Therapeutic Communities in the USA: A Dynamic Present and a Challenging Future

1. 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 (R01-DA-14976) The University of Georgia

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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 DeLeon’s model of TCs • Centers removed if identity as TC was in error The University of Georgia

8. 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

9. Distribution of TC Age The University of Georgia

10. 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

11. Organizational Size in FTEs The University of Georgia

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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 DeLeon and his colleagues, we examined the similarities between our sample and these classic elements of TCs The University of Georgia

18. 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

19. 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

20. 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

21. TC Culture: The Use of Work • “Work is utilized as part of the 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

22. 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

23. 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

24. Comparing TCA and Non-TCA Members: Treatment Ideology • Looking at 14 different dimensions of TC treatment ideology derived from DeLeon 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

25. 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

26. 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 the 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

27. 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

28. 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

29. 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 • Non-residential TCs reported significantly higher percentages of MA-level counselors than the two types of residential programs The University of Georgia

30. 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 difference between mixed and non-residential TCs was not significant The University of Georgia

31. Innovation Adoption The University of Georgia

32. 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