Therapeutic Communities

Therapeutic communities use interpersonal interactions within a structured community milieu to treat substance abuse. They have shown promising outcomes, especially among people with substance use disorders who require a highly structured environment to succeed. Therapeutic communities are used frequently in correctional institutions to treat inmates with severe substance use disorders and who exhibit antisocial behavior. Positive outcomes have been found for many participants, such as reduced substance use and recidivism after release from incarceration. Since therapeutic communities focus on communal processes to facilitate change, this treatment may not be an effective means to individualize care. In addition, the communities may not be helpful for autonomous, high-functioning individuals or people with severe co-occurring psychiatric disorders. However, these communities have functioned well in correctional settings and seem to be well designed to serve the needs of inmates with severe substance use disorders who are motivated to change their behavior.

Substance Abuse Treatment within Therapeutic Communities

Therapeutic communities are commonly used in correctional institutions to treat substance use disorders and other life problems. Therapeutic communities operate under the assumption that substance use is a consequence of a dysfunctional lifestyle that requires a holistic treatment solution to facilitate change. Holistic healing occurs within a highly structured peer milieu that seeks righteous living without substance use. In therapeutic communities, the interpersonal interactions within the context of communal living are considered to be the mechanism for treating substance use. The community models appropriate behavior for individual members, serves to correct the behaviors of individuals when they are inappropriate, and shapes changes in individuals. The historical roots of therapeutic communities for substance abuse can be traced to the Synanon community.

Therapeutic communities often include group work and may provide opportunities to participate in 12-step support groups. However, therapeutic communities differ from traditional treatment in that they view engaging in everyday life activities within the context of the community as a critical part of the healing process. For example, treatment involves engaging in work activities that benefit the community. In correctional institutions, staff and senior community members assume mentorship roles for the junior members of the community. They often function as closed communities, operating as independently of their surroundings as possible, and frequently require junior members of the group to limit exposure to events outside the community until they reach a certain level of maturity in the program.

Emphasis is placed on the importance of social relationships and reciprocal social support among participants and staff in the therapeutic community which can contribute to persistence in treatment engagement and better treatment results. Encouraging friends and family to participate in treatment also has been used to enhance social support with positive results among therapeutic community participants. Following treatment, participants often report improved relations with friends and family.

Research on Therapeutic Communities

Data concerning the efficacy of therapeutic communities are somewhat sparse, and interpretation of results is complicated by the lack of a standardized model, which makes comparisons across sites difficult. Therapeutic communities can work well for people who have severe substance use problems and would benefit greatly from treatment in a highly structured environment. Researchers examining the efficacy of therapeutic communities in the United States and Europe have found evidence that inmates, homeless people, adolescents, older adults, and certain ethnic minority groups may benefit from participation. Positive outcomes have included lower levels of distress, drug and alcohol use, and criminal involvement among participants. In addition, there is evidence that participation may enhance self-esteem, promote the taking of prescribed medications as directed, lead to gainful employment, and increase social and coping skills. Relapse prevention strategies and aftercare have been used to improve the efficacy of therapeutic communities’ intervention in substance use disorders.

Evidence suggests a positive relationship between the length of association with therapeutic communities and successful outcomes after treatment. Motivation to participate in therapy and change current behavior patterns commonly is related to better treatment retention and less drug use after treatment. Participants in therapeutic communities often report greater motivation to change and higher satisfaction with treatment than people in other types of substance abuse treatment. However, these results may be confounded with self-selection biases since members choose to join these communities and participation requires a high degree of commitment.

Differential treatment outcomes associated with gender have been found. Because of these differences, some researchers have suggested that it may be helpful to use gender-specific treatment strategies. Women commonly enter therapeutic communities with lower levels of social functioning than men. They may exhibit evidence of greater psychological distress, often including suicidality and trauma histories, which need to be addressed in treatment. After participation in therapeutic communities, many women experience less victimization by their partners and are less likely to engage in risky sexual behaviors, including trading sex for money.

Participants who are higher functioning and do not require highly structured care may not benefit from therapeutic communities. In addition, research suggests that people with severe mental health disorders may not have positive outcomes in therapeutic communities. Participants with greater psychological distress and more mental health symptoms when they enter the therapeutic communities seem to be more likely to drop out. Participants in need of limited social and environmental stimulation may find it difficult to tolerate the intense social interactions encouraged in this treatment model. Tailoring treatment to the needs of individuals with greater mental health symptoms would likely increase the chance of a successful outcome. One of the criticisms of the therapeutic community model in general has been that it does not account for individual differences or needs in treatment. However, the therapeutic community model meets the needs of inmates with severe substance use disorders in correctional settings such as jails, prisons, and halfway houses by providing a highly structured and safe community dedicated to staying substance free.

References:

1. Broekaert, E. (2001). Therapeutic communities for drug users: Description and overview. In B. Rawlings & R. Yates (Eds.), Therapeutic communities for the treatment of drug users (pp. 29—12). London: Jessica Kingsley.
2. De Leon, G. (1999). The therapeutic community treatment model. In B. S. McCrady & E. E. Epstein (Eds.), Addictions: A comprehensive guidebook (pp. 306-327). New York: Oxford University Press.

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