Therapeutic Communities in the USA A Dynamic Present

Therapeutic Communities in the USA: A Dynamic Present and a Challenging Future Paul M. Roman, Ph. D. The University of Georgia This research is supported by the National Institute on Drug Abuse (R 01 -DA-14976) The University of Georgia

TCs in the American Treatment System Our key research questions: – What are the characteristics of programs across the United States that identify themselves as TCs? – What are the distinctions between those that follow the traditional residential model vs. modified TCs? – To what extent do these TCs endorse the ideological components of the classic TC model? – What major issues face American TCs in the future? The University of Georgia

Overview Features • TCs are a growing sector of American treatment • They are becoming increasingly integrated • They have a unique model of treatment that should be recognized as a “evidence based practice” The University of Georgia

Challenges • The issue of continuing strength of organizations of TCs promoting the integrity and importance of the TC model • Adjusting funding to a comprehensive, “whole person” model • Maintaining the core technology of TCs while adapting realistically to change. The University of Georgia

Project Design Features • This study is a nationally representative sample of community-based self-identified therapeutic communities in the US • The panel longitudinal design has several elements – Initial wave of on-site interviews with program administrators – Data also collected via: § Mailback questionnaires with program administrators § Mailback questionnaires with counselors § Follow-up telephone interviews at 6, 12, and 18 months to track changes in service delivery – Follow-up wave of data collection from program administrative staff to be completed in Fall 2006 – Follow-up data collection about 70 percent complete The University of Georgia

Research Design: Sample Construction • Constructing a nationally representative sample of TCs was achieved using a two-stage design: – Creation of 10 strata of US counties based on population – Random sampling of US counties to be representative of the US population – Identification of all possible substance abuse treatment centers in those counties using SAMHSA’s national directory of substance abuse facilities and directories provided by all 50 state substance abuse directors – Centers were randomly selected from the 10 strata for telephone screening The University of Georgia

Research Design: Screening for Eligibility • Telephone screening collected information about center’s eligibility for the study • All TCs were required to be community-based • Central criterion for inclusion was that the program self-identified as a therapeutic community – This allows for measurement of the range of programs that identify as TCs – On-site interview contains measures to examine the extent to which these organizations fit De. Leon’s model of TCs – Centers removed if identity as TC was in error The University of Georgia

Diversity of TCs in the Sample • The independent units of the larger multi -site TC organizations were included in the sampling frame • There is 57 units of these multi-site organizations in the sample • This represents 15 percent of the sample; 85 percent are not part of large multi-site systems The University of Georgia

Distribution of TC Age The University of Georgia

A Look at TC Ownership Government Owned 8. 5% Hospital <1% Individual 6. 6% Religious Order 4. 0% University <1% Private Foundation 29. 4% Board of Directors 26. 0% 503(c) non-profit corporations 24. 4% The University of Georgia

Organizational Size in FTEs The University of Georgia

Services Offered at National Sample of 380 TCs Residential (90% offer some form) • Long-term (>180 Days) 44. 5 • Six-month 36. 8% • Three-month 30. 3% • Short-term (< 30 days) 18. 4% The University of Georgia

Services Offered at National Sample of 380 TCs (cont’d) • Outpatient – Partial Hospitalization (at least 20 hours/week) 11. 6% – Intensive Outpatient (9 -20 hours/week) 27. 9% – Outpatient (<9 hours/week) 40. 5% • Aftercare 48. 7% The University of Georgia

Availability of Residential Care • The vast majority of TCs (90. 0%) offer some form of residential care – The average residential TC has about 51. 9 beds • About 10. 0% (n=31) do not offer any form of residential care The University of Georgia

Availability of Adolescent Residential Programs • Among TCs offering residential care (n = 278), the availability of four types of adolescent programs was examined • Residential programs for adolescents were relatively rare, with only 10. 7% of TCs offering any type of adolescent residential programming The University of Georgia

Outpatient Services in Residential TCs • In TCs that offer residential care, there is some evidence of service diversification with regard to the availability of outpatient programming • However, 60. 4% of residential TCs have no PHP, IOP, or OP levels of care The University of Georgia

Cultural Aspects of the Classic TC Model • The classic TC model involves a unique cultural approach to: – The goals and stages of treatment – The roles of peers and staff – The importance of hierarchy within the community – The use of work in the treatment process • Using measures developed by De. Leon and his colleagues, we examined the similarities between our sample and these classic elements of TCs The University of Georgia

TC Culture: Treatment Goals • “A main goal of the primary treatment stage is building a sense of ownership or belonging in the community. ” – 0 = no extent – 5 = very great extent • Residential-only and Mixed programs strongly endorse this measure, while non-residential programs report significantly lower agreement The University of Georgia

TC Culture: The Role of Clients • “Clients confront the negative behavior and attitudes of each other and the community. ” – 0 = no extent – 5 = very great extent • Residential-only and Mixed programs are similar in their response, but non-residential programs report less agreement with this measure The University of Georgia

TC Culture: Hierarchy in the TC • “Clients are stratified by levels of responsibility and clinical status, such as Junior, Intermediate, and Senior. ” – 0 = no extent – 5 = very great extent • Non-Residential TCs report less agreement with this measure than Residential-Only and Mixed TCs The University of Georgia

TC Culture: The Use of Work • “Work is utilized as part of therapeutic program (i. e. to build self-esteem and social responsibility). ” – 0 = no extent – 5 = very great extent • Although Residential-Only and Mixed TCs are similar, Non-Residential TCs are less likely to use work as part of the treatment process The University of Georgia

Comparing TCA and Non-TCA Members • There should be differences between those TC organizations that commit themselves to a national membership organization and those which do not • There should be differences between those TC organizations that have structured opportunities to interact intensely with TC peers at national meetings, and those which do not • There should be differences between those TC organizations that have daily opportunities for networking and information-gathering from peers vs. those who do not The University of Georgia

Comparing TCA and Non-TCA Members • Slightly less than a quarter of TCs in our sample (23. 9%) are members of TCA • Keep in mind that we define our units as having significant local administrative decision-making, so these figures offer multiple counts of established TC networks The University of Georgia

Comparing TCA and Non-TCA Members: Treatment Ideology • Looking at 14 different dimensions of TC treatment ideology derived from De. Leon and colleagues’ work, there are significant differences between the overall groups of TCA members and non-TCA members on 8 of the dimensions The University of Georgia

Comparing TCA and Non-TCA Members • TCA member organizations are significantly more likely to endorse: – Right living involves positive social values, such as work ethic social productivity, and community responsibility – The most important role of the clinical staff is to facilitate the clients’ commitment to the shared community values The University of Georgia

Comparing TCA and Non-TCA Members Clients are stratified by levels of responsibility and clinical status, such as Junior, Intermediate and Senior*** Clients are aware of therapeutic goals of fellow residents and try to assist them in achieving these goals*** Peer feedback occurs more frequently than staff counseling The University of Georgia

Comparing TCA and Non-TCA Members • Clients confront the negative behaviors and attitudes of each other and the community*** • Encounter groups are used to confront negative behaviors and attitudes*** • There are periodic “house runs” or thorough inspection of the premises The University of Georgia

Treatment of Dually Diagnosed Clients by Setting • Of the total sample of TCs, 69. 2% report that they treat clients that have been dually diagnosed • There is variation in the treatment of dually diagnosed clients across the three types of settings The University of Georgia

Educational Attainment by Setting • We examined the percentage of counselors with at least a Master’s-level degree – The average TC reported that 30. 4% of their counseling staff had attained at least a Master’s-level degree The University of Georgia • Non-residential TCs reported significantly higher percentages of MA-level counselors than the two types of residential programs

Recovery Status by Setting • We examined the percentage of counselors that were personally in recovery – The average TC reported that 56. 5% of their counseling staff were personally in recovery • Residential-only TCs had significantly more counselors in recovery than the other two types The University of Georgia – The difference between mixed and nonresidential TCs was not significant

Innovation Adoption The University of Georgia

Challenges • The issue of continuing strength of organizations of TCs promoting the integrity and importance of the TC model • Adjusting funding to a comprehensive, “whole person” model • Maintaining the core technology of TCs while adapting realistically to change. The University of Georgia