"The Gold Standard" and Related Considerations for a Maturing Science of Substance Abuse Treatment. Therapeutic Communities; A Case in Point.

The randomized control trial (RCT) is commonly celebrated as the "Gold Standard" of research designs. However, such evidentiary distinctions contain serious implications for the scientific acceptance, funding, and public perception of various treatments for substance abuse. This issue and related considerations are briefly discussed from the perspective of therapeutic community treatment and research.

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.

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.

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.

The Therapeutic Community: A Unique Social Psychological Approach to the Treatment of Addictions and Related Disorders.

The evolution of the contemporary Therapeutic Community (TC) for addictions over the past 50 years may be characterized as a movement from the marginal to the mainstream of substance abuse treatment and human services. TCs currently serve a wide array of clients and their diverse problems; through advances in research in treatment outcomes, the composition of staff has been reshaped, the duration of residential treatment has been reduced, the treatment goals have been reset and, to a considerable extent, the approach of therapy itself has been modified. An overview of the TC as a distinct social-psychological method for treating addiction and related disorders is provided by this paper. Included in this is a focus on the multifaceted psychological wounds that consistently show a strong association with addiction and thereby require initiating a recovery process characterized by life-style and identity changes.

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.

Evaluating peer-influence processes in a prison-based therapeutic community: a dynamic network approach.

BACKGROUND: The Therapeutic Community (TC) is a common treatment modality for incarcerated individuals with substance use disorders. TCs rely on peer group processes to promote lasting behavioral and identity change, yet prior research has not adequately tested the peer influence mechanisms underlying the theoretical model. This study applied dynamic network analysis to estimate peer influence processes central to TC philosophy. METHODS: A stochastic actor-oriented model (SAOM) was applied to ten months of social network data collected from prisoner surveys within a TC unit (N = 62) in a medium-security Pennsylvania prison. Respondents (N = 177, 84% of unit) completed at least one prison survey and provided network and community role model nominations. RESULTS: Although residents' levels of treatment engagement were significantly correlated with their nominated peers, estimates of peer influence for treatment engagement were non-significant in longitudinal network models. Nor were estimates of peer influence significantly greater for peers perceived as community role models. Rather, inmates connected with peers who were of similar treatment engagement as themselves (i.e., a peer selection process), and the latter primarily resulted from racial homophily in the TC social network. CONCLUSIONS: Inconsistent with the desired treatment model, treatment engagement diffusion was not evident in the sampled TC. Results suggested that highly-engaged residents clustered together at the center of the TC's social structure but had little impact on less-engaged and peripheral inmates. The relatively short (i.e., four-month) program length and moderate-to-low treatment fidelity likely contributed to the lack of peer influence processes.

Client matching: a severity-treatment intensity paradigm.

Despite considerable effort to develop matching strategies and client placement protocols, research studies fail to yield compelling results regarding the benefits of matching to treatment. The most consistent findings suggest a matching paradigm, which defines a successful placement as the least treatment intensity required addressing the severity of the disorder. The purpose of the present study is to provide further empirical support for the validity of a severity-intensity paradigm utilizing data from the Drug Abuse Treatment Outcome Studies. A "passive match" approach employed the Client Matching Protocol decision algorithm, which recommended clients to long-term residential or outpatient drug-free treatment. One-year outcomes for clients matched to long-term residential treatment were better on all outcome variables compared to those undertreated in outpatient drug-free treatment. Findings supported the validity of the severity-intensity paradigm in that undertreated clients showed less improvement compared to matched and overtreated clients.

The impact of a social network intervention on retention in Belgian therapeutic communities: a quasi-experimental study.

BACKGROUND: Although numerous studies recognize the importance of social network support in engaging substance abusers into treatment, there is only limited knowledge of the impact of network involvement and support during treatment. The primary objective of this research was to enhance retention in Therapeutic Community treatment utilizing a social network intervention. AIMS: The specific goals of this study were (1) to determine whether different pre-treatment factors predicted treatment retention in a Therapeutic Community; and (2) to determine whether participation of significant others in a social network intervention predicted treatment retention. DESIGN, SETTING AND PARTICIPANTS: Consecutive admissions to four long-term residential Therapeutic Communities were assessed at intake (n = 207); the study comprised a mainly male (84.9%) sample of polydrug (41.1%) and opiate (20.8%) abusers, of whom 64.4% had ever injected drugs. Assessment involved the European version of the Addiction Severity Index (EuropASI), the Circumstances, Motivation, Readiness scales (CMR), the Dutch version of the family environment scale (GKS/FES) and an in-depth interview on social network structure and perceived social support. Network members of different cohorts were assigned to a social network intervention, which consisted of three elements (a video, participation at an induction day and participation in a discussion session). FINDINGS: Hierarchical regression analyses showed that client-perceived social support (F1,198 = 10.9, P = 0.001) and treatment motivation and readiness (F1,198 = 8.8; P = 0.003) explained a significant proportion of the variance in treatment retention (model fit: F7,197 = 4.4; P = 0.000). By including the variable 'significant others' participation in network intervention' (network involvement) in the model, the fit clearly improved (F1,197 = 6.2; P = 0.013). At the same time, the impact of perceived social support decreased (F1,197 = 2.9; P = 0.091). CONCLUSIONS: Participation in the social network intervention was associated with improved treatment retention controlling for other client characteristics. This suggests that the intervention may be of benefit in the treatment of addicted individuals.

Motivation and readiness for therapeutic community treatment: psychometric evaluation of the Dutch translation of the Circumstances, Motivation, Readiness, and Suitability scales.

There is empirical evidence that treatment motivation and readiness are closely linked to retention. Several instruments have been developed to measure these concepts; such instruments can reliably assess the stages of motivation and readiness, and predict treatment retention and outcome. However, limited efforts have been undertaken in Europe to translate those instruments and to determine their reliability and validity. In this study, the psychometric properties of a Dutch translation of the Circumstances, Motivation, Readiness, and Suitability (CMRS) scales by De Leon and Jainchill and the shortened CMR Intake Version are illustrated in a Flemish sample of therapeutic community residents (n = 207). Exploratory factor analyses confirm three CMR subscales, although confirmatory factor analysis reveals only a moderate fit for both the CMRS and the CMR. In contrast, the predictive power of the instrument is strong, specifically for 1-year retention. Significant correlations were found between CMRS measures and age, drug severity, legal referral, and social problems. It is concluded that the Dutch translation of the CMRS and the CMR can be employed as a valid indicator of treatment motivation and readiness, although additional research concerning factorial structures is needed.

Recovery-oriented perceptions as predictors of reincarceration.

The present prospective study explored whether a specific class of client subjective assessments predicts later recovery. Measures of client perceptions of self-change in substance abusers were obtained a year after release from a prison-based therapeutic community. Analyses assessed the contribution of these perceptions-along with motivation, age, and risk index of social deviancy-in predicting reincarceration at 3-year follow-up. Results showed that two factors (Individual Growth and Socialization) significantly differentiated reincarceration and nonreincarceration at 1-year postrelease and significantly predicted reincarceration at 3-year follow-up. Findings underscore the relevance of perceptions of self-change early in recovery to later recovery behaviors. Research on recovery factors needs a uniform assessment protocol, which organizes client perceptions, beliefs, and attributions in accordance with a recovery stage framework.

Correlates of HIV transmission risk factors and considerations for interventions in homeless, chemically addicted and mentally ill patients.

A study was conducted to ascertain correlates of HIV high risk behaviors and attitudes toward HIV. A questionnaire was administered to 103 men living in a modified therapeutic community (TC) for homeless, chemically addicted and mentally ill men. The psychiatric diagnoses of the sample population included psychotic disorders (48%), depressive disorders (36%), and bipolar disorders (16%). Forty-two percent reported that their primary substance of abuse was cocaine and another 40% named alcohol as the substance to which they were most addicted. Two logistic regression analyses were conducted, one with needle sharing as the outcome measure and one with endorsement of the need for lifestyle changes to reduce risk of HIV transmission. Cocaine users were 3.4 times more likely to have shared needles than the rest of the sample. Patients who had a history of sexually transmitted diseases (STDs) were 17 times more likely to endorse the need for lifestyle changes. The level of HIV transmission knowledge was unrelated to HIV risk behaviors or attitudes.

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.

TC-oriented supported housing for homeless MICAs.

This article describes a TC-oriented aftercare program for homeless mentally ill chemical abusers (MICAs) in a supported housing facility, and presents some preliminary data on program effectiveness. The study divided the clients who had completed a residential modified TC program into two groups--those who participated in the TC-oriented supported housing program and those who did not. The data show similarities in the profile of the two groups. Improvement in negative behaviors (e.g., drug use and crime) occurred during the residential program and stabilized during the supported housing program, while improvement in prosocial behaviors (e.g., psychological functioning and employment) was incremental and continuous over the course of both programs. Those who participated in the TC-oriented supported housing program demonstrated significantly better outcomes than those who did not. These findings provide preliminary evidence for the effectiveness of a TC-oriented supported housing program as an aftercare strategy for homeless MICA clients following residential treatment.

Posttreatment victimization and violence among adolescents following residential drug treatment.

This article examines the relationships among experiences of childhood abuse, psychiatric disorders, self-reported victimization, and violent behavior, with a focus on gender differences. Data were obtained from treatment entry and 5-year post-treatment interviews of 446 adolescent clients in therapeutic community (TC) drug treatment programs throughout the United States and Canada. Fifty-eight percent of the sample indicated that they engaged in serious violent behaviors (e.g., beatings, threatening or using weapons against other people, or violent crimes such as assaults, rapes, murders) in the 5 years following their separation from TC treatment. Multivariate logistic regression analyses revealed that victimization in the posttreatment period was the most significant factor associated with violent behavior, and pretreatment childhood abuse experiences and psychiatric disorders were not significantly related to the odds of violent behavior. There were significant gender differences in self-reported victimization and violent behavior. The findings suggest that violence in young adulthood for males is related to increasing involvement in violent lifestyles that include drug trafficking, while violence among females is associated with the social and psychological consequences of drug involvement and victimization. High rates of violent involvement and victimization among former adolescent clients suggests the utility of incorporating interventions such as safety-oriented strategies for females or interventions that address involvement in the drug use lifestyles (i.e., use and dealing) for both males and females into residential treatment to reduce the likelihood of future violence.

Motivation and readiness for drug treatment: differences by modality and special populations.

The purpose of this research is to expand our knowledge of motivational factors among admissions to various substance abuse treatment modalities and among those entering special programs. Differences in motivation are reported in a convenience sample of more than 6,000 admissions to 38 programs. Results from multilevel analyses show (a) an ordered increase in motivation by settings from referral to outpatient, to methadone maintenance, and to the highest levels in residential programs and (b) significantly lower motivation among admissions to programs for special populations. Results are discussed in relation to the demand characteristics of treatment and non-recovery reasons for entering treatment.

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.

Matching to sufficient treatment: some characteristics of undertreated (mismatched) clients.

A previous study by the investigative team using Drug Abuse Outcome Study data supported the validity of a sufficient treatment matching paradigm, which defines successful placement as the least treatment intensity required to address the severity of a disorder. The least favorable outcomes were obtained in the under-treated clients who received insufficient treatment intensity. The purpose of the current study was to further clarify characteristics of the undertreated clients. Four groups, those matched and mismatched to long-term residential (LTR) and drug-free outpatient (ODF) treatment, were compared on several baseline variables. Results indicated that the severity levels of drug use, social and psychological problems, and motivation for those mismatched to ODF (undertreated) were significantly lower than the clients matched to LTR but generally higher than the clients matched to ODF and those mismatched to LTR (overtreated). These findings underscore the importance of identifying clients at risk for under-treatment and facilitating their entry into treatments of sufficient intensity. More generally, they highlight the need to develop a range of treatment options of sufficient intensity to meet severity differences among clients.