Therapeutic communities are a form of long-term residential treatment for substance abuse disorders which emerged in the late 1950s out of the self-help recovery movement with groups such as Alcoholic Anonymous. During the 1960s, the first generation of addiction TCs spread throughout the United States and later on across the world. Today the TC approach has been adopted in more than 65 countries.
The therapeutic community’s treatment approach: community as method
TCs are drug-free residential settings that use various treatment stages that reflect increased levels of personal and social responsibility among participants. Peer influence, mediated through a variety of group processes, is used to help individuals assimilate social norms and develop effective social skills. TCs utilize a recovery-oriented approach focusing on the whole person and overall changes in their lifestyles, not merely on the abstinence from drug use.
The essential element of this approach is community: TCs differ from other treatment approaches principally in their use of the community, i.e. their social organization, staff and residents, as key agents of change. This approach is often referred to as “community as method.” Following this concept, residents are required to participate actively in group living and daily activities to drive personal change and the attainment of treatment goals. The change process occurs through a myriad of structured and unstructured interactions designed to help participants acquire healthy lifestyle habits. The TC treatment model is fundamentally a mutual self-help approach (not only are the individuals in treatment the main contributors to the change process, but they also assume partial responsibility for the recovery of their peers, an important aspect of an individual’s own treatment) which strives to sustain the main characteristics of a prosocial and positive family environment. This includes structure to provide order in daily living; nurturance through physical and psychological safety; individual acceptance and encouragement, conditional only upon honest participation; and the transmission of healthy values.
“Upon entering a TC, one does not see the trappings of an institution, clinic, hospital, or even a treatment program per se. Instead, elements of a home, school, and business are apparent and a variety of housekeeping, educational, vocational, and community activities are in progress. From an anthropological perspective, the social environment of the TC more largely resembles an energetic village than an institution or service setting.” (1).
Evolution of TCs
Historically, TCs were mutual self-help alternatives to medically oriented strategies to address addiction and most did not allow programme participants to use medications of any kind, including methadone and buprenorphine (opioid medications with lower potential of misuse than illicit opioids, effective in treating opioid addiction). Since the early 1990s however, TCs’ attitudes toward medications have changed gradually, reflecting the evolution of social attitudes toward substance abuse and addiction treatment, the advent of the HIV/AIDS epidemic, and the recognition of addiction as a medical condition. This evolution was also marked by a profound shift in the demographics of people seeking addiction treatment. Altogether, these developments have led today’s TCs to take a comprehensive approach to treatment by addressing residents’ other health conditions and by supporting those undergoing maintenance programmes for opioid addiction.
Many organizations have adjusted their programmes or developed modified TCs designed to address the specific needs of ever-growing populations with complex clinical profiles and treatment needs, including people with co-occurring mental health problems, youth involved in the juvenile justice system, adolescents, women, both with and without dependent children, people who are homeless, etc.
How effective are therapeutic communities?
For many years, the National Institute on Drug Abuse has been conducting studies to advance knowledge of the outcomes of drug abuse treatment as typically delivered in the United States. These studies collected baseline data from over 65,000 individuals admitted to publicly funded treatment agencies, including TC programmes, methadone maintenance, out-patient drug-free, short-term inpatient, and detoxification programmes. These studies found that participation in a TC was associated with several positive outcomes. For example, the Drug Abuse Treatment Outcome Study (DATOS), the most recent long-term study of drug treatment outcomes, showed that those who successfully completed treatment in a TC had lower levels of cocaine, heroin, and alcohol use; criminal behavior; unemployment; and indicators of depression than they had before treatment.
The weight of the direct research evidence from all sources and over many years, in many countries supports the conclusion that the TC is an effective and cost-effective treatment model, especially with the most challenging populations – those with severe drug use, social and psychological problems. However, despite such considerable body of research, TCs still face a lack of randomized, double-blind control trials and this is the reason why it is often asserted that the effectiveness of the TC treatment model has not been “proved” – assertions which may have serious implications for the acceptance, and future development of, TCs.
In conclusion, addiction TCs are established in many countries around the world; they play an important role as part of the national addiction treatment systems and most of them have been able to overcome the strained relations they used to have with harm reduction initiatives and opioid substitution treatment (OST) programmes, thus becoming much better attuned to each other.
“If more European facilities providing TC interventions are to treat OST clients, it will be vital to document treatment outcome as well as encouraging collaboration between these services and regular screening and monitoring of drug users’ needs. While OST has proven its effectiveness with respect to health conditions and use of illicit drugs, TCs can look to the long-term perspectives of reintegration, social inclusion or drug abstinence”. (Vanderplasschen, Vandevelde et Broekaert, 2014, 66)
(1) The Therapeutic Community, Theory, Model, and Method – George De Leon, Springer Publishing Company (2000), p. 119
(2) Therapeutic communities for treating addictions in Europe – Wouter Vanderplasschen, Stijn Vandevelde and Eric Broekaert, European Monitoring Centre for Drugs and Drug Addiction (2014)