women with drug addictions often focus on issues related to family and children. Some model programs have found
that allowing a woman's children to live with her in the TC can improve her mental health and lengthen retention. Although evidence tends to support the benefits of specialized services for women, more research is needed to determine the optimal structure of TC treatment in meeting women's needs.
The closely supervised residential TC environment provides benefits for troubled youth. A study on adolescent drug treatment outcomes showed that adolescents treated in TC programs were more likely than those in outpatient drug-free programs to have prior drug abuse treatment experience, more severe problems, and a criminal justice history. Despite being more difficult to treat, however, adolescents in these programs had significantly improved outcomes in drug use, psychological adjustment, school performance, and criminal activities.
Another study compared the outcomes for adolescents referred through probation to TC treatment to outcomes for those referred to group homes with no specialized drug treatment services. The group homes were the same size and offered the same length of stay as the TC setting. The study found robust reductions in drug use, criminal behavior, and measures of psychological dysfunction at 3 months for all placements. However, after that period, those in the TC sustained or increased their improvements in problematic behaviors, while those in the group homes did not.
Several studies have examined longer term effects for adolescents participating in TCs. For example, one study followed adolescents treated in six TCs. One year after treatment, these adolescents showed significant declines in alcohol, marijuana, and other illicit drug use, as well as reductions in criminal activity and other deviant behavior. Although the planned length of stay varied among the six participating TCs, completing treatment was significantly related to better outcomes. Reductions in drug use were also strongly related to having good relationships with counselors and to avoiding deviant peers after treatment. Posttreatment criminal activity was higher for those who associated with deviant peers.
It is often necessary to modify some of the traditional components of the TC to accommodate adolescent developmental differences and to facilitate their maturation. The modifications may include less hierarchy and confrontation and greater priority to education than work. For example, many TCs for adolescents have an onsite school. In addition, such programs offer a range of family services that require family participation. After formal treatment is completed, continuing care is often arranged.
Individuals with co-occurring mental health disorders
Individuals with co-occurring mental health and substance abuse disorders are among the most difficult to treat. Such individuals often have serious and complex impairments in multiple areas, in addition to drug abuse and mental illness. TCs can be adapted to treat individuals with mental disorders, including, in some cases, the use of psychotropic medications to treat serious mental illness. A recent study compared a TC for people who were homeless, mentally ill, and substance abusers to a community residence based on a traditional mental health treatment model. In the mental health model, individuals were housed within a less restrictive alternative to the psychiatric hospital by coupling a high level of personal freedom with counseling, skills training, and monitoring of medication compliance. The TC provided integrated mental health and drug abuse treatment in a highly structured, hierarchical environment that stressed mutual self-help and treatment community participation. Those in the TC showed more improvement on all measures of psychopathology than those in the community residence. In addition, the TC program retained the most impaired individuals longer than did the community residence. The investigators concluded that the increased structure provided by the TC may be a better option for this population than the less restrictive community residence model.
Another study that tested modifications to the TC to accommodate homeless drug abusers with co-occurring mental health problems included greater flexibility in program requirements, reduced duration of activities
and level of confrontation, and greater responsiveness to individual needs. A second set of modifications, for a low-intensity TC, allowed residents greater freedom to leave the facility during the early stages of treatment, offered services in day treatment settings outside the residence, decreased the level of peer responsibility, and increased the amount of direct staff assistance. The modified TCs were compared to "treatment as usual," which consisted of a heterogeneous mix of alternatives often encountered after discharge from shelters or psychiatric facilities. Analyses comparing the outcomes of modified TC treatment to the usual options found that drug use was reduced in both groups, although participation in the modified TCs led to significantly greater improvements for criminal activity and indicators
Populations involved in the criminal justice system
As drug abuse and crime are often linked, many drug-abusing or addicted individuals also are involved with the criminal justice system. Some of the most extensive research studies on TCs have been conducted on treatment for populations involved in the criminal justice system. These studies have found benefits for prison-based TC treatment in preparing inmates to return to the community and for creating a safer, better managed prison environment. Drug-involved offenders have the best outcomes when they participate in community-based TC treatment while transitioning from incarceration to re-entry to the community.
One such study followed drug-abusing and addicted inmates in the Delaware Correctional System to determine the effectiveness of a continuum of care on relapse to drug use and recidivism to criminal activity. The continuum of care began in prison with a State-funded TC program called The Key. Inmates transitioned back into the community through a work-release program that allowed them to work in the community but required their return to a secure facility overnight. Some inmates were randomly assigned to usual work release, and some were assigned to Crest, a TC work-release program. In the third stage of treatment, some who had completed the Crest work-release TC and were living in
the community continued in an aftercare program, which provided continued monitoring by TC counselors, outpatient counseling, group therapy, and family sessions.
One year after scheduled completion of work release, significantly higher percentages of inmates who had participated in Crest or in both Key and Crest were drug-free and arrest-free than those assigned to usual work release. Further, outcomes for those who participated in both Key and Crest were better than for all three other groups.
At 3 years after work release, Crest treatment graduates and especially those who continued with aftercare had significantly better outcomes than those who dropped out in terms of avoiding both relapse to drug use and re-arrest. This study also highlights the value of continuing treatment of offenders during their transition back into the community.
Another study conducted in the R.J. Donovan Correctional Facility in San Diego, California, investigated the effect of the TC on criminal recidivism for inmates with drug problems. This study compared rates of re-incarceration and time until re-incarceration for those randomly assigned to a prison-based TC (the Amity program) to rates for a no-treatment control group. After prison, some who completed the Amity program chose to enter Vista, a community-based TC aftercare program designed to complement and continue the prison program's curriculum. Those who benefited most were the individuals who continued and completed treatment in Vista.
Similar outcomes were found at 3 years after release from prison. Only 27 percent of those completing Vista treatment had been returned to custody, compared to 75 percent of the no-treatment controls. Among those who were re-incarcerated, the amount of exposure to treatment was significantly related to the number of days until return to custody, with greater treatment exposure related to a longer time until re-incarceration.
Persons living with HIV/AIDS
Several studies have shown that the TC can be effective in caring for HIV-infected substance abusers and in modifying risk behavior to reduce HIV transmission. In the late 1980s, when AIDS was considered a terminal illness, several approaches to modifying the TC were developed to provide a comprehensive, multilayered therapeutic milieu addressing the multiple problems of individuals with HIV/AIDS.
One such model in New York merged modified TC principles with nursing home standards of medical and psychiatric care to improve physical and psychological health. This model has evolved in step with advances in treatment for AIDS. Another modified TC model in San Francisco was designed to engage HIV-infected persons in treatment, retain them, and link them to appropriate medical, psychiatric, and other social services. The modifications to this TC included providing these individuals with accelerated entry into the program, a more comprehensive assessment, a higher ratio of professional mental health and medical staff, and greater attention to staff issues such as stress, grief, and burnout.
Several studies have found that TC treatment reduces HIV risk by reducing injection drug use. Length of treatment, an important predictor of drug use outcomes, may also be important in reducing some HIV risk behaviors. In a study conducted in San Francisco, reductions in injection drug use and risky
sexual practices were found for both a traditional TC and a modified day-treatment TC. The longer the person was in treatment, the less likely he
or she was to engage in risky behaviors.