TC programmes for the rehabilitation of drug users play a role as part of the national addiction treatment system
Excerpt from “Therapeutic communities for treating addictions in Europe”, a document from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), by Wouter Vanderplasschen, Stijn Vandevelde and Eric Broekaert
Therapeutic communities (TCs) as defined in this report — drug-free, hierarchical, concept-based — are among the longest standing treatment modalities for drug addicts in Europe. In most European countries, TCs were the first treatment solution in response to the emerging drug problems in the 1960s and 1970s. (…) TCs promote changes towards a drug-free lifestyle through living together in a structured way for a substantial period of time. This approach was in line with the early drug policies in most European countries that focused on total abstinence and rehabilitation of drug addicts. Existing institutions were not willing or able to treat this new group of persons, alternative treatments were not available and a considerable number of volunteers involved in TCs helped to intervene at limited public cost.
The advent of the HIV/AIDS epidemic in the mid-1980s, however, posed new challenges for national drug treatment systems. The ever-growing population of drug users exhibiting complex clinical profiles and treatment needs has prompted the development and growth of opioid substitution treatment (OST) and harm reduction measures to contain the spread of drug use-related infectious diseases in Europe. With an emphasis on abstinence and a high threshold for treatment entry, TCs were driven out into the periphery of drug treatment systems.
While the clinical effectiveness and cost-effectiveness of OST as a treatment option has been repeatedly confirmed using rigorous research designs, the evidence base behind TCs is yet to be strengthened. Mature methodologies are yet to be applied to the study of TCs in Europe and, to date, the lack of randomised controlled studies has prevented TCs from establishing themselves as a prominent model of treatment and care, with the exception of a few countries in the south and east of Europe (e.g. Spain, Italy and Poland) where TC bed space is relatively high.
Over recent decades, other (residential) treatment modalities have adopted typical TC tools, such as the structuring of daily life or the confrontation of one’s behaviour during group therapy sessions. TCs have also moved into specific niches such as treatment of drug users with dual diagnoses, mothers with children, and prison inmates.
TCs in the Future
The future of TCs will depend on how well these programmes continue to target areas where they can make the most impact and achieve the most good at adequate cost. This means continuing the implementation of modified TC programmes for particularly vulnerable populations, such as the homeless and those with co-existing disorders, as well as establishing programmes in a range of settings, including prison. A few European countries (Spain, Romania, the United Kingdom) have introduced TCs to the prison setting. While positive outcomes from prison-based TCs have been reported in the literature from the USA, these findings may not be directly translated into the European context — randomized controlled studies of European TCs need to be carried out to investigate the clinical efficacy and economic value of these programmes.
While there was a strained relation between abstinence oriented and harm reduction programmes during the 1990s, today TC treatment, OST and harm reduction initiatives are increasingly becoming better attuned to each other. In fact, they serve the same clients and persons in OST today can simultaneously access residential TC treatment. 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 opioid substitution treatment has proven its effectiveness with respect to health conditions and use of illicit drugs, therapeutic communities can look to the long-term perspectives of reintegration, social inclusion or drug abstinence.
The TC movement has become reconciled to approaches that advocate the introduction of shorter programmes and outreach and community-based interventions. For example, the length of the residential treatment phase has been reduced in most countries to around 12 months or less. A growing emphasis on expenditure containment is likely to contribute to further reductions in the planned duration of TC treatment episodes, as well as a number of other possible changes to the TC model and the way it is practised. This includes an emphasis on the role of informal volunteers and self-help elements at the expense of ‘professional’ staff members, akin to North American TC programmes. The ways in which the quantity and, more importantly, the quality of the TC intervention are negotiated will determine its future role in addiction treatment.
Throughout the history of addiction TCs in Europe, a number of programmes have been referred to as a sect (1), steered by charismatic leadership and not subject to external controls. Today, governmental control and adherence to standards such as the standards and ethics code formulated by the World Federation of Therapeutic Communities (WFTC) provide a general framework for TC professionals. For accreditation purposes and continued quality control, however, more detailed standards are necessary and the set of ‘Service Standards for Addiction Therapeutic Communities’ developed by the Community of Communities is an encouraging example. Although quality control in TCs in most countries is limited to staffing issues, TCs themselves appear to be open to more in-depth and comprehensive assessment and accreditation of their services. The Survey of Essential Elements Questionnaire’ (2) is potentially a candidate instrument with uses in the assessment of TC essential treatment elements, and therefore as an indicator of treatment fidelity. This may also help to reduce the heterogeneity of the concepts provided in Europe under the name of ‘TC’.
In conclusion, TC programmes for the rehabilitation of drug users are established in many European countries and play a role as part of the national addiction treatment systems.
There is some evidence for the effectiveness of TCs in terms of reduced substance use and criminal activity, at least in the USA and a culture of TC research is being developed in Europe. This review has documented the available evidence and current TC practices in the Member States, with a focus on improving knowledge and, ultimately, the quality of care and service provision in TC programmes in Europe.
- (1) Broekaert et al., 2006
- (2) De Leon and Melnick, 1993; Melnick and De Leon, 1999